The manner and frequency of Internet use may reflect the needs, preferences, values, personal motivations and personality characteristics of users. The aim of this research was to analyse the relationship between the Big Five Personality factors and impulsivity with Problematic Internet Use and the Negative Impact of WhatsApp. The sample consisted of 630 university students  aged between 18 and 62 years (M = 21.23). The results indicated that the Big Five Personality factors and impulsivity correlated significantly with Problematic Internet Use and the Negative Impact of WhatsApp. Impulsivity proved to be the most important predictor of Problematic Internet Use and the Negative Impact of WhatsApp. It can be concluded, cautiously, that impulsive people have a greater predisposition to develop Problematic Internet Use and, also to experience a greater negative impact due to the use of WhatsApp. Internet access via mobile phone has increased considerably in recent years . DespiteProblematic Internet Use is growing phenomenon in our society. Despite increasing research in this field, there is no agreement today on a unified definition or criteria for its diagnosis , which mAmong various online activities, it has been found that text messaging and instant messaging have been linked to Problematic Internet Use and mobile phone abuse .Instant messaging has several different features compared to other Internet applications that make this one more attractive to users. Features such as providing information about users' connection status, pop-ups when users receive a message, the immediacy of responses or the ability to have multiple simultaneous conversations -individually or in groups- . WhatsApNot all Internet and/or WhatsApp users develop problematic use of the Internet/WhatsApp, there are certain variables that increase the vulnerability of individuals when experiencing such problematic use.The way and frequency of Internet use may reflect the needs, preferences, values, personal motivations and personality characteristics of users . AccordiSimilarly, some research has found that conscientiousness, openness to experience and agreeableness are negatively related to Problematic Internet Use .Impulsivity is another characteristic that has been associated with problematic Internet and smartphone use, increasing psychological vulnerability to addictions and being a risk factor for the development of Internet addiction  and probThe present study aimed to analyse the relationship between the Big Five Personality Factors and Impulsivity with Problematic Internet Use and the Negative Impact of WhatsApp. The main novelties of the study are twofold: To jointly analyse Problematic Internet Use and WhatsApp and to evaluate the negative impact experienced by WhatsApp users through an innovative scale that has proven to have good psychometric properties and to be very useful .As a hypothesis we hope to contrast: 1) Problematic Internet Use will be directly related to Openness to experience and Neuroticism and inversely to Agreeableness, Extraversion and Conscientiousness. 2) WhatsApp's Negative Impact will be directly related to Openness to experience and Neuroticism and inversely to Agreeableness, Extraversion and Conscientiousness. 3) Impulsivity will be directly related to Problematic Internet Use and the Negative Impact of WhatsApp. 4) Low levels of Agreeableness, Conscientiousness, Neuroticism, Openness to experience, Extraversion, and Impulsivity will predict Problematic Internet Use. 5) Low levels of Agreeableness, Conscientiousness, Neuroticism, Openness to experience, Extraversion, and Impulsivity will predict the Negative Impact of WhatsApp.M = 21.23 and SD = 4.32). All participants (100%) reported connecting to the Internet. Instant messaging was used by 100% of students. In addition, 100% used WhatsApp and 98.5% reported that WhatsApp was the most widely used of all instant messaging applications.The sampling method used was for convenience. The sample consisted of 630 Spanish university students (75.7% women), aged between 18 and 62 years . The students received no incentives whatsoever for participating in the study. The research was evaluated and accepted by the Ethics Commission of the University of Murcia (Spain), so guaranteeing it respected the ethical principles of research with human beings.The Generalized Problematic Internet Use Scale GPIUS2,  evaluateThe WhatsApp Negative Impact Scale WANIS;  evaluateThe Reduced NEO Five-Factor Inventory NEO-FFI;  is a redThe State Impulsivity Scale SIS;  evaluatet-tests were calculated for independent samples. Pearson correlations and stepwise linear regression analyses were conducted to examine the predictive ability of the Big Five personality factors and impulsivity in Problematic Internet Use and the Negative Impact of WhatsApp.Data analysis was performed using the SPSS statistical package (v. 22.0). t(627) = 2.722, p = .007, and in the total WhatsApp Negative Impact Scale score, t(627) = 2.184, p = .029, with women obtaining the highest scores —Reward, Automatism and Attentional—correlated significantly and directly with the variables of Problematic Internet Use . The corr = .58, p < .01.The correlations of Impulsivity with the Negative Impact of WhatsApp were significant and direct . Reward To examine the predictive power of the Big Five Personality Factors and Impulsivity on Problematic Internet Use, a multiple linear stepwise regression analysis was performed .Problematic Internet Use was explained by Impulsivity and Extraversion (35.2%). The most widely explained variable of the pathological use of the Internet was Preference for Online Social Interaction (38.4%), with four predictors: Extraversion, Impulsivity, Neuroticism and Agreeableness.Impulsivity was the greatest predictor in all cases except in the Preference for Online Social Interaction, where it was Extraversion (β = −0.427).The Negative Impact of WhatsApp was explained by Impulsivity, Openness to Experience, Neuroticism and Conscientiousness (37.6%). The most explained variable of the Negative Impact of WhatsApp was Negative Consequences of WhatsApp Use (37.3%), with four predictors: Impulsivity, Conscientiousness, Openness to Experience and Extraversion .Impulsivity was a variable predictor of the Negative Impact of WhatsApp and each of its component dimensions. It was also the strongest predictor in all cases. Openness to Experience was another personality trait that predicted both the Negative Impact of WhatsApp and all its dimensions.The first objective was to examine the influence of sociodemographic variables on Problematic Internet Use and on the Negative Impact of WhatsApp. No statistically significant differences were observed in Problematic Internet Use by sex . In relaRegarding age, our results support previous studies that considered adolescents and young people to be the most vulnerable users for the development of Problematic Internet Use . CompareAge correlated significantly and negatively with the Negative Impact of WhatsApp and all factors of the WANIS scale. Therefore, the younger the age of the university students, the more negative consequences that were derived from its use, the greater control of intimate relationships made through WhatsApp and the more problematic the use that was experienced. This may be because young people are more vulnerable to addiction in general and to Problematic Internet Use in particular , possiblThe second objective was to analyse the relationship between problematic Internet use and the Negative Impact of WhatsApp on the Big Five personality factors.Problematic Internet use correlated significantly and negatively with Agreeableness, Conscientiousness, Openness to experience and Extraversion and directly with Neuroticism. Our results are consistent with studies that found a negative relationship between Problematic Internet Use and Agreeableness , ConscieProblematic Internet Use had the highest correlations with Agreeableness and Conscientiousness. People with low agreeableness are seen by others as less pleasant, have difficulty establishing peer networks, and participate less frequently in group activities. These people may be rejected by others, leading them to turn to the Internet as a means of fulfilling their personal needs .Individuals with low conscientiousness may be at greater risk of being distracted by all the possibilities offered by the Internet and of getting lost in virtual worlds . Due to Negative Impact of WhatsApp correlated significantly and negatively with Agreeableness, Conscientiousness, Openness to experience and Extraversion, and directly with Neuroticism. These results partially confirm Hypothesis 2 which formulated that the Negative Impact of WhatsApp will be directly related to Openness to experience and Neuroticism and inversely to Agreeableness, Extraversion and Conscientiousness.These results are consistent with previous studies linking instant messaging to conscientiousness  and neurThe third objective was to analyse the relationship between the Problematic Internet Use and Negative Impact of WhatsApp with Impulsivity. The results indicated that Impulsivity was directly associated with Problematic Internet Use and the Negative Impact of WhatsApp, Hypothesis 3 being confirmed. This is congruent with previous research . ImpulsiReward was the dimension of Impulsivity that obtained the highest significant correlations with each of the factors of Problematic Internet Use scale and the WANIS. We would highlight that Reward correlations with Negative Outcomes and with Negative Consequences of WhatsApp use. People with Problematic Internet Use may turn to the Internet to satisfy the need for immediate gratification with no regard to the possible negative consequences of this behaviour . SimilarThe final objective was to examine the predictive power of the Big Five personality factors and Impulsivity on Problematic Internet Use and Negative Impact of WhatsApp.According to our results, the variables that predict Problematic Internet Use were Impulsivity and Extraversion. These results only partially confirm Hypothesis 4 which postulated that low levels of agreeableness, conscientiousness, neuroticism, openness to experience, extraversion and Impulsivity would predict Problematic Internet Use. From these results, we would indicate, although with caution, that impulsive and not very extrovert people could have a greater predisposition to develop Problematic Internet Use. Impulsive and introverted people may have an immediate need to interact with others but may not be able to relate to them because of their shyness. These people may impulsively turn to the Internet to interact with others in a more comfortable and secure way and thus immediately achieve the social gratification they cannot gain from face-to-face interactions .The variables that predicted the Negative Impact of WhatsApp were Impulsivity, Openness to Experience, Neuroticism and Conscientiousness, therefore Hypothesis 5 is only partially confirmed. We can say, albeit cautiously, that people who are impulsive, neurotic, less inclined toward change or novelty, and less conscientious may be more likely to experience a negative impact because of their use of WhatsApp. These people could find in WhatsApp a way of keeping in touch with friends and acquaintances in a comfortable, safe and familiar way.Our results seem to indicate that Impulsivity plays a relevant role in the appearance and maintenance of both problems. At first, impulsive people might turn to the Internet or WhatsApp to immediately satisfy a particular need or desire. Over time, it may be that these people will cease to use WhatsApp or the Internet in a controlled and voluntary way and move towards compulsive or recurrent use, because they are unable to suppress their impulses. This could encourage the development of problematic Internet and/or WhatsApp use and lead them to experience a series of negative consequences similar to those of behavioural addictions .This study has afforded a deeper understanding of problematic Internet and WhatsApp use, two phenomena that, although recent, are increasingly present in our society. This research provides evidence about the relationship of these two issues to the Big Five personality factors and Impulsivity. Specifically, the importance of Impulsivity in problematic Internet and WhatsApp use is clear because, according to the results, impulsive people may have a greater predisposition to develop both problems. This finding is essential for both the prevention and treatment of problematic Internet and WhatsApp use. Hence, programs or workshops that teach how to control and manage impulsivity, train skills to resist the temptation of an immediate reward, learn to expect a later reward, etc. could be an effective way to reduce the risk of the emergence of Problematic Internet Use and decrease the negative impact experienced by using WhatsApp.As limitations of the study we can highlight the use of a sample for convenience, which influences the generalization of the results. On the other hand, it is a transversal study, so preventing the establishment of causal relationships that would better explain the direction of the variables used.


Nutrition in pediatric age, if properly adapted to the various developmental phases, can be considered the first prevention tool for the most common pathologies of this age. New diagnostic approaches and new surgical techniques have made nutrition possible even in neurologically impaired children or patients with malformations. The Special Issue “Pediatric Gastroenterology and Nutrition” underlines the importance of the nutritional status in preventing important pathologies of the infant and evaluates diagnostic and surgical techniques to obtain, in a minimally invasive way, the most suitable means to feed the patient.Proper nutrition is the basis of regular biological development and psychological condition of the child. In fact, it is essential to satisfy the child’s nutritional needs, that is, the quantity of calories and nutrients necessary to ensure an optimal state of health and an adequate growth to their genetic potential and age . The nutPediatric food intake disorders occur in children with genetic syndromes, neurological disorders, and surgical or stomach disorders. In recent years, with the development of neonatal intensive care and neonatal resuscitation techniques, an increasingly large group of patients have survived, reporting important neurological damage that creates swallowing and food dysfunctions in general. Over the past 40 years, the prevalence of cerebral palsy has risen to well over 2.0 per 1000 births [Gastrostomy has been an operation performed in pediatric age for more than 100 years, but in the last 40 years, the techniques have improved considerably, allowing even very young patients to be treated, who may then have an adequate nutritional supply even if they are unable to swallow and they are not taking adequate nutrients orally.Furthermore, the improvement of diagnostic and surgical techniques allows the best results of gastrostomy even in complex patients. In this case, it is easier to diagnose gastroesophageal reflux disease or stomach fixation defects that can also be treated with minimally invasive techniques, in order to have at the same time the possibility of enteral feeding and have protection for the respiratory tract.The Special Issue, “Pediatric Gastroenterology and Nutrition”, mainly analyzes the problem of appropriate nutrition in relation to pathologies of the pediatric age.In the first paper, Miguel Baños-Peláezand and colleagues carried out a retrospective case-control study on premature infants and found that feeding with exclusive mother’s own milk and fortified human milk can prevent necrotizing enterocolitis compared to fasting on days 7 and 14 .Francesca Destro and Gloria Pelizzo presented a very interesting study on the opportunity to use a temporary gastrojejunostomy to treat gastro-esophageal reflux disease in particular patients, such as those with long-gap esophageal atresia repair. The placement of the gastrojejunostomy is much less invasive than the fundoplication, so it is useful to postpone the definitive treatment of reflux disease in these cases . FurtherAnother important topic in children is nutrition in neurologically impaired patients. Considering the need, or not, of a fundoplication to protect the respiratory tract, Elisa Zambaiti and her colleagues report the experience of a single center, in which there was no difference between gastrostomy with and without fundoplication .Caruso Anna Maria, who evaluated the use of esophageal high-resolution manometry during laparoscopic fundoplication in order to reduce the side effects related to the technique, has presented a preliminary study .Finally, Giovanni Parente and Mario Lima conducted a preliminary study on the treatment of nonresponsive fecal incontinence in children born with anorectal malformations. Their idea is to implant autologous adipose tissue in the anal sphincter, after a lipoaspiration from the abdominal wall, processing of the lipoaspirate with a Lipogems system, and intersphincteric injection of the adipose tissue processed through endosonographic assistance .In conclusion, this Special Issue emphasizes the importance of nutrition in preventing disease and improving the clinical condition of neuropathic, malformed, or operated patients.


End-user involvement constitutes an essential goal during the development of innovative solution, not only for the evaluation, but also in codesign, following a user-centered strategy. Indeed, it is a great asset of research to base the work in a user-centered approach, because it allows to build a platform that will respond to the real needs of users. The aims of this work are to present the methodology adopted to involve end-users  in the evaluation of a novel virtual coaching system based on the personalized clinical pathways and to present the results obtained from these preliminary activities. Specific activities involving end-users were planned along the development phases and are referred to as participatory design. The user experience of participatory design is constituted by the two different phases: the “end-user's perspective” phase where the user involvement in experiential activities is from an observational point of view, whereas the “field study” phase is the direct participation in these activities. Evaluation tools  were planned to assess different aspects of the system. Thirty patients [14 with poststroke condition and 16 with Parkinson's disease (PD)], 13 healthy elderly, and six health professionals were enrolled from two clinical centers during the two phases of participatory design. Results from “end-user's perspective” phase showed globally a positive preliminary perception of the service. Overall, a positive evaluation  was obtained for each domain of the scale in both groups of patients and healthy subjects. The evaluation of the vCare system during the “field study” phase was assessed as excellent (>80 points) from the point of view of both patients and health professionals. According to the majority of patients, the rehabilitation service through the solution was reported to be interesting, engaging, entertaining, challenging and useful for improving impaired motor functions, and making patients aware of their cognitive abilities. Once refined and fine-tuned in the aspects highlighted in the this work, the system will be clinically tested at user's home to measure the real impact of the rehabilitative coaching services. The continuity of care and personalized rehabilitation for people who experienced acute episodes or who are affected by chronic diseases is often interrupted after transitioning from the hospital to the home environment. Home rehabilitation measures require the presence of a coach following the patient along the assigned care plan .Smart solutions based on a virtual coach (VC) can help to provide a personalized home rehabilitation plan according to the patient's condition and habits to enhance the quality of life (QoL) and to empower patients toward a healthy lifestyle. In this scenario, innovative information and communication technologies (ICT) system based on an intelligent avatar, acting as a VC, could offer home rehabilitation programs to elderly subject or to patients with neurological and cardiological issues. The avatar could be displayed on a mobile device or on a smart television to communicate with patients mainly through natural speech communication. The whole architecture could be arranged in a smart digital environment composed of environmental sensors, wearable sensors, and gaming devices.The main goal of a new generation of VC is to assist and counsel the patient during home rehabilitation activities. Immersive virtual simulations may represent a potentially effective training tool over and above existing methods for training primary care providers .Indeed, several projects have recently focused on VCs development to improve patients' rehabilitation through an intelligent environment, integrating machine learning technologies together with well-elaborated coaching and clinical pathway services .The vCare project, funded under the European Commission (EC) Horizon 2020 call “personalized coaching for well-being and care of people as they age” (SC1-PM15-2017), fits into this context by proposing a new ICT-based concept. The proposed platform encapsulates a set of coaching services for empowering and motivating people, which helps them to proceed with a personalized rehabilitation that complies with age-related physical, cognitive, mental, and social conditions by a VC .The project's final solution will particularly be tailored for patients affected by stroke, Parkinson's disease (PD), and then eventually involving cardiovascular patients. These neurological diseases are especially relevant for elderly people .End-user involvement constituted an essential goal in vCare, not only for the evaluation, but also in codesign, following a user-centered strategy. Senior users, suffering from neurodegenerative and other chronic diseases, at different stages and belonging to different social groups, will assess the suitability of the vCare platform at addressing their health and social issues and improving their QoL.The aims of this work are (i) to present the methodology adopted to involve end-users  in the evaluation of a novel VC system based on personalized clinical pathways; (ii) to present the preliminary results obtained on investigating the first users' feedback. The whole testing and validation process of the vCare solution prototype was designed in a user-centered perspective. Specific activities involving end-users were planned along the development phases and are referred to as participatory design. Users' feedback about the system, which gathered through standardized questionnaires, open discussion, and direct experience of the prototype, is taken into consideration along the development process to tailor specific needs and increase the final acceptance.This work describes the participatory experience of two different types of neurological patients  in the evaluation of an ICT system (vCare system). In particular, the overall user-centered evaluation approach is presented, which takes into account the phases related to end-user's perspective and system usability.With regard to the inclusion of technology in the daily lives of patients, it has been seen that patients' priorities may differ from those of careers and professionals, so it is important to take all perspectives into account when developing technological tools and making care plans .Patients identify technology as something useful, which allows them to use it for leisure, to increase their freedom and independence . They shInformal careers find that technology incorporated into their lives and the people they care for daily lives provides them with an increased peace of mind and relief from the burden of care. Similarly, formal careers embrace the fact that technologies can ease the monitoring of people in need of care and possibility of interactions with other stakeholders .Health professionals consider that technologies reduce their workload and allow them to devote more attention to patients that require it. However, they believe that for technology to enrich rather than weaken the patient–physician relationship, medical humanism must be in the center of the design thinking behind emerging technologies and software. Most importantly, considerable effort will be needed to plan how technology improves the quality of human interactions rather than simply focusing on efficiency, both among team members and with patients and their families .Families as informal careers give preference to patient safety rather than autonomy when they are responsible for patients. When patients are under the responsibility of formal caregivers, they give preference to patient autonomy rather than patient safety .When creating such new technological solutions, acceptance and perceived usability by patients and healthcare providers should be evaluated from the earliest stages of the development and be included in the design process to tailor users' specific needs and to reduce the risk of non-acceptance . Such a It is well known that the development of drugs goes through several modifications, including understanding its effects and impact on the user prior to making it public and ensuring adoption. None of these medications is developed entirely based on evidence-based literature or personal experiences. This is similar to what user-centered design (UCD) aims to achieve, but with technology solutions .The concept of UCD describes a design and a development process in which the influence of the end-user is considered. UCD is a multidisciplinary and an iterative design process that involves, actively engaging, the users and incorporates their feedback to ensure that tools are developed with a full understanding of their needs and requirements , 13.User-centered design characterizes an iterative design process where the feedback of the user is integrated throughout the whole developing process . To takeIn general, innovative technological solutions should be developed considering the needs of end-users in a real-life context. Indeed, the UCD approach not only involves the analysis of real demands of end-users, but also the test of the validity of developed solutions or products with regard to user behavior in real scenario . To makeA group of neurological patients, a group of healthy subjects, and a group of health professionals were enrolled from two clinical centers according to the two targeted diseases .Subjects who suffered from an acute stroke event were enrolled among patients of Casa di Cura del Policlinico (CCP), a rehabilitation hospital in Milan . Patients with PD were enrolled by the Neurology department at Cruces University Hospital and Biocruces Bizkaia Health Research Institute . In addition, groups of healthy elderly were enrolled in each site.The inclusion and exclusion criteria for each clinical center and pathology are reported in Regarding healthy controls, they were recruited taking into account the following exclusion criteria: the presence of cognitive impairments  that interfere with the ability to willingly understand and give informed consent and age <18 years.Health professionals were enrolled according to the following eligibility criteria: (i) be qualified and work in a medical or social area specializing in the proper targeted disease; (ii) be part of the clinical team of one of the patients included in the work; (iii) willing to participate in the work; and (iv) able and willing to provide informed consent.Each participant signed the informed consent forms before the beginning of evaluations and all research procedures were in accordance with the Declaration of Helsinki. Ethics Committees of involved centers reviewed and approved the protocol.The vCare prototype is under development in a highly multidisciplinary context, involving physicians (neurologist and cardiologist), physiotherapists, neuropsychologists, bioengineers, and ICT developers. The whole evaluation methodology of the system has been designed as an incremental testing approach composed of three different phases according to our previous work  as folloUser involvement along the process is referred to as “participatory design”, which is considered the core of vCare evaluation approach. Participatory design is meant to provide valuable suggestions for the deployment process in a user-centered perspective.-user's perspective phase), whereas the second is the direct participation in these activities (field study phase). Both the evaluation tools  and technical testing were planned to assess different aspects of the system. In fact, the end-user's perspective phase and the field study phase were the part of TL and LL . Actually, the user experience of participatory design is constituted by two different phases: the first one is the user involvement in some experiential activities from an observational point of view , a group of patients and a group of healthy subjects were enrolled to give a preliminary evaluation of the proposed system. At this stage, end-users could not interact with the system, but they acknowledged its features and functionalities through a demonstration video.https://vcare-project.eu/). Then, vCare concept movie was presented (or shared using online-sharing service) to the enrolled subjects. The CCP center shared the demonstration video through an e-mail sent directly to the subject or to his/her caregiver. Afterwards, each involved subject was asked to watch the vCare storytelling video on their own through personal devices, whereas OSA center showed their demonstration video in a physical meeting with the participants.This phase  started with a first colloquial interaction  with a general presentation to the participants of the burden of neurological disease in Europe and in specific country. The general aim of the vCare project was clarified by the investigator, and further details regarding the end-user involvement in the cocreation process of vCare services were presented. vCare services and functionalities, and also the foreseen interactions with the subjects, were depicted in a video footage meant as a presentation of the system to end-users. Demonstration videos were produced in each clinical center and in their own official language  for the targeted pathologies  administration and qualitative semi-structured interview. The interviewer could support the subject with the compilation of UEQ questionnaire items only in case of difficulties, avoiding any bias action. After administering the questionnaire, the interviewer identified (by the items score) the main critical issues highlighted by respondents, and he/she proceeded with a semi-structured interview with qualitative output to investigate in depth the reasons of the most critical issues.In the field study phase (during LL), the system prototypes were tested, for the first time, directly by a group of patients in a ‘controlled environment', where patients behaved like at their own homes while staying in the clinic supervised by members of the clinical staff. Specific home-like areas  were set up into two clinical centers [CCP  and OSA (Spain)].Subjects experienced 2-week long rehabilitation treatments autonomously under the supervision of clinicians. Both patients and health professionals interacted directly with the system. Specifically, according to patient's clinical status and clinicians' indications, the vCare system proposed personalized rehabilitation treatments providing a suite of motor and cognitive serious games in a virtual reality (VR) environment. During the motor rehabilitation sessions, a 3D-depth camera is used to recognize the user's movements, which were displayed in the VR environment through a monitor (40-inch-wide screen) in real time. For cognitive rehabilitation activities, the patient interacts instead with a tablet (10-inch). In both activities , the patient is encouraged to reach specific goals in relation to his/her performance. Goals are determined by the system according to characteristic rules; in some cases, distractor was presented to increase the difficulty level of the games.For both the activities, the patients joined the serious games sessions scheduled, whereas the health professionals assigned a customized serious game rehabilitation plan and performed patient training, support, and supervision during the session. The activities are grouped into packages of serious games with a precise rehabilitation objective; each game package is composed of a number of predefined games addressing a specific clinical/functional aim. The packages and their rehabilitation purposes are reported in The usability of the platform user interface and also the subjects' satisfaction with the services were assessed by patients at the end of the intervention through the system usability scale (SUS) . Motor aThe UEQ  was admiUser experience questionnaire data belonging to the six domains were analyzed separately and not merged into a single overall score. For each item, the score was transformed from the original range , 7 to ) (p = 0.031).Differentiating the groups of patients in the two targeted pathologies and healthy subjects, the one-way ANOVA resulted in a statistically significant difference only in the novelty domain of the scale (038) see . For thiA total of 34 SUS questionnaires were filled out by enrolled patients; 17 SUS scales were referred to motor activities of vCare solution platform and 17 to cognitive ones.p-value >0.05, resulting in no statistically significant difference between groups.The evaluation of the overall vCare system  usability was rated 82.28 ± 15.12 (mean ± SD) . GeneralThe evaluation of the vCare system in terms of process of patient's characterization and rehabilitation plan's definition was evaluated as excellent from health professionals (83.33 ± 9.31). Healthcare professionals involved in caring of patients with PD showed SUS score over threshold (91.25 ± 1.77), whereas the ones with expertise in caring of patients with stroke presented a score of 79.38 ± 8.98.Analysis between SUS scores and the patients' age showed no correlation in the overall analysis.R < −0.75) were found only in patients with PD.Moderate correlations . To this regard, subjects showed higher appreciation to oral conversations with the VC, although short and direct sentences are preferred to long conversational events.sensor intrusiveness perception, it emerged that sensors for the environmental and indoor monitoring integrated in vCare were not perceived as intrusive by the majority of respondents. Subjects stated that, as long as they can recognize healthcare professionals behind the technological architecture monitoring them through dedicated dashboards, they feel confident about their data protection. On the other hand, few subjects raised doubts related to privacy issues from the remote monitoring.In assessing the rehabilitation activities provided by the vCare system, particular emphasis was given by subjects to the serious games for both physical and cognitive rehabilitation. From the demonstration video, subjects perceived the physical rehabilitation through serious games engaging, even if some concerns arose about safety issues for games including balance rehabilitation. Subjects showed appreciation for the possibility to monitor the indoor behavior of patients with related correctional feedback. In this regard, users highlighted the importance of receiving motivational feedback in line with the psychological status of the patient. No data protection issues were raised on these activities.Regarding the Considering VC as an ongoing service, in an overall perspective of benefits and limits of the vCare system, subjects appreciated the multiple clinical context , the focus of the system on QoL improvement, the multiple healthcare professionals' skills combined in a novel service, and the different rehabilitation approaches, provided seven days a week at home without excluding in-hospital examinations.vCare was reported to be interesting, engaging, entertaining, challenging and useful for improving impaired motor functions, and making patients aware of their cognitive abilities. Particularly for motor activities, the overall rehabilitation experience was considered to be able to stimulate movement consciousness and the real-time interaction with the screen, without using intrusive devices  to command the pointer, helped to enhance product attractiveness. Some patients particularly appreciated system's feedback on motor game score and the fact that having this system installed at home would mean not necessarily leaving the house for physical activity. In general, the interaction with both motor and cognitive games was deemed almost natural, easy, intuitive, and well explained, despite the fact that most patients did not have daily practicality with technology. In fact, only a few patients did not feel very much in control with the interaction because of a personal lack of technological affinity. In the specific case of cognitive games, according to most of the patients, no unnecessary efforts were required to solve the tasks although some of them were more complicated than others; tasks were almost well explained and many patients thought to be able to complete cognitive games on their own. Only in few cases, neurophysiologist's instructions were initially indispensable.According to the majority of patients, the rehabilitation service through the Some system bugs, in terms of sensitivity and accuracy, were also highlighted by the patients.Definitely, most of the patients would have like to continue exercising with vCare solution at home, because they considered that the majority of serious games are exciting and motivating; some patients reported experiencing benefits and one of them declared that cognitive activities could support the traditional therapy. On the contrary, few patients believed that cognitive games are too elementary, boring, and uninspiring, which makes this activity appear less useful than more common leisure activities. In addition, the particular case of motor games seemed to be mostly indispensable in the prescription of this kind of rehabilitation by the physician, with the guarantee of improvements in patients' physical impairments. In assessing the overall solution novelty, most of the patients consider it to be innovative, although few have already had experience with similar game modality. Some other critical issues were emerged. For few patients, cognitive solution did not seem so innovative because, in their opinion, better games are available nowadays; thanks to technology and, moreover, they did not consider the usefulness of this approach to be very high for patients with their disabilities. Furthermore, not every patient thought that the cognitive solution was creative. Concerning specifically the motor games, a small number of patients did not consider the system a viable and effective substitute of the traditional physical rehabilitation; it could be only a creative, useful, and enjoyable entertaining activity. The need for a motor rehabilitation that is more tailored to the needs of patients also emerged.Novel technological solutions should be developed and implemented considering the real needs and wants of the ultimate end-users. To this end, most recently, UCD approaches are encapsulated in the development stages to address end-users' real needs and avoid poor final acceptance . The ratIn the case of applications in digital health for rehabilitative purposes, acceptability and usability determine a key role in the final usage of a product, especially in the elderly. The introduction of smart solutions, as VCs, has emerged more and more in the last years to provide personalized home rehabilitation programs for people in need of care. In order to make an impact in this field, the acceptance and effectiveness of such solutions is crucial .The EC-funded project vCare adopted a UCD strategy from the beginning of the evaluation process. Users are included in the creation through participatory design activities meant to engage them to participate actively in the virtual coaching codesign. The main goal is to guarantee a final release fully consistent with users' expectations.Participatory design activities that are described here were meant to engage end-users to participate actively in the virtual coaching design process (codesign process) in order to guarantee a final release fully consistent with users' expectations. The approach is meant to be incremental for a fine-tuning of the prototype: first preliminary impressions were gathered from a demonstration video (end-user's perspective phase), and then the transition to a field study allowed to test the usability of the system coming from direct experience in a controlled environment and the distance between projection and direct use.-user's perspective phase showed globally a positive preliminary perception of the service. All domains of the UEQ scale showed similar evaluations of the system from both the patients' perspective and the healthy subjects' perspective. Evaluations from the two groups seem to suggest that, even if the system is addressed to pathological subjects, it is similarly perceived as attractive, interesting, and innovative from healthy people. Subgroups investigation showed consistent results with the patients vs. control evaluation, except for the novelty domain of the scale. Differences in ratings of this domain may be explained by the formulation of the related UEQ items linked to the absence of a direct experience of the system at this stage. Indeed, novelty is measured in terms of how the user retains captivating and engaging the software design. Since subjects were not directly using the system, they could have had a different perception of these aspects.Results from endFrom these first results correlated with qualitative feedback from the open discussions, some important remarks emerged associated with the user-friendliness of the system. “Attention points” that should be taken into account in refining the solution are related mainly to an easy-to-use interface and software accessibility by elderly people. In such technological solutions, the interaction of the patient with the system should be natural and prompt in order to limit the abandonment of the use. Moreover, strong identification of healthcare professionals operating behind the system is crucial. As long as patients can feel the assistance and follow-up from a real healthcare professional to the rear of the technological infrastructure, sensor intrusiveness is perceived as minimal. To this purpose, specific dashboards for medical doctors, physiotherapists, and neuropsychologists are being integrated in vCare in order to monitor patient's needs and improvements. Finally, although a VC cannot provide the empathy of a human caregiver, the ‘psychological' dimension  should be well-finished to empower the patient to pursue correct habits, similarly to a real career.After a first presentation of vCare through demonstration videos, during the field study phase, a group of patients tested the vCare system for the first time in a ‘controlled environment'.Overall, results from SUS questionnaires were revealed above the threshold reported in the literature to define an excellent usability of the system (SUS score > 80), in both patients and health professionals. None of the subgroups of patients rated the system with a poor usability; lower SUS scores were assigned by stroke survivors, more markedly for cognitive rehabilitation. However, no statistically significant difference in the SUS score was found between groups.Lower SUS score regarding the cognitive activities, while remaining generally good, probably reflects the more critical issues emerged from the semi-structured interview evaluation for the cognitive solution; system bugs, as problems with tablet's touch sensitivity and accuracy, contributed to worse patients' feedbacks together with the need of a greater variability and difficulty of games.Overall, the rehabilitation experience was considered as positive and useful, an interesting way to practice physical activity at home. Indeed, the interview revealed that some patients with PD considered that it is useful to have the vCare rehabilitation system at home to achieve a better follow-up of disease's symptoms and prevent the unavoidable decline due to social distancing required by the COVID-19 pandemic period.The high usability values obtained could be corroborated also by the intuitiveness of the system interaction; progressive confidence with this technology was referred by most of the patients in subsequent sessions, allowing an independent use of it at home without many troubles. Indeed, most of them were confident that they would be able to interact with the system autonomously without further overview, due to the almost ease of use and right level of accessibility with respect to their technological attitude. Only in few cases, further instructions and support were considered necessary; user manuals and/or short demo videos to remind how to use the system would have been appreciated. This result, in particular, seems to satisfy the requirements that emerged from the end-user's perspective phase: easy-to-use interface and natural interaction with the system. Therefore, although not for everyone, this solution could effectively replace conventional therapy, most patients would have been interested in continuing this innovative vCare rehabilitation program at home.Finally, results obtained from the interviews could also explain the reason why motor activity's usability values that close to the maximum level were not achieved. Indeed, patients remarked that some improvements in the system responses and in the accuracy of movement recognition were needed in order to avoid frustration. Moreover, the necessity emerged for the system to be more customized and related to patients' needs; sometimes, a more immersive and realistic game environment with simulation of real-life scenarios and a higher complexity level of the games would have been appreciated in order to stimulate a more constant physical activity. In fact, although some exercises were declared to be more complicated than others, requiring a good level of attention and a positive attitude especially using the impaired limbs, one patient considered that motor games are not excessively tiring.One of the limitations of the work is the low number of the users, however justified by the preliminary and explorative aspect of this investigation. Despite the quantitative analysis proved interesting, due to low number of involved users, the statistical analysis, at this stage, was only aimed at providing additional information without any oversimplification. For this reason, in the discussion section, we have avoided any inference or generalization of the reported results.In fact, a further phase (Pilot Tests Phase) has already been foreseen. On the other hand, we observed a positive patient's attitude in collaborating in the development of a coaching system of which he/she will become a user.end-user Perspective phase) to the examination of the proposed “product”  (field study phase). As strategy to mitigate this risk, both semi-structured interviews that proposed in the two phases were created following UEQ template.During both phases of this work, the collection of qualitative data (semi-structured interviews) was privileged with the aim of maintaining constant that the dialogue with patients and not reducing their participation to a simple parametric evaluation. Another limit is the poor evaluability of the progression of the patient's participation from the speculative analysis of the solution   where the implemented and tested system will be clinically validated at users' homes to measure the impact of the new vCare rehabilitation coaching service. Groups of patients will be enrolled for each clinical site according to specific enrolment criteria and will follow a personalized rehabilitation program with vCare at home during a 6-month period. Acceptability of the solution, clinical improvement, risk reduction, and overall QoL improvement will be deeply investigated and evaluated. Further details about this last phase of clinical validation are presented in Kyriazakos et al. .Future efforts need to greatly extend the demographic, socioeconomic, and cultural reach of the populations addressed, to test whether levels of acceptability are maintained, and if not, how these can be achieved. Finally, future works should incorporate new evidence-based interventions and incorporate them into the platform.The continuity of care in chronic diseases or after acute episodes is often interrupted once the patient has been discharged from the hospital. To fill this gap, the EC-funded project “vCare”  aims to develop a smart solution based on a VC providing personalized home rehabilitation programs for patients affected by stroke, Parkinson's disease, heart failure, and ischemic heart disease. The project incorporates the involvement of final users in each stage of development to create a solution compliant to end-users' needs and preferences.To the current stage of system development, user experience and usability of the platform were tested in a two-fold assessment. Results indicated good ratings of the product and, in general, high level of enthusiasm and curiosity by neurological patients. Indeed, several of them would be glad to use vCare system at home. Moreover, suggestions about possible improvements were gathered from open feedback and discussions.Our result seems to satisfy an easy-to-use interface and an intuitive interaction between users and the developed platform. Consequently, although with some limitations, the proposed solution could be, in the next future, a valid rehabilitative program at home together with standard treatments.Once refined and fine-tuned in the aspects highlighted in the present evaluations, the system will be clinically tested at user's home to measure the real impact of the rehabilitative coaching services.As a matter of fact, users' feedback gathered during the testing phases will be taken into consideration along the development and refinement process in terms of functional optimisation, customization, and further patient's engagement to increase the final acceptance and the vCare use adherence.The datasets recorded and/or analysed during the current study are available from the corresponding author on reasonable request.The studies involving human participants were reviewed and approved by Comitato Etico Milano Area 2. The patients/participants provided their written informed consent to participate in this study.AS, ET, and PT analyzed the data, interpreted the results, and took the lead in writing the manuscript. AS and ET contributed equally to the work. All authors provided critical feedback and helped to shape the manuscript.This work was partially supported by the EC within the vCare project (funded by Horizon 2020 Research and Innovation Programme under the Grant Agreement No. 769807).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Imagery rescripting (ImRs) is increasingly used in cognitive-behavioral therapy (CBT) to change beliefs and meanings about the self associated with negative and traumatic memories. It is quintessentially an imagery intervention that targets the self and autobiographical memory (AM); however, to date most of the research into its effectiveness has focused on symptom alleviation. The mechanisms of change remain unclear. In this article, we outline a narrative identity model of change in ImRs and note the value of the narrative identity literature in helping us understand memory-focused therapeutic interventions.ImRs describes a family of techniques in which patients recall and then imaginatively change a disturbing image/memory. The aims of this imagery manipulation can include any of the following: introducing a new perspective , contextualizing or adding information to the memory that was unavailable at the time , seeing how the memory contributed to negative beliefs or experiences of the self, realizing how the memory contributes to distressing intrusive images, and activating a more understanding and compassionate attitude toward the self. The methods range from unstructured approaches exploring interventions such as bringing the adult self into the memory to structured approaches such as Arntz and Weertman's  three-stencapsulated beliefs”) showed reductions following ImRs. Subsequently published research has examined the effects of ImRs in binge eating disorder , social , and self (constructing and maintaining a sense of self) .–28.direc)  prop propdirerm goals , 32, 34.ews, see , 36; seeews, see ].We also propose that our understanding of ImRs may benefit from literature on the self and personality outcomes of therapy. This literature is relatively limited. A systematic review on self changes in CBT for SAD, for example, concluded that CBT produced significant reductions in negative self-related thoughts and beliefs and significant increases in positive ones . These cBased on the existing literature, our model  proposesPersonality changes may be amplified as individuals link the rescripted memories to other memories, modify further goals, and try to re-establish a sense of coherence in their life story and a sense of self-continuity and unity. They may, for example, reappraise other memories or new experiences in light of the rescripted memories' new meanings. Ultimately, these changes may influence the ways in which the rescripted memories – and potentially similar memories – exert their self and directive functions . In termOur model  takes a Despite these limitations, we think that our model advances our understanding of ImRs. As the need to understand mechanisms of change in therapy becomes more pressing, we believe that it is essential for research into ImRs and similar interventions to recognize the complexity of personality. This may enable us to maximize the effectiveness of these interventions, delineate better when to use them, and identify who might relapse. Psychotherapy is an arena in which individuals make sense of their experiences and construct a coherent narrative identity , 59, 60.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.The open access publication fee was provided by the University of Southampton.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Martins et al. recently published a trial titled “Thrombectomy for Stroke in the Public Health Care System in Brazil”—the RESILIENT trial—in which they randomized 111 patients to receive standard care plus thrombectomy and 110 patients in the control group  –4.One may argue that the results of the trial are not new and, maybe, it was unethical to randomize patients not to receive thrombectomy. However, this study was necessary to show the feasibility of thrombectomy for stroke in a middle-income country. Actually, this is a welcome study that may foster public health managers to approve the routine use of this treatment modality, which could save near 2 million lives a year if expanded globally .This challenge is a worldwide concern, which led the Society of Vascular and Interventional Neurology to launch the Mission Thrombectomy, aiming for a global expanding of thrombectomy to reduce the morbidity and mortality related to stroke. Despite this effort, many organizational restrictions persist, keeping important inequalities and disparities in the access to thrombectomy .The Brazilian health system (SUS) is based on the principle of health as a citizen's right and the state's duty; it therefore relies on the doctrinal principles of universality, integrality, and equity . For insFortunately, the accessibility for stroke care has also improved over the last decade, mainly due to the efforts by the National Stroke Policy Act, which defined the requirements and levels of stroke centers, improved the specific budget for stroke care and rehabilitation, and helped funding training health professionals for stroke interventions . HoweverWith regard to thrombectomy for stroke, the concern will be how to provide universal access to high-tech treatment in a country with such high disparities. The RESILIENT investigators themselves recognize that most of the treating hospitals had only one or two angiography suites for multiple specialties. Besides, different centers contributed different numbers of patients; this demonstrates heterogeneity, even in a controlled setting.It took 17 years from the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group (NINDS)  trial puFuture political and research initiatives should explore ways to expand the accessibility to thrombectomy and reduce its costs. A possible way to accelerate the time from clinical onset of stroke to the endovascular thrombectomy would be exploring the safety and efficacy of treatment under local anesthesia. In low- and middle-income countries, this would allow for wider availability without the constraint related to the routine use of general anesthesia in both adult  and pediIn summary, the RESILIENT trial opens the door for a promising future for stroke care in low- and middle-income countries. However, this future will depend on the translation of scientific evidence to public policies. The scientific community did its part.PH, CM, and RB: conception. GM, MZ, and RB: analysis of data. PH: draft. GM, CM, MZ, and RB: critical review. All authors have final approval of the manuscript and agreement to be accountable for all aspects of the work.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Chronic migraine is a difficult disease to diagnose, and its pathophysiology remains undefined. Its symptoms affect the quality of life and daily living tasks of the affected person, leading to momentary disability. This is a pilot, randomized, controlled, double-blind clinical trial study with female patients between 18 and 65 years old with chronic migraine. The patients underwent twelve mindfulness sessions paired with anodal transcranial direct-current stimulation (tDCS) over the left dorsolateral prefrontal cortex (DLPFC), with current intensity of 2 mA applied for 20 min, three times a week for 4 weeks. In addition, 20 min of mindfulness home practices were performed by guided meditation audio files. A total of 30 participants were evaluated after the treatment, and these were subdivided into two groups—active tDCS and sham tDCS, both set to mindfulness practice. The FFMQ-BR (Five Facet of Mindfulness Questionnaire), MIDAS (Migraine Disability Assessment), and HIT-6 (Headache Impact Test) questionnaires were used to evaluate the outcomes. After the treatment, the active mindfulness and tDCS group showed better results in all outcomes. The sham group also showed improvements, but with smaller effect sizes compared to the active group. The only significant difference in the intergroup analysis was the outcome evaluated by HIT-6 in the post treatment result. Our results provide the first therapeutic evidence of mindfulness practices associated with left DLPFC anodal tDCS with a consequent increase in the level of full attention and analgesic benefits in the clinical symptoms of patients with chronic migraine. Chronic migraine is a primary multifactorial neurological disorder  is a neuromodulatory technique that enables greater pain control and a decrease in the clinical symptoms of migraine, as it can modulate the excitability and excessive cortical neural hyperresponsiveness inherent to this pathology and can be used, both in prophylaxis and in crisis intervention  (NCT04219345). Written and informed consent was obtained from all participants.This study was approved by the Institution's Ethics Committee, conducted in accordance with the 1964 Helsinki Declaration and registered on the Clinical Trials platform  guidelines  . The hidden allocation process was carried out using sequential, numbered, opaque and sealed envelopes. Outcome evaluators, subjects and patients were blinded to the procedures performed.Participants were randomly allocated in a 1:1 ratio to receive tDCS sham or anodic active tDCS in the left DLPFC region, both paired with mindfulness through an online generator , an instrument which assesses variations in mindfulness characteristics, subdivided into five main factors  to assess the participants' mindfulness level , which is an instrument that assesses the inability to perform daily and professional tasks in patients with migraine and that can be applied to people with different educational levels and social backgrounds due to the fact that it is considered easy to be answered Fragoso, . This inThe patients were submitted to 12 treatment sessions, distributed three times a week, for 4 weeks . The dirAt the end of the session, each patient was asked if they felt any adverse effects such as dizziness, tingling, burning, headache, somnolence, and others and the intensity of this sensation .The mindfulness practices were performed by listening to guided audio recorded by an experienced and specialized instructor, and were concurrently carried out with the tDCS application. The audios were later made available via email or WhatsApp, so that the participants could perform alone on days when the associated therapy did not occur. A different audio content was provided each week, totaling 28 days of mindfulness exercises, 12 of which were practiced together with tDCS. The subjects were requested to register the practices on an individual table for monitoring adherence to home exercises. The systematization and theoretical basis of the audio content was chosen from previous studies involving guided mindfulness application  analysis. The sample size was estimated using data from our previous study with tDCS  and the Wilcoxon test for the intragroup comparison . Finally, the occurrence of adverse events was performed with the corresponding descriptive analysis of each event.P-values were adjusted by the Bonferroni method in all statistical analyses, a p-value of < 0.05 was considered significant and the Pearson's effect size “r” was considered as: r ≤ 0.10 small, r = 0.30 medium, and r ≥ 0.50 large.A total of 53 patients with chronic migraine were screened, 30 of whom were eligible to participate in the study and were randomly allocated to both groups. In total, four patients left the study after receiving passive stimulation and three after receiving active stimulation. The reasons for leaving the active group were family problems (one participant) and lack of adaptation and discomfort when performing mindfulness practices (three participants). The reasons in the sham stimulation group were the lack of perceived benefits (one participant) and impossibility to participate in the sessions (two participants). In total, 23 patients successfully completed the study . At the All participants were female, attended formal school for over 8 years, had no associated comorbidities, and there were no reports of smoking or alcoholism. The main demographic and clinical data of the baseline are summarized in Regarding the safety of the procedure used, both groups presented an equivalent amount of adverse effects, all cases considered of mild intensity, having some difference in their clinical presentation , with thU = 98.5, p = 0.29) or post-intervention . Significant results were obtained in both groups regarding the intragroup evaluation, active tDCS  and sham tDCS , with the greatest effect on the active current group.The intergroup comparison regarding the full attention level evaluation of participants (FFMQ-BR questionnaire) did not obtain significant results at both baseline  or at the endpoint  and sham current group , with a larger effect size in the active current group (With respect to the inability to perform daily living activities due to migraine (MIDAS questionnaire), no statistically significant difference was found between groups at baseline , but it did at the end of treatment . The intragroup evaluation was statistically significant for both the active current group  and the sham current group , presenting a larger effect size for the active tDCS, similar to the other outcomes. The comparisons between the outcomes are explained in The intergroup analysis regarding the impact of headache on the participants' quality of life (HIT-6 questionnaire) did not result in a significant comparison of the baseline  and we did not perform specific analyzes with regard to the quantity and type of drug in each of the groups as outcome predictors, which is therefore a limitation. However, we selected participants using stable doses of pain medications and an approximate amount between them for at least 2 months before the intervention. We also asked them not to modify this use during the treatment period.Adherence to home practices of mindfulness was monitored by filling in individual tables with the schedule performed and if there was an interruption with a later restart, as previously instructed. However, some participants claimed to sporadically forget filling in some exercises (maximum of three annotation gaps in the table of four participants), despite having informed that they performed the practice on the non-registration days. Four participants reported difficulty in home training , with three dropouts from the study due to inadequacy to exercise mindfulness. The absence of notes in the table provided can be considered a limitation, since it makes it difficult to assess adherence to this activity to complement the intervention associated with tDCS.Some methodological aspects can also be considered limiting, such as the small size of the groups, which can decrease the statistical power to detect minor effects. In addition, the subjects were recruited from a service specialized within a tertiary institution, so they may not be representative of the general chronic migraine population. Another point would be the limitations of tDCS power found in the literature in relation to intra and interindividual variables  can be useful to refine the design of future studies, thus optimizing the effects of stimulation and providing specific information about the inter-individual differences that may influence tDCS effects on migraine. The inclusion of three more arms in the study  can be useful to provide greater reliability in assessing the synergism of combination therapy and in more accurate conclusions about the placebo effect.Despite the limitations discussed, the results of this study provide the first therapeutic evidence of the practice of mindfulness associated with anodic tDCS of the left DLPFC with its consequent increase in the level of full attention and its analgesic benefits in the clinical symptoms of patients with chronic migraine. It is hoped that this study will encourage further research on the interaction between tDCS and mindfulness training to reduce the negative effects of chronic migraine, including EEG recording, assessment of anxiety and sleep quality.The original contributions presented in the study are included in the article/supplementary materials, further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by Comitê de Ética em Pesquisa—Centro de Ciências da Saúde—Federal of University Paraíba. The patients/participants provided their written informed consent to participate in this study.SA and LP have designed the study and managed all stages of the design and writing process. LP has performed the data analysis and has written the first draft of the manuscript. LL has contributed to the interpretation and review of the data. EA, PB, JS, and JF have operationalized tDCS. LH and AL have written the last draft of the manuscript. All authors have contributed to the revision of the manuscript, read, and approved the submitted version.This study was financed in part by the Coordination for the Improvement of Higher Education Personnel—Brazil (CAPES)—Finance Code 001.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Extensive scientific evidence has shown that prenatal physical activity is a prerequisite for the proper course of pregnancy, fetal development, labour and delivery, and the postpartum period. In 2015, the American College of Obstetricians and Gynecologists published a breakthrough statement that inactivity in pregnancy is risky behaviour. The aim of this paper is to provide answers to the questions concerning who and how should prescribe and conduct exercise programs for pregnant women.Close cooperation between the woman, her obstetric care provider and exercise specialists is necessary to promote exercise in pregnancy. Obstetricians should carefully evaluate women with medical or obstetric complications before starting the exercises. They should also provide women with general information about the benefits of prenatal exercise and the risks of physical inactivity. On the other hand, the design and implementation of the exercise program are tasks for exercise professionals, preferably ones qualified according to the European educational standards for Pregnancy and Postnatal Exercise Specialists.Both empirical observation and scientific research confirm the need to educate obstetric care providers, exercise professionals, and both pregnant women and their families about prenatal physical activity. They all require constantly updated information on how to use exercise to stimulate the positive development of pregnancy, ensure the greatest possible well-being for the future mother, and prepare her for childbirth and the postpartum period. These educational activities should be evidence-based. They must not perpetuate unfounded opinions, often harmful to the woman’s health, on what she should or should not do while exercising during pregnancy. The presented update underlines some pertinent recommendations in this area. Ample scientific evidence showing that prenatal physical activity is a prerequisite for the proper course of pregnancy, fetal development, labour and delivery, and the postpartum period has dramatically changed the approach to this issue , 2. In tet al. . Ea. Ea18]. For the best health benefits, physical activity should be undertaken continuously for several months before conception, and then throughout pregnancy and the postpartum period. Unfortunately, for the first few weeks after becoming pregnant, many women stop exercising or significantly limit physical activity due to fear of miscarriage. Obstetricians often wait until the end of 12 or 13 weeks of gestation to give their patients permission for exercise. Although the risk of spontaneous abortion in the first trimester is about 10% , it is nFor the majority of pregnant women moderate intensity of physical activity is recommended , 5. NeveThe most commonly used tools to monitor prenatal exercise intensity are the scale of Rate of Perceived Exertion (RPE) and the “talk test” . BecauseAlthough abdominal muscle exercises give obvious health benefits including maintaining the correct posture, in pregnancy their performance is often surprisingly and unjustly forbidden. As a combined result of the growing uterus, changes in the curvature of the spine, and the effects of pregnancy hormones, almost 70% of pregnant women experience lower back pain . To minidiastasis recti abdominis. This Latin-derived term denotes the separation of the two rectus abdominis muscles along the white line, a condition present to some extent in the third trimester in 66 to 100% of women [Moreover, both before and during the exercise program, pregnant women should control the condition of their abdomen in terms of of women . If diasIt is still true that other unfounded ideas are transmitted from generation to generation. The need to eliminate running or jumping during pregnancy is one of them. It is an unsubstantiated belief that such activities can lead to miscarriage or premature labour. Certainly, with the development of pregnancy and the growing uterus, it may be necessary to limit high-impact movements. Potentially, they may cause unpleasant bouncing of the pregnant belly or enlarged breasts, aggravate urinary incontinence, or intensify lower back pain. However, the decision to eliminate high-impact movements should be based on the assessment of the well-being of each woman and not be a general rule. Similarly, in most cases there is no need to reduce the training load, for instance in the form of lighter dumbbells or lessened resistance on exercise machines, just because female exerciser is pregnant.Some women are afraid to raise their arms above their heads for fear of miscarriage. This, again, is an unfounded opinion which unnecessarily limits the range of exercises during classes. For a complex exercise program, one should incorporate upper-body movements to activate the whole body, increase the exercise intensity, and improve coordination. Likewise, there is no justification for avoiding frequent changes in direction in pregnancy or making turns, for instance during aerobics or dance classes. Although the centre of gravity of the body, as well as balance and coordination all change during pregnancy, there is no scientific evidence that they increase the risk of collapse or collision during exercise classes compared to the general population.ACOG experts warn that patients who are prescribed prolonged bed rest or restricted physical activity are at risk of venous thromboembolism, bone demineralization, and deconditioning . Severalet al. [In an epidemiological study, Polish women admitted that the lack of knowledge on how to do sports during pregnancy was one of the main reasons why they had limited their physical activity . In ordeet al.  indicateThe above studies prove that educational activities must be systemic. In addition to the development and implementation of the Educational standards for the Pregnancy and Postnatal Exercise Specialist in Europe, work is under way in Poland on a system of qualifications for pre- and postnatal physical activity. In this proposal, qualifications at levels 1 and 2 are directed at obstetricians and midwives to confirm their being prepared for the implementation of simple tasks, such as directing a woman to appropriate activities, recognizing contraindications to physical exertion, recommending simple exercises, etc. The qualifications at level 3 and higher have been developed for exercise professionals and cover specialized knowledge and skills to design and conduct pre- and postnatal exercise programs.Both empirical observations and scientific research confirm the need to educate the public about prenatal exercises. Health and exercise professionals together with the families of pregnant women should support them in starting or continuing their physical activity. Due to common unjustified opinions about the supposedly harmful effects of exercise on the course of pregnancy, this task may be difficult. The correct allocation of assignments is key here: from proper general and obstetric health screening to encouraging women to physical activity by obstetric care providers, to the design and implementation of prenatal exercise programs under the supervision of exercise specialists, preferably qualified according to international educational standards.