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ArticleTitle
Validation of the Italian version of the Movement Disorder Society—Unified Parkinson’s Disease Rating
Scale
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Neurological Sciences
Corresponding Author
Family Name
Antonini
Particle
Given Name
Angelo
Suffix
Division
Author
Organization
Department for Parkinson’s disease, IRCCS San Camillo
Address
Via Alberoni 70, Venice, Italy
Email
[email protected]
Family Name
Abbruzzese
Particle
Given Name
Giovanni
Suffix
Division
Department of Neurosciences, Ophthalmology and Genetics
Organization
Centre for Movement Disorders, University of Genoa
Address
Genoa, Italy
Email
Author
Family Name
Ferini-Strambi
Particle
Given Name
Luigi
Suffix
Division
Organization
Università Vita-Salute San Raffaele
Address
Milan, Italy
Email
Author
Family Name
Tilley
Particle
Given Name
Barbara
Suffix
Division
Organization
University of Texas Health Science Center School of Public Health at Houston
Address
Houston, USA
Email
Author
Family Name
Huang
Particle
Given Name
Suffix
Jing
Division
Organization
University of Texas Health Science Center School of Public Health at Houston
Address
Houston, USA
Email
Author
Family Name
Stebbins
Particle
Given Name
Glenn T.
Suffix
Division
Department of Neurological Services
Organization
Rush University Medical Center
Address
Chicago, IL, USA
Email
Author
Family Name
Goetz
Particle
Given Name
Christopher G.
Suffix
Division
Department of Neurological Services
Organization
Rush University Medical Center
Address
Chicago, IL, USA
Email
Author
Family Name
Barone
Particle
Given Name
Paolo
Suffix
Division
Neurodegenerative Diseases Center
Organization
University of Salerno, Salerno, and IDC-Hermitage-Capodimonte
Address
Naples, Italy
Email
Received
Schedule
11 February 2012
Revised
Accepted
2 May 2012
Abstract
The Movement Disorder Society-sponsored revision of the Unified Parkinson’s Disease Rating Scale (MDSUPDRS) has been available in English since 2008. As part of this process, the MDS-UPDRS organizing team
developed guidelines for development of official non-English translations. We present here the formal process
for completing officially approved non-English versions of the MDS-UPDRS and specifically focus on the
first of these versions in Italian. The MDS-UPDRS was translated into Italian and tested in 377 native-Italian
speaking PD patients. Confirmatory and exploratory factor analyses determined whether the factor structure
for the English-language MDS-UPDRS could be confirmed in data collected using the Italian translation. To
be designated an Official MDS translation,’ the Comparative Fit Index (CFI) had to be ≥0.90 relative to the
English-language version. For all four parts of the Italian MDS-UPDRS, the CFI, in comparison with the
English-language data, was ≥0.94. Exploratory factor analyses revealed some differences between the two
datasets, however these differences were considered to be within an acceptable range. The Italian version of
the MDS-UPDRS reaches the criterion to be designated as an Official Translation and is now available for
use. This protocol will serve as outline for further validation of this in multiple languages.
Keywords (separated by '-')
Parkinson’s disease - MDS-UPDRS - Unified Parkinson’s Disease Rating Scale - Rating scales
Footnote Information
The members of the MDS-UPDRS Italian Validation Study Group are given in the Appendix.
Electronic supplementary material The online version of this article (doi:10.1007/s10072-012-1112-z)
contains supplementary material, which is available to authorized users.
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Neurol Sci
DOI 10.1007/s10072-012-1112-z
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Angelo Antonini • Giovanni Abbruzzese • Luigi Ferini-Strambi •
Barbara Tilley • Jing Huang • Glenn T. Stebbins • Christopher G. Goetz
Paolo Barone • MDS-UPDRS Italian Validation Study Group
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Received: 11 February 2012 / Accepted: 2 May 2012
Ó Springer-Verlag 2012
Abstract The Movement Disorder Society-sponsored
revision of the Unified Parkinson’s Disease Rating Scale
(MDS-UPDRS) has been available in English since 2008.
As part of this process, the MDS-UPDRS organizing team
developed guidelines for development of official nonEnglish translations. We present here the formal process
for completing officially approved non-English versions of
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The members of the MDS-UPDRS Italian Validation Study Group are
given in the Appendix.
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Electronic supplementary material The online version of this
article (doi:10.1007/s10072-012-1112-z) contains supplementary
material, which is available to authorized users.
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A. Antonini (&)
Department for Parkinson’s disease, IRCCS San Camillo,
Via Alberoni 70, Venice, Italy
e-mail:
[email protected]
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Validation of the Italian version of the Movement Disorder
Society—Unified Parkinson’s Disease Rating Scale
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the MDS-UPDRS and specifically focus on the first of
these versions in Italian. The MDS-UPDRS was translated
into Italian and tested in 377 native-Italian speaking PD
patients. Confirmatory and exploratory factor analyses
determined whether the factor structure for the Englishlanguage MDS-UPDRS could be confirmed in data collected using the Italian translation. To be designated an
‘Official MDS translation,’ the Comparative Fit Index
(CFI) had to be C0.90 relative to the English-language
version. For all four parts of the Italian MDS-UPDRS, the
CFI, in comparison with the English-language data, was
C0.94. Exploratory factor analyses revealed some differences between the two datasets, however these differences
were considered to be within an acceptable range. The
Italian version of the MDS-UPDRS reaches the criterion to
be designated as an Official Translation and is now available for use. This protocol will serve as outline for further
validation of this in multiple languages.
G. Abbruzzese
Department of Neurosciences, Ophthalmology and Genetics,
Centre for Movement Disorders, University of Genoa,
Genoa, Italy
Keywords Parkinson’s disease MDS-UPDRS
Unified Parkinson’s Disease Rating Scale Rating scales
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L. Ferini-Strambi
Università Vita-Salute San Raffaele, Milan, Italy
Introduction
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B. Tilley J. Huang
University of Texas Health Science Center School of Public
Health at Houston, Houston, USA
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G. T. Stebbins C. G. Goetz
Department of Neurological Services,
Rush University Medical Center,
Chicago, IL, USA
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P. Barone
Neurodegenerative Diseases Center, University of Salerno,
Salerno, and IDC-Hermitage-Capodimonte, Naples, Italy
After its introduction in the 1980s, the Unified Parkinson’s
Disease Rating Scale (UPDRS) has become the gold
standard clinical rating scale for Parkinson’s disease (PD)
[1, 2]. In 2008, a new Movement Disorder Society (MDS)sponsored revision of the UPDRS, known as the MDS
UPDRS, successfully passed clinimetric testing with high
internal consistency and reliable factor structures for each
part of the scale [3].
The new MDS-UPDRS comprises four parts: Part I
evaluates non-motor experiences of daily living
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ORIGINAL ARTICLE
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Methods
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Translation of the MDS-UPDRS
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The MDS-UPDRS was translated into Italian by a team of
PD expert investigators in Italy and was then back-translated by colleagues fluent in English and Italian and not
involved in the original translation. This back-translation
was then reviewed by a team of US experts (Glenn Stebbins, Christopher Goetz, Nancy LaPelle, and Barbara
Tilley) who had been involved in the development of the
original American version.
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Cognitive pretesting
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Cognitive pretesting using a structured interview format
was performed to evaluate specific items of the MDSUPDRS in terms of task difficulty for examiner and
respondent, and respondent interest, attention span, discomfort, and comprehension. Items were selected for
cognitive pretesting when the observed differences were
between the back-translated Italian version and the English
version. In addition, questions that were identified in cognitive testing of the American version were also tested [4].
Questions included in cognitive pretesting were MDSUPDRS Parts 1.2 Hallucinations and Psychosis; 1.6 Features Of Dopamine Dysregulation Syndrome; 1.10 Urinary
Problems; 2.13 Freezing; 3.12 Postural Stability; 3.17 Rest
Tremor Amplitude; 4.1 Time Spent With Dyskinesias; and
4.2 Functional Impact Of Dyskinesias. Based on the results
of the initial cognitive pretesting, other round(s) of
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Testing of the Italian version
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A total of 17-experienced Italian movement disorder specialists were recruited to examine native-Italian speaking
PD patients who had provided informed consent. Data
without patient names or medical record numbers were
transferred to the analytic team via a secure website. The
patient sample size for the translation study was based on
the statistical need for a minimum of five subjects per item
of the questionnaire [5]. Thus, as there are 65 items on the
MDS-UPDRS, a sample of at least 325 patients was
required. Any participants with missing values within a
part were deleted from analysis of that part only.
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Factor analysis
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Confirmatory and exploratory factor analyses were performed using M-plus, Version 6.1 (for categorical analyses). An unweighted least squares (ULS) approach to factor
estimation that minimizes the sum of squared differences
between observed and estimated correlation matrices not
counting diagonal elements was used. In addition, an
orthogonal VARIMAX rotation that constrains the factors
to be uncorrelated was used to assist in interpretation of
factors. For Part III, Factor 6, all factor loadings for the
Italian data were negative (in the American data, Factor 2
had negative signs for all factor loadings). This is an artifact of the quadrant of the rotation. A factor analysis using
a standardized CF-VARIMAX rotation, equivalent to the
VARIMAX rotation, gave similar results but without the
minus signs. Since the VARIMAX rotation is more widely
used, we report the VARIMAX rotation without the (-)
signs.
A confirmatory factor analysis (CFA) was used to
determine if the factor structure for the English language
MDS-UPDRS [3] could be confirmed in data collected
using the Italian translation. The CFA was conducted
separately for MDS-UPDRS Parts I–IV with the Italian
data constrained to fall into the factors defined in the
English language data and the CFA results were evaluated
based on the Comparative Fit Index (CFI). To establish a
successful translation and to designate that translation as an
‘Official MDS translation’ of the MDS-UPDRS, the CFI
for each Part (I–IV) of the translated MDS-UPDRS had to
be 0.90 or greater relative to the English language version.
In the original factor structure report, three dopamine
dysregulation syndromes (DDSs) had an item loading of
0.49 on Factor 1 of Part I. However, in the re-running of
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translation and back translation and cognitive pretesting
could be required. Once any issues identified during cognitive pretesting were addressed, the final translation was
obtained.
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(nM-EDL), Part II evaluates motor experiences of daily
living (motor-EDL), Part III evaluates motor function, and
Part IV evaluates motor fluctuations and dyskinesia. As
with the previous version, scores are rated by a mix of both
the physician and patient. Six of the 13 items in Part I
(those dealing with complex behaviors) and all items in
Part IV covering fluctuations and dyskinesia involve raterled interviews of the patient or caregiver. The remaining
questions in Part I and all items in Part II are answered with
a patient/caregiver questionnaire without direct input from
the rater, and Part III involves objective examination by the
rater for all items [3]. The MDS-UPDRS was specifically
designed to be less ambiguous than its predecessor and the
significant patient/caregiver involvement means that it is
vital that they understand the questions asked of them,
preferably in their mother tongue. In order to establish a
successful translation and designate non-English language
versions as an ‘Official MDS translation,’ the MDS has set
a strict protocol and criteria for testing. We present here the
Italian version of the MDS-UPDRS.
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Results
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Cognitive pretesting
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A total of 10 PD patients were interviewed as part of the
cognitive pretesting step. One of the 10 patients interviewed had difficulty comprehending one item on Part 1 of
the Italian MDS-UPDRS (question 1.2 ‘‘Hallucinations and
psychosis’’). Neither patients nor their examiners identified
other difficulties. A second round of cognitive pre-testing
was completed by three PD patients after a modification of
the Italian version of the latter question. No difficulties
were identified with question 1.2 (Hallucinations and psychosis) or any other item on this second round of testing.
The modified version of the scale was approved as the
Official Working Draft of the Italian MDS-UPDRS for
testing in a larger group of patients with PD.
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Testing of the Italian version of the MDS-UPDRS
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In total, 377 native Italian-speaking PD patients were
examined by 16-experienced movement disorder specialists using the Italian translation of the MDS-UPDRS. All
patients fulfilled Brain Bank diagnostic criteria for probable PD. Patient demographic characteristics are given in
Table 1.
For all four parts of the Italian MDS-UPDRS, the CFI,
in comparison with the English-language version, was 0.94
or greater and thus the pre-specified factor structure was
confirmed in the Italian data set (Table 2). Moreover, the
Patients (n = 378)
Ethnicity (%)
Non-hispanic white
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Other
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Gender (%)
Male
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Female
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Age (years, mean ± SD)
H&Y stage
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Table 1 Baseline characteristics
64.5 ± 10.3
2.1 ± 0.7
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the analysis for the current program, the same item had an
item factor loading of only 0.19, falling outside the
acceptable range to be identified with any factor in the
scale. Therefore, the CFIs for the Italian translation versus
the English language version were calculated both with and
without the DDS item.
An exploratory factor analysis (EFA) for the Italian
version of MDS-UPDRS Parts I–IV using the same factor
analytic approach as for the confirmatory factor analysis
but without constraining the factors to follow a pre-specified factor structure was also performed. Separate SCREE
plots were used in addition to the assessment of clinical
interpretability of remaining factors to choose the cut-off
for the number of factors to retain for each MDS-UPDRS
part. The screen plot is a scatter plot of eigenvalues ranked
against the amount of scale variance accounted for by each
eigenvector. The number of factors can be defined by the
number of eigenvectors that independently account of a
significant amount of variance [6]. Once the factors were
chosen, an item was retained in a factor if the factor
loading for the item was C0.40.
Years since PD diagnosis (mean ± SD)
7.1 ± 5.6
Years of education (mean ± SD)
9.6 ± 4.4
overall CFIs for the English language version and the
Italian version with or without the DDS item reached the
criterion of CFI C0.90, showing that the Italian version of
the MDS-UPDRS meets the requirements for designation
as an Official Translation.
Exploratory factor analyses revealed some differences
between the Italian and English language datasets. For Part
I, in contrast to the English language version of the MDSUPDRS, Cognitive impairment loaded on Factor 2 instead
of Factor 1. In Part II, 3 of 13 items loaded differently in
the Italian version in comparison to the English version. In
Part III, 3 of 33 items loaded differently between the two
versions. Given the variability of factor estimates and the
smaller sample size used in the Italian version, the analytic
team considered these differences within an acceptable
range.
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Discussion
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In order for the MDS-UPDRS to fully replace its predecessor, the UPDRS version 3, [2] as the international gold
standard tool for the assessment of PD patients, it is vital
that properly tested translations are made available for use
in non-English speaking countries. The Italian version of
the MDS-UPDRS presented here reaches the criterion to be
designated as an Official translation of the MDS-UPDRS
and as such is now available for use in clinical studies.
The Italian dataset shared a common factor structure
with the English language dataset based on the high CFIs
for all Parts of the MDS-UPDRS. Isolated item differences
in factor loadings were identified, but the overall factor
structure of the Italian version was consistent with that of
the English language version confirming its suitability for
use. Since this study was conducted, a DVD-based teaching
program that covers the four parts of the scale has become
available with visual and verbal (English language)
instructions for the uniform application [7]. It is planned
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Table 2 Confirmatory factor analysis model fit
Part I: Non-motor aspects of experiences of daily living (a 2-factor model)
Italian
CFI = 0.94, RMSEA = 0.07 (374 patients)
English language
CFI = 0.96, RMSEA = 0.06 (849 patients)
Part II: Motor aspects of experience of daily living (a 3-factor model)
Italian
CFI = 0.98, RMSEA = 0.09 (369 patients)
English language
CFI = 0.97, RMSEA = 0.09 (851 patients)
Part III: Motor examination (a 7-factor model)
CFI = 0.94, RMSEA = 0.08 (363 patients)
CFI = 0.95, RMSEA = 0.07 (801 patients)
Part IV: Motor complications (a 2-factor model)
CFI = 1.00, RMSEA = 0.06 (374 patients)
English language
CFI = 1.00, RMSEA = 0.04 (848 patients)
CFI comparative fit index, RMSEA root mean square error of approximation
necessarily recruit centers in countries where official translations are available, so this effort has very practical implications for future patient and research programs.
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Acknowledgments The authors wish to acknowledge all the
investigators and patients who took part in this translation. Editorial
assistance (editing and referencing) was provided by Anita ChadhaPatel PhD, who was supported by an unrestricted grant from the
Neureca Foundation for movement disorders, Milan, Italy.
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that this teaching program will also be translated into different languages and that this will further encourage
international consistency of rating with this important new
tool.
The Italian version of the MDS-UPDRS is the first officially approved non-English translation. The global program
now includes two other completed translations (Spanish and
Estonian) in statistical review and other language teams are
organized for Chinese, Dutch, French, German, Hebrew,
Japanese, Korean, Russian, Slovakian and Thai versions.
Other language teams are encouraged to organize and participate (email contact: CG Goetz,
[email protected]).
Large-scale clinical trials using the MDS-UPDRS will
See Table 3
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Table 3 MDS-UPDRS Italian Validation Study Group
Investigators
Affiliation
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Monica Bandettini di
Poggio
Department of Neurosciences, Ophthalmology and Genetics, Centre for Movement Disorders, University of Genoa,
Genoa, Italy
Giovanni Fabbrini
Department of Neurology and Psychiatry, Sapienza University of Rome
Flavio Di Stasio
Michele Tinazzi
Tommaso Bovi
Silvia Ramat
Sara Meoni
Gianni Pezzoli
Margherita Canesi
Paolo Martinelli
Department of Neurology and Psychiatry, Sapienza University of Rome
Dipartimento di Scienze Neurologiche, Neuropsicologiche, Morfologiche e Motorie, Università di Verona
Dipartimento di Scienze Neurologiche, Neuropsicologiche, Morfologiche e Motorie, Università di Verona
Department of Neurosciences, University of Florence
Department of Neurosciences, University of Florence
Parkinson Institute, Istituti Clinici di Perfezionamento, Milan, Italy
Parkinson Institute, Istituti Clinici di Perfezionamento, Milan, Italy
Dipartimento Scienze Neurologiche Università di Bologna Italy
Cesa Lorella Maria
Scaglione
Dipartimento Scienze Neurologiche Università di Bologna Italy
Aroldo Rossi
Azienda Ospedaliera - Università di Perugia, Perugia (Italy)
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Italian
English language
Nicola Tambasco
Azienda Ospedaliera - Università di Perugia, Perugia (Italy)
Gabriella Santangelo
Department of Psychology, Second University of Naples, Caserta and IDC Hermitage Capodimonte, Naples
Marina Picillo
Department of Psychology, Second University of Naples, Caserta and IDC Hermitage Capodimonte, Naples
Letterio Morgante
Dipartimento di Neuroscienze, Scienze Psichiatriche ed Anestesiologiche, Universita’ di Messina
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Investigators
Affiliation
Francesca
Morgante
Dipartimento di Neuroscienze, Scienze Psichiatriche ed Anestesiologiche, Universita’ di Messina
Neurology Unit University Hospital S.Annna Ferrara, Italy
MariaChiara Sensi
Neurology Unit University Hospital S.Annna Ferrara, Italy
Manuela Pilleri
Department for Parkinson disease, IRCCS San Camillo Venezia
Roberta Biundo
Department for Parkinson disease, IRCCS San Camillo Venezia
Giampietro
Nordera
Casa di Cura Villa Margherita, Arcugnano (Vicenza) Italy
Antonella Caria
Casa di Cura Villa Margherita, Arcugnano (Vicenza) Italy
Claudio Pacchetti
Parkinson’s Dis. and Mov. Dis. Unit, Fondazione Istituto Neurologico Nazionale ‘‘C. Mondino’’, IRCCS,
Roberta Zangaglia
Parkinson’s Dis. and Mov. Dis. Unit, Fondazione Istituto Neurologico Nazionale ‘‘C. Mondino’’, IRCCS,
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Rocco Quatrale
Leonardo Lopiano
Università degli Studi di Torino, Dipartimento di Neuroscienze, SCDU Neurologia 4
Maurizio Zibetti
Università degli Studi di Torino, Dipartimento di Neuroscienze, SCDU Neurologia 4
Mario Zappia
Dipartimento di Neuroscienze U.O.C. di Neurologia - Clinica Neurologica dell’Università degli Studi di Catania, Catania
(Italy)
Alessandra
Nicoletti
Dipartimento di Neuroscienze U.O.C. di Neurologia - Clinica Neurologica dell’Università degli Studi di Catania, Catania
(Italy)
Aldo Quattrone
Dipartimento di Scienze Mediche dell’Università degli Studi Magna Graecia, Catanzaro
Maria Salsone
Dipartimento di Scienze Mediche dell’Università degli Studi Magna Graecia, Catanzaro
Gianni Cossu
S.C. di Neurologia - A.O. ‘‘G. Brotzu’’ Cagliari
Daniela Murgia
S.C. di Neurologia - A.O. ‘‘G. Brotzu’’ Cagliari
Alberto Albanese
Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano
Francesca Del
Sorbo
Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano
ED
Author Proof
Table 3 continued
References
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Journal : Large 10072
Dispatch : 12-5-2012
Pages : 5
Article No. : 1112
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MS Code : NEUS2171
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