## 4 Discussion  
Upper limb impairment in PwMS is often under-recognized, even if it is related to performing everyday activities that are crucial for a patient to maintain their quality of life and participation in daily activities [11; 38]. For this reason, necessary is necessary to implement and develop effective rehabilitation strategies. This evidence-based review aimed to systematically report the state-of-the art on clinical applications and the effectiveness of robotic-assisted upper limb rehabilitation in PwMS. So far, four robotic devices have been tested in PwMS: two end-effectors (Braccio di Ferro, HapticMaster), a passive gravity-supported exoskeleton (Armec Spring), and a hand-robot (Amadeo). Both the HapticMaster and Armec Spring training movements were tested in a 3D virtual environment. The end-effector, called Braccio di Ferro, was tested in two RCTs [29; 33], one randomized crossover study [35], and one case series [36]. The adaptive-type robotic therapy for the upper limbs was feasible in PwMS and was helpful in improving manual dexterity [35; 36] even though no clear conclusion has been made on the best approach to improve motor coordination in patients with cerebellar deficits [35]. Furthermore, [PERSON] et al. demonstrated in a later study that a robotic training protocol that includes reaching tasks and object manipulation may improve movements that involve the grasping function compared to a training protocol that only provides reaching tasks [33]. A recent paper [29] used this device to compare robot-assisted training based on a haptic or sensorimotor exercise in an 8-session protocol (2 per week). Patients in the haptic group had to counteract incoordination and weakness when interacting with a virtual mass-spring system against a \begin{table}
\begin{tabular}{c c c c c c c c c c c c c c} \hline \hline
**Author, Year** & **Q1** & **Q2** & **Q3** & **Q4** & **Q5** & **Q6** & **Q7** & **Q8** & **Q9** & **Q10** & **Q11** & **Q12** & **Q13** & **Q14** & **Q15** & **Q16** & \begin{tabular}{c} **AMSTAR** \\ **2 Score** \\ \end{tabular} \\ \hline \multirow{2}{*}{\
\begin{tabular}{c} [PERSON] \\ et al., 2016 \\ \end{tabular} } & \multirow{2}{*}{Y} & \multirow{2}{*}{N} & \multirow{2}{*}{N} & \multirow{2}{*}{PY} & \multirow{2}{*}{Y} & \multirow{2}{*}{Y} & \multirow{2}{*}{N} & \multirow{2}{*}{PY} & \multirow{2}{*}{N} & \multirow{2}{*}{N} & \multirow{2}{*}{N} & \multirow{2}{*}{N} & \multirow{2}{*}{N} & \multirow{2}{*}{N} & \multirow{2}{*}{N} & \multirow{2}{*}{NMC} & \multirow{2}{*}{Y} & \multirow{2}{*}{
\begin{tabular}{c} Critically \\ low \\ quality \\ \end{tabular} } \\ \hline \hline \end{tabular}
\end{table} 
Table 2: Quality assessment of the RCT studies that were included using the PEDro Checklist. \begin{table}
\begin{tabular}{c c c c c c c c c c c c c c} \hline \hline
**Author, Year** & **Q1** & **Q2** & **Q3** & **Q4** & **Q5** & **Q6** & **Q7** & **Q8** & **Q9** & **Q10** & **Q11** & **Q12** & **Q13** & **Q14** & **Q15** & **Q16** & \begin{tabular}{c} **AMSTAR** \\ **2 Score** \\ \end{tabular} \\ \hline \hline \multirow{2}{*}{\
\begin{tabular}{c} [PERSON] \\ et al., 2016 \\ \end{tabular} } & \multirow{2}{*}{Y} & \multirow{2}{*}{N} & \multirow{2}{*}{N} & \multirow{2}{*}{PY} & \multirow{2}{*}{Y} & \multirow{2}{*}{Y} & \multirow{2}{*}{N} & \multirow{2}{*}{PY} & \multirow{2}{*}{N} & \multirow{2}{*}{N} & \multirow{2}{*}{NMC} & \multirow{2}{*}{N} & \multirow{2}{*}{N} & \multirow{2}{*}{NMC} & \multirow{2}{*}{Y} & \multirow{2}{*}{
\begin{tabular}{c} Critically \\ low \\ quality \\ \end{tabular} } \\ \hline \hline \end{tabular}
\end{table} 
Table 3: Quality assessment of the systematic review that was included using the AMSTAR 2 criteria. resistive load. Instead, subjects in the sensorimotor group performed reaching movements under visual control. This study showed that haptic protocol proved to be slightly superior (without between-group differences) to sensorimotor treatment in improving upper limb dexterity. This could be related to amelioration in upper limb and shoulder coordination.