The DriveSim clinical trial investigates a dynamic driving simulator designed to train and assess functional motor and cognitive skills in individuals with neurological disorders. The study addresses a critical need in current rehabilitation practice, where maintaining patient engagement and providing ecologically valid training environments are essential yet challenging. Neurological conditions such as stroke, Parkinson's disease, amyotrophic lateral sclerosis and mild cognitive impairment often result in deficits in balance, proprioception, coordination, attention and motor planning, all of which critically affect daily functioning and driving ability. The novelty of this study lies in the integration of a three-degree-of-freedom motion platform with active steering, customizable haptic and inertial feedback, and adaptive task modules in a virtual urban scenario. This enables controlled, multisensory rehabilitation sessions that combine motor, vestibular and cognitive stimuli in a single system. The primary objective of the trial is to evaluate the safety, usability and feasibility of the DriveSim platform in both healthy individuals and patients with neurological impairment. Secondary objectives include assessing its impact on postural control, trunk and head stability, upper and lower limb motor performance, cognitive functions, perceived stress and fatigue, and quality of life. The study also aims to support the development of adaptive software capable of automatically adjusting task difficulty based on patient performance. By integrating functional tasks such as slalom, speed control, line keeping and reaction tests with customizable sensory feedback, this research has the potential to enhance the ecological validity of rehabilitation and to provide individualized motor-cognitive training. The expected outcome is a more engaging, adaptable and measurable rehabilitation pathway that may improve functional independence and support safer driving-related abilities in neurological populations.

Neurological conditions such as stroke, Parkinson's disease, amyotrophic lateral sclerosis and mild cognitive impairment are among the leading causes of long-term disability worldwide. These disorders profoundly affect motor coordination, postural stability, sensory integration, executive function and attention, with direct consequences on daily activities and overall independence. In current healthcare practice, rehabilitation is essential to maintain or recover functional abilities, but traditional interventions often lack ecological validity, offer limited multisensory stimulation and rely on repetitive, non-engaging exercises. As a result, there is a growing need for innovative rehabilitation tools capable of delivering realistic, quantifiable and cognitively stimulating training. State-of-the-art rehabilitation increasingly integrates technology to enhance patient interaction, measure performance and personalize the training load. Despite this progress, most existing systems do not combine dynamic body perturbation, interactive cognitive tasks and functional motor activities within a controllable scenario. Multisensory integration, which is essential for safe mobility and driving-related functions, remains insufficiently addressed in conventional therapy. This limitation is particularly evident when training tasks that require simultaneous postural control, visuospatial skills, rapid reaction, decision-making and coordinated use of upper and lower limbs.

The DriveSim Rehab platform was conceived to fill this gap by providing a dynamic three-degree-of-freedom driving simulator equipped with active steering, configurable inertial feedback and a customizable virtual urban environment. Its multisensory nature enables the delivery of controlled proprioceptive, visual and motor challenges that mirror real-world demands while maintaining a safe clinical setting. This approach supports a more engaging and functionally meaningful form of rehabilitation, while enabling precise quantitative monitoring of motor and cognitive performance. The rationale of the study is to evaluate whether DriveSim Rehab can be safely and effectively integrated into rehabilitation pathways for individuals with neurological disorders. The primary objective is to assess the safety, usability and feasibility of the system during its use both in healthy subjects and in patients affected by stroke, Parkinson's disease, amyotrophic lateral sclerosis and mild cognitive impairment. These parameters are essential to determine whether the technology can be introduced into routine clinical practice without risk and with adequate user acceptance. Secondary objectives aim to determine the potential rehabilitative value of the platform. Specifically, the study evaluates its impact on head and trunk control, upper and lower limb motor performance, cognitive functions (including attention, visuospatial abilities and executive functions), perceived stress and fatigue, and quality of life. Additionally, the study supports the creation and validation of adaptive software capable of automatically adjusting task difficulty based on real-time patient performance, with the goal of personalizing treatment intensity and maximizing therapeutic efficacy. By integrating dynamic proprioceptive stimulation, interactive cognitive tasks and functional motor actions within a realistic driving simulation, DriveSim Rehab offers a novel rehabilitative paradigm that could significantly enhance patient engagement and functional outcomes. Its implementation in clinical practice has the potential to support greater independence, improve multisensory integration and provide clinicians with objective metrics to optimize rehabilitation strategies in neurological populations.

METHODS The study is designed as a single-group, multicenter interventional clinical investigation aimed at evaluating the safety, usability and feasibility of the DriveSim Rehab platform in both healthy subjects and individuals with neurological disorders. According to the protocol, the study includes a total sample of 60 participants: 20 healthy volunteers and 40 patients diagnosed with stroke, Parkinson's disease, amyotrophic lateral sclerosis or mild cognitive impairment. All participants undergo a structured assessment and a predefined sequence of rehabilitation exercises using the DriveSim system within a controlled clinical environment. Since the study does not involve comparison with a control group or the use of blinding, all participants receive the same intervention. The treatment consists of a set of functional driving-related tasks performed on the DriveSim dynamic simulator, which integrates a three-degree-of-freedom motion platform, active steering, inertial feedback and an immersive virtual urban scenario. Exercises include slalom, line keeping, obstacle avoidance, reaction-time tasks, speed modulation, head and trunk control challenges, upper-limb steering tasks and coordinated lower-limb movements. Each session also enables collection of kinematic and cognitive performance indicators through instrumented software modules.

The primary endpoints include safety (absence of adverse events or technical issues), feasibility (ability to complete the protocol) and usability (participant-reported experience). Secondary endpoints assess performance in postural control, trunk and head stability, limb motor execution, cognitive tasks (attention, visuospatial function and executive components), perceived stress and fatigue, and health-related quality of life. The protocol specifies the use of descriptive statistics and comparative analyses across sessions to quantify performance changes and to evaluate consistency, reaction times and variability in kinematic measures.

Inclusion Criteria:

• Patients: adults aged 18 to 80 years.
• Patients: confirmed diagnosis of one of the following chronic neurological conditions: stroke, Parkinson's disease, amyotrophic lateral sclerosis (ALS), or mild cognitive impairment (MCI).
• Patients: able to understand and follow study procedures and provide informed consent.
• Healthy volunteers: adults aged 18 to 65 years.
• Healthy volunteers: able to understand and follow study procedures and provide informed consent.
• Healthy volunteers: rehabilitation staff members from the participating centers.

Exclusion Criteria:

• Patients: severe psychiatric disorders or cognitive disorders that impair the ability to complete cognitive tests and self-report questionnaires.
• Patients: unable to provide informed consent.
• Patients: moderate to severe cognitive impairment, defined as an ECAS score below 81.92 in participants with ALS or a Raven's Matrices score below 18.36 in participants with mild cognitive impairment.
• Patients: neurological or physical conditions that significantly limit lower-limb use and prevent standing on the platform, including lower-limb muscle strength of 3 or less on the Medical Research Council (MRC) scale.
• Patients: body weight greater than 100 kg.
• Patients: current or recent participation, within the last 3 months, in other rehabilitation programs or interventions that could affect study results.
• Patients: alcohol or substance dependence that could compromise safety during training sessions.
• Patients: unstable health conditions that could make use of the DRIVESIM and/or head-mounted display unsafe or inappropriate, such as severe cardiovascular disease, severe respiratory disease, or other unstable medical conditions.
• Healthy volunteers: health conditions that could make use of the DRIVESIM and/or head-mounted display unsafe or inappropriate, such as severe cardiovascular disease, severe respiratory disease, or other unstable medical conditions.
• Healthy volunteers: any motor disability.