## 4 Discussion  
While WNV is often asymptomatic, its neuroinvasive form can lead to severe, long-term cognitive and neuromuscular deficits [3; 11; 16]. Nevertheless, comprehensive studies on rehabilitation for these patients have been lacking. This study represents the first comprehensive investigation in Italy into the rehabilitation needs of patients affected by WNND. The cohort included 29 subjects, a notable proportion of whom were over 75 years old, presenting a range of comorbidities such as hypertension, type II diabetes, arteriopathies, and concurrent neoplastic conditions. Despite showing significant independence in ambulation and ADL before their acute phase, the combination of advanced age and diverse comorbidities highlighted increased needs for rehabilitation. Advanced age is often associated with reduced physiological reserve and slower recovery rates [17]. Elderly patients generally face a greater decline in muscle mass, strength, and functional capacity, which can be further aggravated by the severity of WNND. Additionally, comorbidities complicate the recovery process by impairing cardiovascular health, diminishing physical endurance, and delaying healing [4]. These factors contribute to the increased rehabilitation needs and longer treatment durations observed in older adults. Effective rehabilitation in this population requires a more intensive and extended approach to address both the direct impact of WNND and the challenges imposed by their pre-existing conditions [4]. The significant variability in hospitalization, ranging from 7 to 168 days with a median of 20 days, and rehabilitation durations observed in this study could not be correlated with factors such as age, severity of WNND, or comorbidities. This suggests that other individual patient factors, such as the heterogeneous progression of WNND, may influence these durations. Similarly, the initiation and duration of rehabilitation varied widely, with \begin{table}
\begin{tabular}{c c} \hline \hline
**Type of Rehabilitation Protocol** & **Number of Patients (Percentage of** \\  & **Total Population)** \\ \hline Prevention of bed-related complications & 22 (75.86\%) \\ \hline Maintenance of muscle tone-trophism and & 4 (13.79\%) \\ muscle strengthening & 2 (6.90\%) \\ \hline Recovery of postural changes and transfers & 3 (10.34\%) \\ \hline Balance and gait training & 5 (17.24\%) \\ \hline Interventions for dysphagia (diet modification, & 2 (6.90\%) \\ compensatory posture, etc.) & \\ \hline \hline \end{tabular}
\end{table} 
Table 3: Rehabilitation protocols prescribed. rehabilitation commencing as early as 1 day into hospitalization and lasting up to 88 days until discharge or death. In our cohort, rehabilitation was initiated in the acute setting, with an assessment conducted within the first few days of hospitalization in the majority of cases. In our population, the rehabilitative intervention began on the same day as the PMR evaluation. An early initiation of rehabilitation during acute care should be recommended to prevent complications associated with WNND [4; 18; 19]. Therapies were adapted according to the ongoing evaluation of the patients' progress, with modifications made to address evolving needs and limitations throughout the hospitalization period. Overall, patients in our study showed impairments in muscular strength and hypotonia, which contributed to difficulties in mobility and increased susceptibility to prolonged bed rest and limited mobilization. These factors can exacerbate muscle atrophy, limit joint range of motion, and predispose subjects to complications like pulmonary thromboembolism and skin ulcers [20; 21]. Therefore, a key element of the rehabilitation project for these patients was the prevention of bedridden complications and the maintenance of muscle tropism [22; 23; 24; 25]. In addition to assessing predominantly motor aspects, attention was directed towards swallowing and respiratory function. Seven subjects exhibited respiratory insufficiency, necessitating tracheostomy in three cases.