**1. Introduction**

Even though stroke has long been accepted as an adult health problem causing substantial morbidity and mortality, it is also an important cause of acquired brain injury in young patients, occurring most commonly in the neonate and during childhood. Pediatric stroke incidence rates, including both neonatal and childhood and both ischemic and hemorrhagic stroke, range from 3 to 25 per 100,000 children in developed countries. Newborns have the highest risk ratio: 1 in 4000 live births [1,2]. The incidence of arterial ischemic stroke is highest in children aged under 1 year [3]. Children also have a more diversified and larger number of risk factors for stroke that differ significantly from adults [1,4,5]. The risk factors for AIS in the pediatric population are arteriopathy, cardiac disease, cardiac surgery/interventions, sickle cell disease, infections, thrombophilia and perinatal

**Citation:** Bressi, F.; Santacaterina, F.; Cricenti, L.; Campagnola, B.; Nasto, F.; Assenza, C.; Morelli, D.; Cordella, F.; Lapresa, M.; Zollo, L.; et al. Robotic-Assisted Hand Therapy with Gloreha Sinfonia for the Improvement of Hand Function after Pediatric Stroke: A Case Report. *Appl. Sci.* **2022**, *12*, 4206. https://doi.org/ 10.3390/app12094206

Academic Editor: Enrico Vezzetti

Received: 11 March 2022 Accepted: 18 April 2022 Published: 21 April 2022

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factors [1,6]. The clinical presentation of childhood stroke varies depending on the age of the child, and the most common clinic presentations are functional neurological disorders (20.0%), transient neurological deficits (17.8%), migraine (15.6%) and seizure (11.1%) [6,7]. The recovery of the arm function is one of the main goals of rehabilitation attempts after childhood stroke; the upper limb function is essential in the performance of everyday activities and has a significant impact on independent functioning and the overall quality of life of the affected children. The aim of rehabilitation of the upper limbs is to prevent the disuse of the impaired side of the body. Many studies in the literature have shown that therapy involving sensorimotor exercises to simulate meaningful tasks used in daily life increases the functional recovery of the affected upper limb [8–10]. Realistic contexts of functional activities, such as reaching or pointing towards an everyday object, help patients to acquire control strategies to compensate muscle weakness and inaccuracies [11]. In order to rehabilitate the upper limbs, there are different treatments available. Constraint Induced Movement Therapy (CIMT) is a rehabilitative methodology widely used currently, even on infants under one year of age (named baby-CIMT); it is considered feasible and without adverse effects [12]. Kwakkel et al. demonstrated that high-intensity and task-specificity are two of the main features of any successful stroke rehabilitation program [13,14]. In the last few years, therapy aided by a robotic exoskeleton is noted for its capability of supporting repetitive and high-intensity training tasks [15]; a rehabilitation robot can assist the physiotherapist in administering programmable and customizable rehabilitation procedures according to the type of treatment required. When combined with interactive programs such as virtual reality (VR), robot-aided therapy can assign functional meaning to the therapy, creating a motivating environment [16,17]. Active and very inspiring practice, with intensive and oriented repetitions, is essential to induce changes in neuroplasticity within the sensory-motor system and improves performance in motor tasks [17]. The use of robotics and video gaming within a pediatric population can improve motivation and attention while focusing on the practice of specifically difficult motor tasks [18,19].

In the pediatric field, it is possible to combine rehabilitative treatments in any stroke phase, exploiting the potential of innovative technology for sensor-motor and cognitive recovery and for the continuum of care also at home [8]. In pediatric strokes, studies currently available are mainly aimed at the use of virtual reality and tele-rehabilitation. The use of robotic devices in the pediatric population is still under study. In fact, to date, no studies have investigated the efficacy of Gloreha in the motor recovery of hand functions in children after stroke. Therefore, this case report aims to describe the feasibility and the effectiveness of an RMT with Gloreha Sinfonia plus a conventional treatment in the recovery of the sensory-motor capabilities of the paretic hand and the quality of life in a ten-year-old child after stroke.

The paper structure is as follows: Section 2 describes the materials, i.e., Gloreha Sinfonia, the developed rehabilitation exercises, the experimental setup and protocol, the developed assessment system based on VR and force measurement, and the evaluated outcome measures; Section 3 reports the results of the experimental validation, which are discussed in Section 4. Conclusions and future work are provided in Section 5.
