## 4 Discussion  
The aim of this study is to describe the effects on the range of motion, muscle tone and functionality of the paretic upper limb, particularly the hand, when Gloreha Sinfonia combined with conventional therapy was used for rehabilitation treatments in a pediatric stroke patient. The results revealed an improvement in FMA-UE, a significant reduction in RMSE and a significant improvement in Peak Performance. To the best of our knowledge, this is the first study using Gloreha Sinfonia in pediatric strokes. Previous rehabilitation studies on pediatric stroke patients were mostly dedicated to the robotic treatment of the proximal portion of the upper limb, while there are still very few studies on the distal extremity, especially the hand. Gloreha Sinfonia allows the performance of tasks that combine the activity of the entire upper limb. In fact, unlike other robots designed exclusively for shoulder and elbow movements, Gloreha permits the improvement of distal control through the implementation of exercises focused on the use of hands combined with the involvement of the entire upper limb, reproducing activities of daily living. As other studies have previously mentioned, when a patient uses the distal part of the paretic upper limb, at the same time, the proximal segment is also trained, albeit the upper arm is supported or restrained in the distal group [27]. Furthermore, Gloreha Sinfonia is well suited for use in combination with other traditional rehabilitation activities because it can integrate rehabilitation treatments with highly stimulating and interactive exercises for patients. Our results show an important enhancement in FMA-UE, with values that proceed from 34/66 to 49/66 between T0 and T1; they indicate an overall improvement of the upper limb due to a clinical advance both in the shoulder district, implemented thanks to reaching exercises, and to the hand control, achieved thanks to manipulation exercises. These results were significantly higher than the minimal clinically important difference (MCID) seen in adults by [PERSON] et al. [28], but it is not possible to make a comparison with a pediatric population, because their MCID is not present in the literature. In addition, FMA-UE results are in line with ADL records, which report improvements in activities of daily life due to a better use of the upper limb. From Figure 4, it is evident that the child significantly improved her capacity of reaching force peaks and holding force levels. Furthermore, the results show that force control and modulation capability significantly increased after treatment. We know from the girl's parents that she has reported a psycho-emotional improvement and presented new interest in socializing with other children without fear of being judged and perceived less pronounced motor deficits and less disability at the end of therapy. This statement can be considered as another positive effect of the combined (robot + conventional rehab therapy) and continuative therapy. It is important to underline that the girl never complained of pain, demonstrating a good ad safe adaptability of the robot with respect to the child. Another aspect that makes this robot an interesting tool in pediatric applications is the possibility of performing specific repetitive task-oriented exercises, placed in the form of playing a videogame; as already reported, robot-mediated therapy in children with acquired  
Figure 4: Boxplots of RMSE and Peak Performance for session 1 (T0) and session 2 (T1). or congenital brain injury appears to be beneficial: enhancing motivation and improving perception, it incorporates the advantages of the enjoyable game-like experience [15; 29]. Furthermore, the use of a virtual and motivational environment in which the patient has immerged has a positive effect to facilitate motor and sensory and cognitive relearning by stimulating the patient to challenge himself to perform better and to obtain a higher score in the game. Moreover, as recorded also by [PERSON] et al.