Rehabilitative treatment of cleft lip and palate: experience of the Hospital for Rehabilitation of Craniofacial Anomalies - USP (HRAC-USP) - Part 3: Oral and Maxillofacial Surgery

This paper presents the treatment protocol of maxillofacial surgery in the rehabilitation process of cleft lip and palate patients adopted at HRAC-USP. Maxillofacial surgeons are responsible for the accomplishment of two main procedures, alveolar bone graft surgery and orthognathic surgery. The primary objective of alveolar bone graft is to provide bone tissue for the cleft site and then allow orthodontic movements for the establishment of an an adequate occlusion. When performed before the eruption of the maxillary permanent canine, it presents high rates of success. Orthognathic surgery aims at correcting maxillomandibular discrepancies, especially anteroposterior maxillary deficiencies, commonly observed in cleft lip and palate patients, for the achievement of a functional occlusion combined with a balanced face.

Rehabilitative treatment of cleft lip and palate: experience of the Hospital for Rehabilitation of Craniofacial Anomalies/USP (HRAC/USP) - Part 1: overall aspects

C left lip and palate is the most common among craniofacial malformations and causes several esthetic and functional implications that require rehabilitation. This paper aims to generally describe the several aspects related to this complex pathology and the treatment protocol used by the Hospital for Rehabilitation of Craniofacial Anomalies, University of So Paulo (HRAC-USP) along 40 years of experience in the treatment of individuals with cleft lip and palate.

Prosthetic misfit of implant-supported prosthesis obtained by an alternative section method

PURPOSE. Adequate passive-fitting of one-piece cast 3-element implant-supported frameworks is hard to achieve. This short communication aims to present an alternative method for section of one-piece cast frameworks and for casting implant-supported frameworks. MATERIALS AND METHODS. Three-unit implant-supported nickel-chromium (Ni-Cr) frameworks were tested for vertical misfit (n = 6). The frameworks were cast as one-piece (Group A) and later transversally sectioned through a diagonal axis (Group B) and compared to frameworks that were cast diagonally separated (Group C). All separated frameworks were laser welded. Only one side of the frameworks was screwed. RESULTS. The results on the tightened side were significantly lower in Group C (6.43 +/- 3.24 mu m) when compared to Groups A (16.50 +/- 7.55 mu m) and B (16.27 +/- 1.71 mu m) (P<.05). On the opposite side, the diagonal section of the one-piece castings for laser welding showed significant improvement in the levels of misfit of the frameworks (Group A, 58.66 +/- 14.30 mu m; Group B, 39.4.8 +/- 12.03 mu m; Group C, 23.13 +/- 8.24 mu m) (P<.05). CONCLUSION. Casting diagonally sectioned frameworks lowers the misfit levels. Lower misfit levels for the frameworks can be achieved by diagonally sectioning one-piece frameworks. [J Adv Prosthodont 2012;4:89-92]

A 15-year study on the treatment of undernourished children at a nutrition rehabilitation centre (CREN), Brazil

Objective: To build a life table and determine the factors related to the time of treatment of undernourished children at a nutrition rehabilitation centre (CREN), Sao Paulo, Brazil. Design: Nutritional status was assessed from weight-for-age, height-for-age and BMI-for-age Z-scores, while neuropsychomotor development was classified according to the milestones of childhood development. Life tables, Kaplan-Meier survival curves and Cox multiple regression models were employed in data analysis. Setting: CREN (Centre of Nutritional Recovery and Education), Sao Paulo, Brazil. Subjects: Undernourished children (n 228) from the southern slums of Sao Paulo who had received treatment at CREN under a day-hospital regime between the years 1994 and 2009. Results: The Kaplan-Meier curves of survival analysis showed statistically significant differences in the periods of treatment at CREN between children presenting different degrees of neuropsychomotor development (log-rank = 6.621; P = 0.037). Estimates based on the multivariate Cox model revealed that children aged >= 24 months at the time of admission exhibited a lower probability of nutritional rehabilitation (hazard ratio (HR) = 0.49; P = 0.046) at the end of the period compared with infants aged up 12 months. Children presenting slow development were better rehabilitated in comparison with those exhibiting adequate evolution (HR = 4.48; P = 0.023). No significant effects of sex, degree of undernutrition or birth weight on the probability of nutritional rehabilitation were found. Conclusions: Age and neuropsychomotor developmental status at the time of admission to CREN are critical factors in determining the duration of treatment.

Mandibular Bisphosphonate-Related Osteonecrosis After Dental Implant Rehabilitation: A Case Report

It has been a matter of debate as to whether dental implant therapies are suitable for patients subjected to long-term use of bisphosphonates (BPs). This report presents a case of a 76-year-old woman who developed BPs-related osteonecrosis of the jaw (BRONJ) in the left hemimandible after dental implant exposure. The implants and the necrotic crestal bone were removed, and postoperatively, a delay in tissue healing with bone exposure was noticed. The histologic analysis of the block biopsies revealed a lamellar bone tissue exhibiting necrotic areas and bacterial colonies associated with the bone outer surface. The bone-implant interface showed viable lamellar bone with enlarged vascular spaces in the areas between the implant threads. The possible mechanisms for the loss of implants in BRONJ patients are discussed, and the potential protocols for dental implant rehabilitation for patients under BP therapies are presented. (Implant Dent 2012;21:449-453)

Aesthetic analysis of an implant-supported denture at the cleft area

Objective: To evaluate the aesthetics of an implant-supported denture at the cleft area, comparing the peri-implant tissues and prosthetic crown with the contralateral tooth. Settings: Hospital for Rehabilitation of Craniofacial Anomalies, Bauru, São Paolo, Brazil. Patients: A total of 39 individuals of both genders, with complete unilateral cleft lip and palate, who received secondary alveolar bone graft and were rehabilitated with single implant-supported dentures at the area of the missing maxillary lateral incisor after completion of orthodontic treatment. Interventions: The following parameters were analyzed in follow-up sessions: length and width of prosthetic crown and contralateral tooth, characteristics of implants, filling of interproximal space by the papilla, and smile height of the patients. Results: The implant-supported prosthetic crowns were longer than the contralateral tooth (p < .001). Among the 78 papillae analyzed, 29 (37.17%) received a score of 3; 32 (41.02%) papillae had a score of 2; and 17 (21.79%) received a score of 1. Concerning the smile height, among the 39 patients analyzed, 23 (56.41%) had a medium smile, 15 (38.46%) had a high smile, and two (5.12%) presented a low smile. Conclusion: The use of dental implants to rehabilitate the edentulous cleft area is an excellent option. However, adequate evaluation of the bone quantity and quality, positioning and shape of adjacent teeth, smile height, and patient expectations should be considered to achieve success and avoid aesthetic deformities such as elongated teeth and absence of gingival papillae.

Connecting accuracy of interchanged prosthetic abutments to different dental implants using scanning electron microscopy

The present study evaluated the interchangeability of prosthetic components for external hexagon implants by measuring the precision of the implant/abutment (I/A) interface with scanning electron microscopy. Ten implants for each of three brands (SIN, Conexão, Neodent) were tested with their respective abutments (milled CoCr collar rotational and non-rotational) and another of an alternative manufacturer (Microplant) in randomly arranged I/A combinations. The degree of interchangeability between the various brands of components was defined using the original abutment interface gap with its respective implant as the benchmark dimension. Accordingly, when the result for a given component placed on an implant was equal to or smaller then that gap measured when the original component of the same brand as the implant was positioned, interchangeability was considered valid. Data were compared with the Kruskal-Wallis test at 5% significance level. Some degree of misfit was observed in all specimens. Generally, the non-rotational component was more accurate than its rotational counterpart. The latter samples ranged from 0.6-16.9 µm, with a 4.6 µm median; and the former from 0.3-12.9 µm, with a 3.4 µm median. Specimens with the abutment and fixture from Conexão had larger microgap than the original set for SIN and Neodent (p<0.05). Even though the latter systems had similar results with their respective components, their interchanged abutments did not reproduce the original accuracy. The results suggest that the alternative brand abutment would have compatibility with all systems while the other brands were not completely interchangeable.

Rehabilitation with forage grasses of an area degraded by urban solid waste deposits

Dry matter yield and chemical composition of forage grasses harvested from an area degraded by urban solid waste deposits were evaluated. A split-plot scheme in a randomized block design with four replicates was used, with five grasses in the plots and three harvests in the subplots. The mineral content and extraction and heavy metal concentration were evaluated in the second cut, using a randomized block design with five grasses and four replicates. The grasses were Brachiaria decumbens cv. Basilisk, Brachiaria ruziziensis, Brachiaria brizantha cv. Marandu and cv. Xaraés, and Panicum maximum cv. Tanzânia, cut at 42 days of regrowth. The dry matter yield per cut reached 1,480 kg ha-1; the minimum crude protein content was 9.5% and the average neutral detergent fiber content was 62.3%. The dry matter yield of grasses was satisfactory, and may be an alternative for rehabilitating areas degraded by solid waste deposits. The concentration of heavy metals in the plants was below toxicity levels; the chemical composition was appropriate, except for phosphorus. The rehabilitated areas may therefore be used for grazing.

A new approach for the dynamic modelling of the human knee

Mathematical models of the knee joint are important tools which have both theoretical and practical applications. They are used by researchers to fully understand the stabilizing role of the components of the joint, by engineers as an aid for prosthetic design, by surgeons during the planning of an operation or during the operation itself, and by orthopedists for diagnosis and rehabilitation purposes. The principal aims of knee models are to reproduce the restraining function of each structure of the joint and to replicate the relative motion of the bones which constitute the joint itself. It is clear that the first point is functional to the second one. However, the standard procedures for the dynamic modelling of the knee tend to be more focused on the second aspect: the motion of the joint is correctly replicated, but the stabilizing role of the articular components is somehow lost. A first contribution of this dissertation is the definition of a novel approach — called sequential approach — for the dynamic modelling of the knee. The procedure makes it possible to develop more and more sophisticated models of the joint by a succession of steps, starting from a first simple model of its passive motion. The fundamental characteristic of the proposed procedure is that the results obtained at each step do not worsen those already obtained at previous steps, thus preserving the restraining function of the knee structures. The models which stem from the first two steps of the sequential approach are then presented. The result of the first step is a model of the passive motion of the knee, comprehensive of the patello-femoral joint. Kinematical and anatomical considerations lead to define a one degree of freedom rigid link mechanism, whose members represent determinate components of the joint. The result of the second step is a stiffness model of the knee. This model is obtained from the first one, by following the rules of the proposed procedure. Both models have been identified from experimental data by means of an optimization procedure. The simulated motions of the models then have been compared to the experimental ones. Both models accurately reproduce the motion of the joint under the corresponding loading conditions. Moreover, the sequential approach makes sure the results obtained at the first step are not worsened at the second step: the stiffness model can also reproduce the passive motion of the knee with the same accuracy than the previous simpler model. The procedure proved to be successful and thus promising for the definition of more complex models which could also involve the effect of muscular forces.

Rehabilitation Engineering in Parkinson's disease

Impairment of postural control is a common consequence of Parkinson's disease (PD) that becomes more and more critical with the progression of the disease, in spite of the available medications. Postural instability is one of the most disabling features of PD and induces difficulties with postural transitions, initiation of movements, gait disorders, inability to live independently at home, and is the major cause of falls. Falls are frequent (with over 38% falling each year) and may induce adverse consequences like soft tissue injuries, hip fractures, and immobility due to fear of falling. As the disease progresses, both postural instability and fear of falling worsen, which leads patients with PD to become increasingly immobilized. The main aims of this dissertation are to: 1) detect and assess, in a quantitative way, impairments of postural control in PD subjects, investigate the central mechanisms that control such motor performance, and how these mechanism are affected by levodopa; 2) develop and validate a protocol, using wearable inertial sensors, to measure postural sway and postural transitions prior to step initiation; 3) find quantitative measures sensitive to impairments of postural control in early stages of PD and quantitative biomarkers of disease progression; and 4) test the feasibility and effects of a recently-developed audio-biofeedback system in maintaining balance in subjects with PD. In the first set of studies, we showed how PD reduces functional limits of stability as well as the magnitude and velocity of postural preparation during voluntary, forward and backward leaning while standing. Levodopa improves the limits of stability but not the postural strategies used to achieve the leaning. Further, we found a strong relationship between backward voluntary limits of stability and size of automatic postural response to backward perturbations in control subjects and in PD subjects ON medication. Such relation might suggest that the central nervous system presets postural response parameters based on perceived maximum limits and this presetting is absent in PD patients OFF medication but restored with levodopa replacement. Furthermore, we investigated how the size of preparatory postural adjustments (APAs) prior to step initiation depend on initial stance width. We found that patients with PD did not scale up the size of their APA with stance width as much as control subjects so they had much more difficulty initiating a step from a wide stance than from a narrow stance. This results supports the hypothesis that subjects with PD maintain a narrow stance as a compensation for their inability to sufficiently increase the size of their lateral APA to allow speedy step initiation in wide stance. In the second set of studies, we demonstrated that it is possible to use wearable accelerometers to quantify postural performance during quiet stance and step initiation balance tasks in healthy subjects. We used a model to predict center of pressure displacements associated with accelerations at the upper and lower back and thigh. This approach allows the measurement of balance control without the use of a force platform outside the laboratory environment. We used wearable accelerometers on a population of early, untreated PD patients, and found that postural control in stance and postural preparation prior to a step are impaired early in the disease when the typical balance and gait intiation symptoms are not yet clearly manifested. These novel results suggest that technological measures of postural control can be more sensitive than clinical measures. Furthermore, we assessed spontaneous sway and step initiation longitudinally across 1 year in patients with early, untreated PD. We found that changes in trunk sway, and especially movement smoothness, measured as Jerk, could be used as an objective measure of PD and its progression. In the third set of studies, we studied the feasibility of adapting an existing audio-biofeedback device to improve balance control in patients with PD. Preliminary results showed that PD subjects found the system easy-to-use and helpful, and they were able to correctly follow the audio information when available. Audiobiofeedback improved the properties of trunk sway during quiet stance. Our results have many implications for i) the understanding the central mechanisms that control postural motor performance, and how these mechanisms are affected by levodopa; ii) the design of innovative protocols for measuring and remote monitoring of motor performance in the elderly or subjects with PD; and iii) the development of technologies for improving balance, mobility, and consequently quality of life in patients with balance disorders, such as PD patients with augmented biofeedback paradigms.

Funzionalizzazione della mandibola dopo ricostruzione con lembo libero rivascolarizzato di fibula "single strut". Al di là del deficit di verticalità.

Obiettivi: Valutare la modalità  più efficace per la riabilitazione funzionale del limbo libero di fibula "single strut", dopo ampie resezioni per patologia neoplastica maligna del cavo orale. Metodi: Da una casistica di 62 ricostruzioni microvascolari con limbo libero di fibula, 11 casi sono stati selezionati per essere riabilitati mediante protesi dentale a supporto implantare. 6 casi sono stati trattati senza ulteriori procedure chirurgiche ad eccezione dell'implantologia (gruppo 1), affrontando il deficit di verticalità  della fibula attraverso la protesi dentaria, mentre i restanti casi sono stati trattati con la distrazione osteogenetica (DO) della fibula prima della riabilitazione protesica (gruppo 2). Il deficit di verticalità  fibula/mandibola è stato misurato. I criteri di valutazione utilizzati includono la misurazione clinica e radiografica del livello osseo e dei tessuti molli peri-implantari, ed il livello di soddisfazione del paziente attraverso un questionario appositamente redatto. Risultati: Tutte le riabilitazioni protesiche sono costituite da protesi dentali avvitate su impianti. L'età  media è di 52 anni, il rapporto uomini/donne è di 6/5. Il numero medio di impianti inseriti nelle fibule è di 5. Il periodo massimo di follow-up dopo il carico masticatorio è stato di 30 mesi per il gruppo 1 e di 38.5 mesi (17-81) di media per il gruppo 2. Non abbiamo riportato complicazioni chirurgiche. Nessun impianto è stato rimosso dai pazienti del gruppo 1, la perdita media di osso peri-implantare registrata è stata di 1,5 mm. Nel gruppo 2 sono stati riportati un caso di tipping linguale del vettore di distrazione durante la fase di consolidazione e un caso di frattura della corticale basale in assenza di formazione di nuovo osso. L'incremento medio di osso in verticalità è stato di 13,6 mm (12-15). 4 impianti su 32 (12.5%) sono andati persi dopo il periodo di follow-up. Il riassorbimento medio peri-implantare, è stato di 2,5 mm. Conclusioni: Le soluzioni più utilizzate per superare il deficit di verticalità  del limbo libero di fibula consistono nell'allestimento del lembo libero di cresta iliaca, nel posizionare la fibula in posizione ideale da un punto di vista protesico a discapito del profilo osseo basale, l'utilizzo del lembo di fibula nella versione descritta come "double barrel", nella distrazione osteogenetica della fibula. La nostra esperienza concerne il lembo libero di fibula che nella patologia neoplastica maligna utilizziamo nella versione "single strut", per mantenere disponibili tutte le potenzialità  di lunghezza del peduncolo vascolare, senza necessità  di innesti di vena. Entrambe le soluzioni, la protesi dentale ortopedica e la distrazione osteogenetica seguita da protesi, entrambe avvitate su impianti, costituiscono soluzioni soddisfacenti per la riabilitazione funzionale della fibula al di là  del suo deficit di verticalità . La prima soluzione ha preso spunto dall'osservazione dei buoni risultati della protesi dentale su impianti corti, avendo un paragonabile rapporto corona/radice, la DO applicata alla fibula, sebbene sia risultata una metodica con un numero di complicazioni più elevato ed un maggior livello di riassorbimento di osso peri-implantare, costituisce in ogni caso una valida opzione riabilitativa, specialmente in caso di notevole discrepanza mandibulo/fibulare. Decisiva è la scelta del percorso terapeutico dopo una accurata valutazione di ogni singolo caso. Vengono illustrati i criteri di selezione provenienti dalla nostra esperienza.

Bioengineering of exercise: biomechanical and metabolic aspects

The field of research of this dissertation concerns the bioengineering of exercise, in particular the relationship between biomechanical and metabolic knowledge. This relationship can allow to evaluate exercise in many different circumstances: optimizing athlete performance, understanding and helping compensation in prosthetic patients and prescribing exercise with high caloric consumption and minimal joint loading to obese subjects. Furthermore, it can have technical application in fitness and rehabilitation machine design, predicting energy consumption and joint loads for the subjects who will use the machine. The aim of this dissertation was to further understand how mechanical work and metabolic energy cost are related during movement using interpretative models. Musculoskeletal models, when including muscle energy expenditure description, can be useful to address this issue, allowing to evaluate human movement in terms of both mechanical and metabolic energy expenditure. A whole body muscle-skeletal model that could describe both biomechanical and metabolic aspects during movement was identified in literature and then was applied and validated using an EMG-driven approach. The advantage of using EMG driven approach was to avoid the use of arbitrary defined optimization functions to solve the indeterminate problem of muscle activations. A sensitivity analysis was conducted in order to know how much changes in model parameters could affect model outputs: the results showed that changing parameters in between physiological ranges did not influence model outputs largely. In order to evaluate its predicting capacity, the musculoskeletal model was applied to experimental data: first the model was applied in a simple exercise (unilateral leg press exercise) and then in a more complete exercise (elliptical exercise). In these studies, energy consumption predicted by the model resulted to be close to energy consumption estimated by indirect calorimetry for different intensity levels at low frequencies of movement. The use of muscle skeletal models for predicting energy consumption resulted to be promising and the use of EMG driven approach permitted to avoid the introduction of optimization functions. Even though many aspects of this approach have still to be investigated and these results are preliminary, the conclusions of this dissertation suggest that musculoskeletal modelling can be a useful tool for addressing issues about efficiency of movement in healthy and pathologic subjects.

Technical innovations for the diagnosis and the rehabilitation of motor and perceptive impairments of the child with Cerebral Palsy

The treatment of the Cerebral Palsy (CP) is considered as the “core problem” for the whole field of the pediatric rehabilitation. The reason why this pathology has such a primary role, can be ascribed to two main aspects. First of all CP is the form of disability most frequent in childhood (one new case per 500 birth alive, (1)), secondarily the functional recovery of the “spastic” child is, historically, the clinical field in which the majority of the therapeutic methods and techniques (physiotherapy, orthotic, pharmacologic, orthopedic-surgical, neurosurgical) were first applied and tested. The currently accepted definition of CP – Group of disorders of the development of movement and posture causing activity limitation (2) – is the result of a recent update by the World Health Organization to the language of the International Classification of Functioning Disability and Health, from the original proposal of Ingram – A persistent but not unchangeable disorder of posture and movement – dated 1955 (3). This definition considers CP as a permanent ailment, i.e. a “fixed” condition, that however can be modified both functionally and structurally by means of child spontaneous evolution and treatments carried out during childhood. The lesion that causes the palsy, happens in a structurally immature brain in the pre-, peri- or post-birth period (but only during the firsts months of life). The most frequent causes of CP are: prematurity, insufficient cerebral perfusion, arterial haemorrhage, venous infarction, hypoxia caused by various origin (for example from the ingestion of amniotic liquid), malnutrition, infection and maternal or fetal poisoning. In addition to these causes, traumas and malformations have to be included. The lesion, whether focused or spread over the nervous system, impairs the whole functioning of the Central Nervous System (CNS). As a consequence, they affect the construction of the adaptive functions (4), first of all posture control, locomotion and manipulation. The palsy itself does not vary over time, however it assumes an unavoidable “evolutionary” feature when during growth the child is requested to meet new and different needs through the construction of new and different functions. It is essential to consider that clinically CP is not only a direct expression of structural impairment, that is of etiology, pathogenesis and lesion timing, but it is mainly the manifestation of the path followed by the CNS to “re”-construct the adaptive functions “despite” the presence of the damage. “Palsy” is “the form of the function that is implemented by an individual whose CNS has been damaged in order to satisfy the demands coming from the environment” (4). Therefore it is only possible to establish general relations between lesion site, nature and size, and palsy and recovery processes. It is quite common to observe that children with very similar neuroimaging can have very different clinical manifestations of CP and, on the other hand, children with very similar motor behaviors can have completely different lesion histories. A very clear example of this is represented by hemiplegic forms, which show bilateral hemispheric lesions in a high percentage of cases. The first section of this thesis is aimed at guiding the interpretation of CP. First of all the issue of the detection of the palsy is treated from historical viewpoint. Consequently, an extended analysis of the current definition of CP, as internationally accepted, is provided. The definition is then outlined in terms of a space dimension and then of a time dimension, hence it is highlighted where this definition is unacceptably lacking. The last part of the first section further stresses the importance of shifting from the traditional concept of CP as a palsy of development (defect analysis) towards the notion of development of palsy, i.e., as the product of the relationship that the individual however tries to dynamically build with the surrounding environment (resource semeiotics) starting and growing from a different availability of resources, needs, dreams, rights and duties (4). In the scientific and clinic community no common classification system of CP has so far been universally accepted. Besides, no standard operative method or technique have been acknowledged to effectively assess the different disabilities and impairments exhibited by children with CP. CP is still “an artificial concept, comprising several causes and clinical syndromes that have been grouped together for a convenience of management” (5). The lack of standard and common protocols able to effectively diagnose the palsy, and as a consequence to establish specific treatments and prognosis, is mainly because of the difficulty to elevate this field to a level based on scientific evidence. A solution aimed at overcoming the current incomplete treatment of CP children is represented by the clinical systematic adoption of objective tools able to measure motor defects and movement impairments. A widespread application of reliable instruments and techniques able to objectively evaluate both the form of the palsy (diagnosis) and the efficacy of the treatments provided (prognosis), constitutes a valuable method able to validate care protocols, establish the efficacy of classification systems and assess the validity of definitions. Since the ‘80s, instruments specifically oriented to the analysis of the human movement have been advantageously designed and applied in the context of CP with the aim of measuring motor deficits and, especially, gait deviations. The gait analysis (GA) technique has been increasingly used over the years to assess, analyze, classify, and support the process of clinical decisions making, allowing for a complete investigation of gait with an increased temporal and spatial resolution. GA has provided a basis for improving the outcome of surgical and nonsurgical treatments and for introducing a new modus operandi in the identification of defects and functional adaptations to the musculoskeletal disorders. Historically, the first laboratories set up for gait analysis developed their own protocol (set of procedures for data collection and for data reduction) independently, according to performances of the technologies available at that time. In particular, the stereophotogrammetric systems mainly based on optoelectronic technology, soon became a gold-standard for motion analysis. They have been successfully applied especially for scientific purposes. Nowadays the optoelectronic systems have significantly improved their performances in term of spatial and temporal resolution, however many laboratories continue to use the protocols designed on the technology available in the ‘70s and now out-of-date. Furthermore, these protocols are not coherent both for the biomechanical models and for the adopted collection procedures. In spite of these differences, GA data are shared, exchanged and interpreted irrespectively to the adopted protocol without a full awareness to what extent these protocols are compatible and comparable with each other. Following the extraordinary advances in computer science and electronics, new systems for GA no longer based on optoelectronic technology, are now becoming available. They are the Inertial and Magnetic Measurement Systems (IMMSs), based on miniature MEMS (Microelectromechanical systems) inertial sensor technology. These systems are cost effective, wearable and fully portable motion analysis systems, these features gives IMMSs the potential to be used both outside specialized laboratories and to consecutive collect series of tens of gait cycles. The recognition and selection of the most representative gait cycle is then easier and more reliable especially in CP children, considering their relevant gait cycle variability. The second section of this thesis is focused on GA. In particular, it is firstly aimed at examining the differences among five most representative GA protocols in order to assess the state of the art with respect to the inter-protocol variability. The design of a new protocol is then proposed and presented with the aim of achieving gait analysis on CP children by means of IMMS. The protocol, named ‘Outwalk’, contains original and innovative solutions oriented at obtaining joint kinematic with calibration procedures extremely comfortable for the patients. The results of a first in-vivo validation of Outwalk on healthy subjects are then provided. In particular, this study was carried out by comparing Outwalk used in combination with an IMMS with respect to a reference protocol and an optoelectronic system. In order to set a more accurate and precise comparison of the systems and the protocols, ad hoc methods were designed and an original formulation of the statistical parameter coefficient of multiple correlation was developed and effectively applied. On the basis of the experimental design proposed for the validation on healthy subjects, a first assessment of Outwalk, together with an IMMS, was also carried out on CP children. The third section of this thesis is dedicated to the treatment of walking in CP children. Commonly prescribed treatments in addressing gait abnormalities in CP children include physical therapy, surgery (orthopedic and rhizotomy), and orthoses. The orthotic approach is conservative, being reversible, and widespread in many therapeutic regimes. Orthoses are used to improve the gait of children with CP, by preventing deformities, controlling joint position, and offering an effective lever for the ankle joint. Orthoses are prescribed for the additional aims of increasing walking speed, improving stability, preventing stumbling, and decreasing muscular fatigue. The ankle-foot orthosis (AFO), with a rigid ankle, are primarily designed to prevent equinus and other foot deformities with a positive effect also on more proximal joints. However, AFOs prevent the natural excursion of the tibio-tarsic joint during the second rocker, hence hampering the natural leaning progression of the whole body under the effect of the inertia (6). A new modular (submalleolar) astragalus-calcanear orthosis, named OMAC, has recently been proposed with the intention of substituting the prescription of AFOs in those CP children exhibiting a flat and valgus-pronated foot. The aim of this section is thus to present the mechanical and technical features of the OMAC by means of an accurate description of the device. In particular, the integral document of the deposited Italian patent, is provided. A preliminary validation of OMAC with respect to AFO is also reported as resulted from an experimental campaign on diplegic CP children, during a three month period, aimed at quantitatively assessing the benefit provided by the two orthoses on walking and at qualitatively evaluating the changes in the quality of life and motor abilities. As already stated, CP is universally considered as a persistent but not unchangeable disorder of posture and movement. Conversely to this definition, some clinicians (4) have recently pointed out that movement disorders may be primarily caused by the presence of perceptive disorders, where perception is not merely the acquisition of sensory information, but an active process aimed at guiding the execution of movements through the integration of sensory information properly representing the state of one’s body and of the environment. Children with perceptive impairments show an overall fear of moving and the onset of strongly unnatural walking schemes directly caused by the presence of perceptive system disorders. The fourth section of the thesis thus deals with accurately defining the perceptive impairment exhibited by diplegic CP children. A detailed description of the clinical signs revealing the presence of the perceptive impairment, and a classification scheme of the clinical aspects of perceptual disorders is provided. In the end, a functional reaching test is proposed as an instrumental test able to disclosure the perceptive impairment. References 1. Prevalence and characteristics of children with cerebral palsy in Europe. Dev Med Child Neurol. 2002 Set;44(9):633-640. 2. Bax M, Goldstein M, Rosenbaum P, Leviton A, Paneth N, Dan B, et al. Proposed definition and classification of cerebral palsy, April 2005. Dev Med Child Neurol. 2005 Ago;47(8):571-576. 3. Ingram TT. A study of cerebral palsy in the childhood population of Edinburgh. Arch. Dis. Child. 1955 Apr;30(150):85-98. 4. Ferrari A, Cioni G. The spastic forms of cerebral palsy : a guide to the assessment of adaptive functions. Milan: Springer; 2009. 5. Olney SJ, Wright MJ. Cerebral Palsy. Campbell S et al. Physical Therapy for Children. 2nd Ed. Philadelphia: Saunders. 2000;:533-570. 6. Desloovere K, Molenaers G, Van Gestel L, Huenaerts C, Van Campenhout A, Callewaert B, et al. How can push-off be preserved during use of an ankle foot orthosis in children with hemiplegia? A prospective controlled study. Gait Posture. 2006 Ott;24(2):142-151.