Multiple sclerosis is a slowly progressive disease, immunosuppressants and other drugs can delay the progression and progression of the disease, but the most patients will be left with varying degrees of neurological deficit symptoms, such as muscle weakness, muscle spasm, ataxia, sensory impairment, dysphagia, cognitive dysfunction, psychological disorders, etc. From the early stage of the disease to the stage of disease progression, professional rehabilitation treatment can reduce the functional dysfunction of multiple sclerosis patients, improve neurological function, and reduce family and social burdens. With the development of various new rehabilitation technologies such as transcranial magnetic stimulation, virtual reality technology, robot-assisted gait, telerehabilitation and transcranial direct current stimulation, the advantages of rehabilitation therapy in multiple sclerosis treatment have been further established, and more treatment means have also been provided for patients. NonstanThe treatment methods of MS include disease recurrence control, disease modification therapy and symptomatic treatment . Researc2MS basic pathological characteristics are focal demyelination, inflammatory reaction and gliosis, while axons are relatively preserved . At presRecent studies have shown that the pathogenesis of MS involves a variety of factors, which may be the result of the interaction of glial cells, immune factors,and environmental and nutritional factors , 21. We Rehabilitation therapy reduces inflammatory cytokines in the peripheral immune system, protects the central nervous system, slows neurodegeneration, induces neuroplasticity, and ultimately slows the progression of the disease , 23. The3During the treatment of MS, medications have certain side effects and may have adverse effects on other functions . Special3.1Rehabilitation evaluation is the premise and basis of rehabilitation treatment. Through rehabilitation assessment, we can fully understand the dysfunction of MS patients, which can provide a basis for the formulation and revision of rehabilitation treatment plans.MS has the characteristics of the multi-system disease, which leads to a variety of functional disorders in patients, such as limb movement disorders, sensory disorders, cognitive function changes, speech and swallowing disorders, bowel and stool dysfunction, ataxia, walking instability and other symptoms, which determine the complexity of rehabilitation evaluation content, therefore, the focus of evaluation is the dysfunction of function and living ability. The Disability Status Scale (DSS) was first developed by Kurtzke in 1955 on a 10-point scale, with 0 representing regular and 10 representing death, but the scale cannot distinguish small changes in disease severity . In the The activities of daily living scale (ADL), Operational Activities of Daily Living scale (IADL) and Multiple Sclerosis Quality of Life (MSQOL) were generally used to assess the living ability –33. The Environmental status scale (ESS) and socioeconomic scale (SES) can be used to evaluate the social disability of MS , 39. CogThe comprehensive cognitive function screening scales included MS Screening Examination for Cognitive Impairment (SEFCI), Mini-mental State Examination (MMSE), etc. The Rey Auditory Verbal Learning Test (AVLT) and Wechsler Memory Scale (WMS-R) were used to assess memory function –43. Moto3.2MS presents complex and diverse dysfunction. The purpose of its rehabilitation treatment is to maintain and improve its function and improve the quality of life to the greatest extent. The principles of rehabilitation treatment should be targeted and vary from person to person. The content of rehabilitation treatment includes sports training, sensory training, psychological rehabilitation, cystorectal (second stool) function training, speech and swallowing training, cognitive function, rehabilitation education, etc. Specific measures include (but are not limited to): exercise therapy, occupational therapy, muscle strength exercise, application of assistive devices, physical factor therapy, percutaneous nerve stimulation, vibration therapy, acupuncture, psychological intervention, etc. , 45.3.3The standard and planned systematic rehabilitation training for MS patients in the early stage can delay the occurrence of neurological dysfunction and reduce post-disease disability. The research of Asano et al. showed that the dysfunction of MS patients recovered the fastest in the first 3 months of illness, but the function of patients still improved after 12 months of illness . Therefo4In recent years, with the continuous deepening of relevant research on TMS, VR, RAGT, TR, tDCS and so on, many practical and innovative interventions have emerged in the rehabilitation technology of MS patients. These rehabilitation treatment technologies will open up a broader space for the treatment of MS and help to further improve the rehabilitation treatment effect of MS patients. Individual study characteristics, treatment characteristics, assessments, and outcomes Table 2.4.1TMS causes axon depolarization increases the excitability of the corticospinal system, stimulates the plasticity of neurons, enhances the ability of synaptic transmission, and improves the responsiveness of the nervous system, to achieve the goal of targeted treatment . rTMS haKorzhova et al. evaluated the effect of TMS or intermittent Theta explosive magnetic stimulation (iTBS) on patients with MS secondary spasms. At the end of treatment, the modified Ashworth scale (MAS) scores of patients in both TMS and iTBS groups were significantly improved, but there was no significant improvement in the sham stimulation control group . Gaede eTMS is one of the most mature non-invasive brain stimulation technologies. It can directly regulate the central nervous system and has advantages that other treatment methods do not have. However, TMS stimulation parameters, including frequency, intensity, stimulation mode, location, treatment frequency, etc., need further multi-center and large sample studies to determine the optimal treatment plan.4.2VR technology stimulates the brain through high-intensity, multi-sensory, repetitive, task-oriented strong feedback, and intervenes in motor, cognitive and sensory functions, so that patients can immerse in the virtual environment and achieve the ideal effect of rehabilitation training. Rehabilitation training through VR technology can promote the activation of the mirror neuron system of MS patients, resulting in cortical and subcortical changes in the brain, and further stimulate the synaptic reorganization and remyelination of the brain’s motor regions.Some studies have found that rehabilitation training through VR technology can stimulate synaptic reorganization and remyelination in brain motor regions,and rehabilitation training carried out under VR helps improve the balance, movement and cognitive function of MS patients , 68.MS can cause extensive dysfunction. Rehabilitation training is carried out under VR technology to improve the balance, movement and cognitive function of MS patients. Munari et al. divided MS patients into VR combined with robot training group and robot training group. After 6 weeks of rehabilitation training, the BBS score of VR combined with robot training group was significantly higher than that of robot training group (P<0.05) . HoweverPeruzzi et al. designed a single-blind randomized controlled trial to observe the effect of VR training on the gait of MS patients. The subjects in the control group received treadmill training, and the subjects in the experimental group received treadmill training based on VR. The results showed that the walking endurance and speed, stride frequency and stride length, range of motion and strength of lower limb joints of the two groups of subjects were significantly improved, The improvement of the balance function in the experimental group was significantly higher than that in the control group (P<0.05) . JonsdotThe application of VR technology in the field of rehabilitation has its own inherent advantages, but at present, there is little research on the application of VR in the rehabilitation training of MS patients in China. In the long run, the future development needs a unified consensus standard to standardize the intervention strategy.4.3RAGT through a weight loss support system and exoskeleton support is able to generate sufficient repetitive gait movement, increase the training intensity and time, improve the gait characteristics of patients, help improve balance, increase the stability of lower limbs, and reduce the risk of falls . RAGT caGandoli et al. suggested that lower extremity RAGT training can improve the gait, postural control, balance function, disability level, and activities of daily living in patients with MS, and the possible mechanism is that rehabilitation training on specific tasks may enhance neuroplasticity . Dalgas RAGT training can provide MS patients with a training environment conducive to balance control and unlimited repetitions, enabling them to achieve early walking. Through weight-loss walking training, not only can improve the participation level of MS patients but also the spasticity of their lower limb muscle tissue can be reduced by continuous stretching . RAGT caIn China, the research on RAGT has significant differences among different regional institutions. In the future, it is necessary to strengthen the communication between developing countries and different countries or institutions abroad, and strengthen the degree of scientific research cooperation, to promote the application of RAGT in MS patients.4.4Telemedicine was first proposed in the 1960s and developed rapidly in developed countries. TR as a rehabilitation model uses Internet communication technology to administer treatment between physicians and patients across time and space. Its convenient, fast, cheap, and time-free characteristics are of great significance to continuing patient rehabilitation training after discharge , 73.Charvet et al. conducted a double-blind, randomized, controlled trial to recruit 135 patients with MS, of which 74 patients received home-based TR training, and the other 61 patients underwent home-based rehabilitation training by themselves for 12 weeks. The results showed that the cognitive function of MS patients receiving home-based TR training was significantly improved, indicating that TR training can better improve the cognitive function of MS patients . Jeong eIn general, the TR system is a kind of home-based rehabilitation supplementary means with high acceptance and good safety for patients, which is beneficial to the rehabilitation of MS patients after discharge, and reduces the care burden of patients’ families, to truly achieve the whole-process rehabilitation of MS patients.At present, developed countries have established relatively complete TR systems, while TR in most developing countries is still at the initial stage of exploration and research. Developing countries can learn from the experience of developed countries, improve TR technology and improve the rehabilitation guidance plan, to guide MS patients to carry out TR more comprehensively and effectively in the future.4.5TDCS is a non-invasive nerve regulation technique. This technology transmits weak direct current to the surface of the cerebral cortex through at least two electrodes to achieve the purpose of neural regulation. Compared with other neural control methods, tDCS has certain portability, safety and ease of use .In recent years, tDCS has been widely used as a tool to regulate cognitive function, improve mental disorders and neurological disorders. However, at present, the mechanism of tDCS on MS is not clear, and it is mainly used to alleviate the symptoms of MS.Mori et al. divided MS patients into two groups in a randomized, double-blind experiment. One group received false stimulation and the other group received anode-tDCS for five consecutive days. The research results showed that the pain and quality of life of patients with anode-stimulation were significantly improved, and no depression and anxiety were found. This proves that anode tDCS can reduce the chronic central pain of MS patients, and the action time can achieve an ideal effect. Although the mechanism of anode tDCS in treating MS disease is still unclear, it is likely to be closely related to the remodeling of brain nerve function . WorkmanThe most common adverse reaction of tDCS is that during the stimulation, the scalp will be accompanied by slight tingling, itching and slight dizziness. These reactions will disappear within a few hours after the stimulation, without any long-term side effects, and have high safety.5MS patients have many clinical manifestations and related complications, and are prone to relapse. There are many clinical and rehabilitation issues that need further research, such as bladder rectal dysfunction, pain, and autonomic dysfunction. With the development of various new rehabilitation technologies, such as TMS technology, VR technology, RAGT, TR, tDCS, etc,making rehabilitation therapy become an indispensable treatment method for MS. However, in some developing countries, it is necessary to learn from the experience of developed countries and apply advanced rehabilitation treatment technologies to the treatment of MS patients. In the future, with the continuous deepening of relevant research, more advanced rehabilitation treatment methods will be applied to the treatment of MS.All authors contributed to the article and approved the submitted version.


Although still underutilized ,2, exercIn this scenario, the new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has generated a further potential element of disability in a growing and increasingly long-lived world population , thus inInterestingly, pulmonary rehabilitation has also been proven to deliver some unexpected benefits to convalescent COVID-19 patients. Literature evidence suggests that endothelial dysfunction may play a key role in the pathogenesis of COVID-19 and its residual manifestations . In factThis is by no means novel considering that a growing number of scientific articles seem to be moving in this direction, showing a beneficial effect of cardiac and pulmonary rehabilitation on vascular health and, potentially, on the increased cardiovascular risk . In randCollectively, these data highlight the pleiotropic and unexpected benefits that rehabilitation can bring to the management of a number of clinical conditions, thus focusing attention on the need for more high-quality evidence on the usefulness of rehabilitation in diseases for which the strength of recommendation is still weak. Among these, interstitial lung disease is one of the airway diseases with low/moderate and (sometimes) conflicting evidence and, therefore, a weak recommendation for this multidisciplinary approach ,31. HoweLike pulmonary rehabilitation, cardiac rehabilitation is currently limited to a relatively low number of clinical conditions in most guidelines, including coronary artery disease, heart failure with reduced ejection fraction, and peripheral artery disease . LiteratAlongside these clinical conditions for which the evidence is solid and numerous, there are others for which the data on cardiac rehabilitation are scarce and not univocal. The 2022 American College of Cardiology/American Heart Association guidelines highlight this paucity for heart failure with preserved or mildly reduced ejection fraction, prioritizing the need for high-quality randomized controlled trials on cardiac rehabilitation over small studies mainly focused on exercise training . SimilarTaken together, these data appear to support the enormous, and often unexpected, benefits that rehabilitation and exercise-based interventions can offer to a long list of clinical conditions, some of which are not exactly considered a preferred target for this approach. The mechanisms underlying these potential benefits, in terms of functional capacity, quality of life, rehospitalizations, and mortality, are multiple and still poorly understood, with a potential major role in the control of inflammation and endothelial dysfunction. Although rehabilitation programs are usually designed for single pathologies, it should be considered that a patient is rarely affected by isolated clinical conditions, as they are often interconnected and tend to coexist in the same individual. Therefore, the new paradigm of rehabilitation directed against multimorbidity should be introduced and considered when developing clinical recommendations and designing randomized controlled trials on the utility of this exercise-based approach in different clinical settings. In this scenario, it should be considered that the recent SARS-CoV-2 pandemic has given a significant boost to the digitization process and to tele-assisted medicine in several Countries, and it is reasonable to assume that telerehabilitation could contribute to satisfying the growing unmet needs of rehabilitation services in the future.


SGW), activator modulus (M) and activator dosage (AR) on its strength was established. The results showed that the maximum compressive strength of AA-FASM after 28 days of sealed curing was about 59 MPa, while the strengths of dry- and water-saturation-cured specimens decreased by 9.8% and 13.7%, respectively. The seal-cured samples also had the smallest mass change rate and linear shrinkage and the most compact pore structure. Due to the adverse effects from a too-high or too-low modulus and dosage of the activators, the shapes of upward convex, slope and inclined convex were under the interaction of SGW/M, SGW/AR and M/AR, respectively. The correlation coefficient R2 > 0.95 and p-value < 0.05 indicated that the proposed model could be used to predict strength development given the complex factors. Optimal proportioning and curing conditions were found to be SGW = 50%, M = 1.4, AR = 50% and sealed curing.Alkali-activated fly-ash–slag blending materials (AA-FASMs) are gradually being studied and applied more because of their good performance. There are many factors affecting the alkali-activated system, and the effect of single-factor variation on the performance of AA-FASM has been mostly reported; however, there is a lack of unified understanding of the mechanical properties and microstructure of AA-FASM under curing conditions and multiple-factor interaction. Therefore, this study investigated the compressive strength development and reaction products of alkali-activated AA-FASM under three curing conditions including seal (S), dry (D) and water saturation (W). Based on the response surface model, the relationship between the interaction of slag content ( Too-high and too-low moduli are not good for geopolymerization.(2)SG/RAInteraction of WThe shape change of the response surface may be related to Cad system  and the d system . The inc N-A-S-H . In addi N-A-S-H . The rep N-A-S-H  pointed SGW and activator dosage AR on the compressive strength model of AA-FASM is shown in AR = 45% and AR = 55% (SGW = 75%). Under the same slag content, specimens with low CaO/(SiO2+Al2O3) in the alkali-activated system tended to have a low compressive strength distribution, which can also be reflected by the size of the alkaline solution content, such as B8 less than B7 strength with CaO/(SiO2+Al2O3) of 0.432.The effect of the interaction between the slag content AR in the early ages was not obvious, which was similar to the literature [SGW and AR promoted the compressive strength of AA-FASM to increase with the increase in slag content and the decrease in activator dosage, and this phenomenon is also reflected in AR in the range of 45~55% did not cause an adverse effect due to excessive alkalinity. Furthermore, for an alkali activator with a high dosage, there is a relatively large amount of water, and an increase in water content will be detrimental to the geopolymerization [SGW and AR does not cause complex changes in the response surface of compressive strength, it still shows obvious trend changes.(3)AInteraction of M/RThe influence of terature . The intrization . SimilarM and activator dosage AR on the compressive strength model of AA-FASM is shown in SGW/M and SGW/AR, the differences between the predicted values of compressive strength under the interaction of M/AR were relatively small. The good adaptability of the response surface was verified by the analysis of variance or the evolution of surface shape, which was helpful for the selection of parameters for the preparation of AA-FASM.The effect of the interaction between the activator modulus SGW = 25%) without cracks, a denser curve or arc crack network appeared on the surface of B3 (SGW = 75%). The presence of microcracks indicated that it has great shrinkage sensitivity. It is generally believed that the hardened paste of the alkali-activated material is mainly composed of gels [ of gels ,46, whic of gels  also poiSGW = 50%, activator modulus M = 1.4, activator dosage AR = 50% and the seal-curing condition.Combining the basic mechanical properties, microstructure and response surface models and cracking characteristics of AA-FASM, it was recommended that the optimal proportioning parameters and curing condition be selected as follows: slag content The high-correlation regression model showed that the response surface method can be used to predict the compressive strength of mixtures, which was similar to the results of the studies ,48,49. O(1)The compressive strength is up to 59 MPa after 28 days of sealed curing, while the strengths of the group with the same mix proportion under drying and water-saturation curing decrease by 9.8% and 13.7%, respectively. Sealed curing locks the water within the system, so the sample has the smallest mass loss, linear shrinkage, total porosity and refined pore size.(2)p-values are all less than 0.05. These results show that compressive strength can be predicted precisely using the response surface method.The correlation coefficients of the response surface models for the AA-FASMs cured for 1 day, 3 days and 28 days are both higher than 0.95, and the (3)SGW, activator modulus M and activator dosage AR have significant effects on the strength development of AA-FASM. Because of the interaction of SGW/M, the response surface experiences a change in shape from a protruding corner, rising arc-shaped to convex surface. The response surface under the interaction of SGW/AR is mainly characterized by slope growth, while the interaction surface of M/AR shows a transition from a concave to a convex shape.The slag content (4)In the studied range of factors, the optimal mix proportion parameter and curing conditions of AA-FASM are slag content of 50%, activator modulus of 1.4, activator dosage of 50% and sealed curing.In this paper, the effects of seal, dry and water-saturation curing on the performance and microstructure of alkali-activated fly-ash–slag materials were studied. Meanwhile, the interactions among the factors of slag content, activator modulus and dosage were verified by using the response surface model. The main conclusions of this study can be drawn as follows:


Medulloblastoma (MB) is the most common type of malignant pediatric brain tumor. Neuropilin-1 (NRP1), encoded by the NRP1 gene, is a transmembrane glycoprotein overexpressed in several types of cancer. Previous studies indicate that NRP1 inhibition displays antitumor effects in MB models and higher NRP1 levels are associated with poorer prognosis in MB patients. Here, we used a large MB tumor dataset to examine NRP1 gene expression in different molecular subgroups and subtypes of MB. We found overall widespread NRP1 expression across MB samples. Tumors in the sonic hedgehog (SHH) subgroup showed significantly higher NRP1 transcript levels in comparison with Group 3 and Group 4 tumors, with SHH samples belonging to the α, β, Δ, and γ subtypes. When all MB subgroups were combined, lower NRP1 expression was associated with significantly shorter patient overall survival (OS). Further analysis showed that low NRP1 was related to poorer OS, specifically in MB subgroups SHH and Group 3 MB. Our findings indicate that patients with SHH and Group 3 tumors that show lower expression of NRP1 in MB have a worse prognosis, which highlights the need for subgroup-specific investigation of the NRP1 role in MB. Medulloblastoma (MB) is the most frequent type of malignant brain tumor in children and is an important cause of cancer-related morbidity and mortality in pediatric patients. Multimodal treatment with chemotherapy, radiotherapy, and surgery has improved cure rates, but about one-third of patients still relapse, and survivors experience long-term neurological, cognitive, and endocrinological sequalae ,2. ClassMB hijacks the biological mechanisms that mediate normal central nervous system (CNS) development and plasticity ,11,12. NNRP1 expression is abnormally increased in various cancer types, including MB ,15,16,17NRP1 expression across MB tumors. Tumors in the SHH subgroup (n = 223) showed significantly higher transcript levels of NRP1 in comparison with Group 3 (n = 144) and Group 4 (n = 326) tumors , lower NRP1 expression was associated with shorter OS (p < 0.0001). When the molecular subgroups were analyzed separately, we observed that low NRP1 was related to shorter patient OS specifically in MB subgroups SHH and Group 3 (both ps < 0.05). In contrast, patients with Group 4 tumors showed an apparent reduction in OS when NRP1 levels were higher, although this effect did not reach statistical significance , originally described in reference [NRP1 transcription levels in Group 3  and Group 4  tumors compared with SHH tumors  compared to non-tumoral pediatric cerebellar tissue (n = 2). Additionally, over 90% of a set of 32 MB samples of different molecular subtypes showed strong NRP1 expression [Immunohistochemical analyses found NRP1 overexpression in MB  within the Wnt subgroup, as well as higher expression in α and β subtypes in comparison with γ tumors within the Group 4 molecular subgroup. Unexpectedly, our present results indicate that MB patients with SHH and Group 3 tumors that display lower levels of NRP1 transcription have a worst prognosis. A similar pattern was observed in Wnt tumors, although the effect did not reach significance, likely because of a smaller number of samples. In contrast, patients with Group 4 tumors with high NRP1 show an apparent decline in OS. It is possible that the heterogeneity in NRP1 levels between subtypes within specific subgroups (such as Wnt) impacts the association of transcript levels and OS when all tumors belonging to a given subgroup are analyzed together. It should be noted that NRP1 expression may be a minor contributing factor to the already poorer outcome of patients with Group 3 and Group 4 tumors when compared to other molecular subgroups.The present findings, obtained from a larger patient cohort, indicate that WNT and SHH tumors, which present relatively better prognosis, show higher Although most previously published findings indicate that NRP1 promotes tumor growth and contributes to reducing cancer patient survival ,21, it mhttp://r2.amc.nl). Tumors were classified into different molecular subgroups and subtypes according to data available in the dataset. A feature of the R2 platform, namely the Kaplan Scan , where an optimum survival cut-off is established based on statistical testing, was used.Analyses of NRP1 transcription were first performed in a previously described transcriptome dataset comprising 763 tumor samples from patients with MB ) . Expresshttps://hgserver1.amc.nl/cgi-bin/r2/main.cgi (accessed on 12 July 2023)). Data were acquired, normalized, and log2 transformed. The number of samples analyzed per molecular subgroup was WNT, n = 16, SHH, n = 46, Group 3, n = 41, and Group 4, n = 64 MB tumors. The “ggplot2”, “ggsignif”, and “tidyverse” packages were used for analysis and graph plotting. The “PMCMRplus” package was used for statistical analysis. The packages were used in R version 4.3.0.The database Tumor Medulloblastoma-Pfister-167  was downp values < 0.01 considered to indicate significant statistical differences. Results are presented in boxplot format as log2-transformed signal intensity, with data shown as median and whiskers, minimum to maximum. Patient OS was measured from the day of diagnosis until death or the date of last follow-up. OS was calculated using the Kaplan–Meier estimate, with median values and long-rank statistics; p < 0.05 would indicate significant differences between groups in OS. Data from the Pfister cohort were analyzed with the Kruskal–Wallis analyses if variance followed by Dunn’s tests.Data are presented in box plot format as log2-transformed signal intensity. Comparisons in transcript levels were performed using the Welch’s ANOVA through the R2 platform, with In summary, the present study is the first to report a subgroup-specific decline in OS associated with a reduction in NRP1 expression in MB tumors. This finding highlights the importance of identifying differences among MB groups when characterizing biomarkers and therapeutic targets. Further experiments should aim to clarify whether NRP1 has differential effects on MB growth depending on molecular subtype.


This article describes a one-degree-of-freedom haptic device that can be applied to perform three different exercises for shoulder rehabilitation. The device is based on a force control architecture and an adaptive speed PI controller. It is a portable equipment that is easy to use for any patient, and was optimized for rehabilitating external rotation movements of the shoulder in patients in whom this was limited by muscle–skeletal injuries. The sample consisted of 12 shoulder rehabilitation sessions with different shoulder pathologies that limited their range of shoulder mobility. The mean and standard deviations of the external rotation of shoulder were 42.91 ± 4.53° for the pre-intervention measurements and 53.88 ± 4.26° for the post-intervention measurement. In addition, patients reported high levels of acceptance of the device. Scores on the SUS questionnaire ranged from 65 to 97.5, with an average score of 82.70 ± 9.21, indicating a high degree of acceptance. The preliminary results suggest that the use of this device and the incorporation of such equipment into rehabilitation services could be of great help for patients in their rehabilitation process and for physiotherapists in applying their therapies. Shoulder rotator cuff injuries include tendinopathies and partial or complete tendon ruptures, mostly related to the supraspinatus tendon . ExercisMost upper extremity devices for rehabilitation available on the market are designed to improve flexion and abduction, and not external rotation, which is a fundamental movement in the performance of activities of daily living. Rotation movements are fundamental for performing activities below the horizontal and to execute coordinated movements with the hand for an individual to locate themselves in space . In addiThere is great interest in developing more specific equipment for rehabilitation . This eqThis article describes a one-degree-of-freedom haptic device that can be applied to perform three different exercises for shoulder rehabilitation. This device implements force control behavior. This force control entails resistance to the patient’s shoulder rotation that is customized according to the patient’s status. Therefore, the same equipment can be adapted to the patient’s evolution and all session activities can be recorded for clinician studies. A portable and compact equipment has been designed for shoulder rehabilitation treatments.For the present study, a pre- and post-treatment study was performed for an intervention session using a one-degree-of-freedom haptic device to perform three different exercises for shoulder rehabilitation.The rehabilitation device consists of the following components: the actuator, transmission components, force sensor, handle, and controller. The architecture used is shown in The patient’s hand is positioned inside the handle, which is made of a flexible textile for a comfortable grip. p is modified as a function of the ratio between the force error and the reference; the proposed values are shown in i was set at a value of 2. Kp and Ki were tuned experimentally.In this work, a force controller is proposed based on the cable tension exerted by the patient and an adaptive speed PI controller. The force sensor provides a range of detection from 0 N to 111 N; therefore, the maximum configurable payload of the prototype is 11.32 Kg. The proportional gain KSome trials were performed in the laboratory to properly tune the controllers. The inclusion criteria established for the selection of patients were as follows: upper limb musculoskeletal injury, no pathology for which rehabilitation treatment is contraindicated, and over 18 years of age. Patients who met any of the following exclusion criteria were not admitted to the study: cognitive impairment that prevented the understanding of simple commands, neurological lesion affecting the upper extremity, dermatological lesion of the upper extremity preventing the use of device material, and/or any other type of injury impeding the use of the device.This protocol was approved by the Research Ethics Committee of the Rey Juan Carlos University Institute. The ethical principles for medical research in humans from the Declaration of Helsinki were followed. All subjects signed the informed consent form prior to participation. Trials were carried out at the Getafe Clinical Centre . The clinician adjusted the controller parameters for each patient according to the predefined exercise . These parameters define the shoulder rotation range and the stress of the reflected force on the patient, which is in an interval of 5 N to 15 N. Furthermore, it was verified that the pulley was in the same plane as the patient’s forearm. This alignment makes movements more comfortable as the forces directly oppose shoulder rotation with no movement at the elbow.Each session lasted 15 min and consisted of repeating a cycle of external rotation and internal rotation 30 times, returning to the starting position. These cycles were carried out with the patient sitting down, in a chair with a backrest, and with their feet on the floor. Initially, the arm was positioned close to the body with a 90° elbow flexion, and from this position, the rotation movements were performed. To perform the rotation movements, the patient started the external rotation movement from the initial position up to the maximum rotation they were able to achieve. In this half-cycle, the patient exerted a force greater than that generated by the motor. In the second half of the cycle, when the patient returned to the initial position, performing an internal rotation; this movement was in the opposite direction and the force applied by the motor was greater than that exerted by the patient. The range of motion (ROM) of external rotation was measured using a double-armed 360° goniometer. The patients were in a supine position with the humerus abducted at 90° and the elbow flexed at 90°. Measurements were performed twice and averaged for further analysis . The system usability scale (SUS) was used to assess patient satisfaction with the device. This questionnaire was developed by Brooke  as a usap was < 0.05.Statistical analysis was performed using the SSPS statistical software system . A descriptive analysis of all the variables was performed. The results were expressed as average and standard deviation and median and interquartile range. The normal distribution of the variables was verified using the Shapiro–Wilk test. The hypothesis that the variables did not have a normal distribution was accepted, given the results of this test, the verification of each variable’s histograms, and the sample size. We used the Wilcoxon test, a nonparametric test for related samples. Statistical analysis was performed with a confidence level of 95%, and therefore significant values were those whose The sample consisted of 12 shoulder rehabilitation sessions with 11 patients (n = 11) (5 men and 6 women) with different shoulder pathologies that limited their range of shoulder mobility. In one of the patients, both shoulders were treated. One patient performed two sessions for the rehabilitation of both shoulders, while the rest performed only one rehabilitation session. The ages ranged from 35 to 66 years (54.92 ± 3.16 years). The analysis shows statistically significant changes for the ROM of external shoulder rotations. The mean and standard deviations of the external rotation of shoulder were 42.91 ± 4.53° for the pre-intervention measurements and 53.88 ± 4.26° for the post-intervention measurements. The patient scores on the SUS questionnaire ranged from 65 to 97.5, with an average score of 82.70 ± 9.21, suggesting a high degree of acceptance. These scores are higher than 68, indicating that this device can be rated “excellent” in the acceptability range. The present study showed the use of an active device for shoulder rehabilitation based on a force control architecture. This preliminary study is based on a single treatment session to treat the external rotation movements of the shoulder in the patients in whom this was limited by musculoskeletal injuries. It also described the patient’s acceptance of the device, and the results show a high level of approval from the patients after the first trial.It has been demonstrated that robotic and haptic technologies, such as force control and real-time signal processing, have an effective contribution in upper limb rehabilitation. There are many examples of complex exoskeletons ,16 and rThis equipment can perform a wide variety of movements but is specifically programmed for executing rehabilitation tasks. It is also necessary to design the proper patient interface to fix or attach the patient’s upper limb to the robot structure. These kinds of solutions have the advantage of being able to adapt to different rehabilitation activities. Cost-effective automation devices, such as exoskeletons, are critical to the success of these interventions and rehabilitation programs. With a single treatment session, this active device for shoulder rehabilitation based on force control was found to significantly increase the external rotation movement of the shoulder in the patients who used it. The pre-intervention mean and standard deviations of the ROM of the external rotation of the shoulder were 42.91 ± 4.53°, and 53.88 ± 4.26° in the post-intervention measurements. In addition, patients reported high levels of acceptance of the device; their scores on the SUS questionnaire ranged from 65 to 97.5, with an average score of 82.70 ± 9.21, indicating a high degree of acceptance. These very promising results were obtained with minimal hardware and a user-friendly interaction with the patient. This device is in line with a new generation of compact and simple rehabilitation equipment that is portable and easy to use for the patient , in contThis prototype is currently being improved in order to provide more functionalities to clinicians for performing new rehabilitation exercises and software is also being developed to better characterize the rehabilitation sessions. This study has several limitations. First, the small sample size cannot allow extrapolation of the results. Second, the ROM was evaluated with a manual goniometer. Futures studies are necessary using objective measures such as using a electrogoniometer or 3D motion analysis. Third, the sample was heterogeneous in respect to the injury and age. It is necessary to take this into account. Finally, the lack of follow-up does not allow us to conclude if the ROM improvement lasted over time. In this paper, a compact and cost-effective prototype for shoulder rehabilitation was described. The most important features are the simplicity of the hardware and its effectiveness in rehabilitation exercises. The equipment is designed to repeat a shoulder rotation while reflecting a force on the patient’s hand. This exercise allows muscle activation, while also increasing the range of shoulder movement. This device allows patients to perform exercises for rehabilitation sessions that are an ideal complement to clinician manipulation. The preliminary results suggest that the use of this device and the incorporation of such equipment into rehabilitation services could be of great help for patients in their rehabilitation process and for physiotherapists in applying their therapies.


Spinal and bulbar muscular atrophy (SBMA), also known as Kennedy’s disease, is a debilitating neuromuscular disease characterized by progressive muscular weakness and neuronal degeneration, affecting 1–2 individuals per 100,000 globally. While SBMA is relatively rare, recent studies have shown a significantly higher prevalence of the disease among the indigenous population of Western Canada compared to the general population. The disease is caused by a pathogenic expansion of polyglutamine residues in the androgen receptor protein, which acts as a key transcriptional regulator for numerous genes. SBMA has no cure, and current treatments are primarily supportive and focused on symptom management. Recently, a form of precision medicine known as antisense therapy has gained traction as a promising therapeutic option for numerous neuromuscular diseases. Antisense therapy uses small synthetic oligonucleotides to confer therapeutic benefit by acting on pathogenic mRNA molecules, serving to either degrade pathogenic mRNA transcripts or helping to modulate splicing. Recent studies have explored the suitability of antisense therapy for the treatment of SBMA, primarily focused on gene therapy and antisense-mediated mRNA knockdown approaches. Advancements in understanding the pathogenesis of SBMA and the development of targeted therapies offer hope for improved quality of life for individuals affected by this debilitating condition. Continued research is essential to optimize these genetic approaches, ensuring their safety and efficacy. Spinal and bulbar muscular atrophy (SBMA), also known as Kennedy’s disease, is an X-linked recessive neuromuscular disease with slow progression, caused by mutations in the androgen receptor gene and primarily characterized by degeneration of lower motor neurons ,2. The dWhile primarily viewed as a lower motor neuron disorder, growing evidence has identified that peripheral muscle tissues also play an important role in the SBMA phenotype. Patients with SBMA have been found to have serum creatine kinase levels consistent with a myopathic cause, and skeletal muscle satellite cells from SBMA patients have been demonstrated to have reduced proliferative ability in vitro ,5,6. FurBeyond the neuromuscular symptoms, SBMA also has an effect on endocrine function. Changes in the functionality of the androgen receptor result in partial androgen insensitivity in many patients, which often appears prior to any muscular symptoms ,9,10. GySBMA has a prevalence of 1–2 individuals per 100,000 people . The mutThe highest prevalence of SBMA in a population found thus far is in the Indigenous population of Saskatchewan, Canada, where the estimated prevalence is 14.7 per 100,000 people . The autThe high prevalence in the Indigenous communities of Saskatchewan has been associated with a founder effect, with the majority of patients in Leckie et al.’s study sharing the same haplotype . Their fLeckie et al. also explored whether Indigenous individuals with SBMA have different phenotypes compared to those documented previously in other parts of the world . Like prThe study also highlights the significant health disparities that Indigenous individuals still face in Canada, stemming from Canada’s colonial history and the wide array of social, economic, and political barriers present for Indigenous Canadians ,19. IndiAR gene encoding for the androgen receptor. The androgen receptor protein is one of many steroid hormone receptors belonging to the nuclear receptor superfamily and works to facilitate the effect of androgens on the body [AR gene is located on the long arm of the X chromosome at Xq11–12 and encodes for a 110 kDa protein product [AR gene is composed of eight exons that encode the three major domains of AR protein known as the transactivation domain, the DNA-binding domain, and the ligand-binding domain [AR gene is conserved in all members of the steroid receptor superfamily [AR gene [Spinal and bulbar muscular atrophy results from mutations in the the body ,23. Firs product ,26,27,28g domain ,29. Integ domain . In conterfamily ,30. The [AR gene ,31. SBMA belongs to a class of diseases known as trinucleotide repeat expansion disorders and results from a pathologic polyglutamine expansion in the first exon of the androgen receptor gene, characterized by glutamine residues encoded at a higher-than-normal range near the transcriptional activation domain of the AR protein . In a heThe androgen receptor functions as a ligand-dependent transcription factor that regulates, in coordination with other co-regulatory proteins, the transcription of the androgen-responsive genes by binding to their regulatory sites when in its androgen-bound form . In its SBMA is a disease characterized by both gain- and loss-of-function mechanisms  Figure . The neuThe mechanism underlying the neurodegenerative gain-of-function symptoms present in SBMA is not yet fully understood . A leadiThe loss-of-function mechanism has been better characterized and is a combination of androgen insensitivity and reduced trophic support. Androgen insensitivity arises due to a reduction in the appropriate function of polyQ-AR protein, corresponding with a decrease in the expression of genes typically activated by testosterone and dihydrotestosterone . AdditioAntisense oligonucleotide therapy is a promising new area of drug development, and multiple drugs using this technology have received FDA approval in recent years . This foAR gene, the pathogenic AR mRNA and protein levels can be reduced, leading to an improved phenotype.The purpose of antisense oligonucleotide (ASO)-mediated AR knockdown is to degrade mutant AR transcripts which are known to accumulate in the nucleus  Figure . By targLieberman et al. aimed to explore the effect of peripheral polyQ-AR suppression in transgenic SBMA mouse models . SpecifiIn a following study, Sahashi et al. explored ASO-mediated knockdown of AR transcripts in SBMA mice but focused on neuronal polyQ-AR expression rather than peripheral . The SBMFinally, Evers et al. aimed to identify a generic ASO candidate which could knock down transcripts from all diseases arising from CAG repeats, such as Huntington’s disease, SBMA, and the spinocerebellar ataxias . DespiteTaken together, these studies demonstrate that antisense-mediated knockdown of AR is highly effective. Furthermore, the findings of Lieberman et al. and Sahashi et al. demonstrate that AR knockdown in both peripheral tissues and the CNS is associated with an improved clinical phenotype for SBMA, suggesting that ASOs may have therapeutic potential for this indication ,61. Of nNumerous isoforms of the AR protein are known to arise due to both internal translation initiation sites and alternative splicing, and isoform production has been shown to be linked to certain AR pathologies such as androgen insensitivity, SBMA, and prostate cancer ,69,70. ORecently, Lim et al. found that AR45 can regulate the transcriptional activity of full-length AR by reducing the binding of AR to its transcriptional cofactor BRD4, downregulating AR-mediated transcription . In the Given the therapeutic potential of overexpressing the AR45 isoform as identified by Lim et al., upregulating AR45 could be an interesting albeit challenging direction for future research ,74. One Overall, both AR knockdown and AR45 overexpression have the potential to be valuable therapeutic approaches for the treatment of SBMA. Examining the different methodologies of Lim et al. and Lieberman et al., it appears that AR knockdown results in a more robust alleviation of the SBMA phenotype than AR45 overexpression ,74. Howe


Reward for altruism and punishment for selfishness are crucial components for the maintenance of society. Past studies have provided strong evidence that people are willing to incur costs to punish selfish behaviors and to reward altruistic behaviors, but how their willingness to do so depends on their relationship with the individuals conducting the anti-social or pro-social behaviors is much less explored. To probe into this question, we devised a three-stage experiment that combined a revised dictator game and third-party reward or punishment. We employed two payoff frameworks, alignment and conflict, and analyzed how third-party’s willingness to reward and punish differed when their interests were either aligned or in conflict with the first-party under observation. We found that due to considerations for personal interests, third-party’s reward and punishment levels deviated from what was deemed “legitimate” by society, that is, the level of reward and punishment that enhances society’s intrinsic motivations to comply with social norms and act pro-socially. When an anti-social behavior was observed, third-party punished less severely under the alignment framework than under the conflict framework; when a pro-social behavior was observed, third-party demonstrated self-serving reward under the alignment framework, but they rewarded altruistically under the conflict framework. These findings provided evidence for third-party’s self-serving reward and punishment. As one important social norm driving pro-social behaviors as well as legitimate sanctioning, altruism has been widely studied in third-party reward and punishment games. In a typical third-party game, first-party conducts a behavior on second-party, either pro-social or anti-social, and this behavior is observed by a disinterested third-party. The existing literature on third-party shows three ways they may react: when the behavior is anti-social, they could either punish perpetrators or compensate victims11; when the behavior is pro-social, they could reward the altruistic first-party16. Most studies explore third-party’s preference between different reactive methods and the impact that their response exerts on first-party’s behaviors. However, relatively few studies research into whether third-party will act the same when they no longer stay disinterested. That is, when observers’ own interests are influenced by their third-party decisions, will the frequency and intensity of reward and punishment differ? Moreover, does the answer to this question vary with third-party’s relationship with the first-party? In this paper, we aim to investigate whether and to what extent third-party’s self-serving belief influences their decisions, and how third-party’s relationship with the first-party affects their willingness to reward and punish.In the past several decades, there has been substantial progress in understanding the evolution of pro-social behaviors based on punishment17, and the punishment inflicted by the angered observers is critical in rule enforcement18. Seip et al.19 finds empirical evidence that angered observers are willing to incur costs to punish. Third-party may also choose to punish in consideration of reputational benefit as they desire to be respected, trusted and valued positively22. Therefore, punishment for norm violation also becomes a social obligation that third-party feel obliged to carry out by ethical norms and social anticipation23. However, when alternatives like compensating victims or withholding help to perpetrators are available, third-party are less likely to punish6, indicating that punishment is perceived as a weaker signal for trustworthiness and cooperation24. When a pro-social behavior is observed, similar to third-party punishment, observers reward others due to reputational benefit and to ultimately benefit themselves25. However, third-party are not always moral. In some cases, they commit second-order free-riding, or they give out reward and punishment that promote anti-social behaviors28.To answer these questions, we better start by understanding the motives behind third-party reward and punishment. When a norm violation is observed, it provokes anger, or moral outrage31. Legitimacy, according to its definition from social psychology, is a “judgement by group members that they ought to voluntarily obey social rules irrespective of the likelihood of reward and punishment”32. In other words, legitimacy obtains when the features of authoritative institutions, or choices of observing third-party, enhance the intrinsic motivations of the public to carry out social norms and act pro-socially33. When third-party give out reward and punishment legitimately, they act in accordance with society’s anticipation of third-party behaviors, enhance society’s intrinsic motivations to behave pro-socially, and gain a positive self-image in this process25. However, when their own interests are influenced by their third-party decisions, they may deviate from social anticipation for legitimate third-party behaviors in order to obtain more personal interests when they can find excuses for themselves23. This indicates that third-party care more about maintaining a positive social image rather than actual adherence to moral principles35, and they tend to gain more personal interests without explicitly revealing their true self-serving preference.In this study, we focus on third-party’s self-serving behaviors. Past studies have long revealed the underlying contradiction in third-party behaviors, which involves a tension between giving legitimate reward and punishment and acting to one’s self-interest37. Among all the factors, Alventosa et al.37 finds solid evidence that payoff schemes of third-party are the driver of experimental outcomes and exert a huge influence not only on third-party behaviors, but also on the behaviors of the observed individuals. In third-party punishment game, existing literature shows two types of interest relationships: third-party’ interests are either diminished or boosted by their punishment decisions. Correspondingly, these two interest relationships lead to two types of third-party punishment: costly punishment and profit-seeking punishment. Costly punishment is inflicted when third-party sacrifice personal interest to punish transgressors. Kriss et al.23 point out that, although third-party exhibit a tendency to incur costly punishment, they are secretly reluctant and incline to circumvent the responsibility to punish when they can do so without explicitly revealing that this is their true preference. Similarly, fewer instances of costly punishment are observed when other forms of responses are available, such as costly compensation11 or withholding help to perpetrators38. In contrast to costly punishment, the other type of punishment, profit-seeking punishment enables third-party to gain profit by depriving violators of resources and capturing these resources themselves. According to39, third-party punish more harshly in profitable treatments than in non-profitable ones, and profit-seeking punishment substantially degrades punishment’s efficacy of encouraging norm conformity. Though these two types of punishment are both analyzed, scarcely any studies combine them and examine how third-party punishment varies when observers’ personal interest is either harmed or boosted by the punishment behavior, leaving room for further study into third-party’s self-serving punishment.Another key focus of this study is the interest relationship between first-party and third-party, which is denoted by third-party’s payoff scheme, and we aim to explore how interest relationship influences third-party behaviors. Past studies have revealed several incentives that influence third-party behaviors: intrinsic motives include third-party’s perception of social norms such as altruism, and their moral willingness to comply with them; extrinsic motives include payoff schemes and decision transparency13. In16, Jana and Daan delve into different types of costly reward and conclude that net positive reward, where the benefit of receiving a reward is higher than the cost of providing it, is more effective in sustaining cooperation than transfer reward. This indicates that when the interests of third-party and first-party are in conflict and third-party have to sacrifice personal interests to reward, they are usually reluctant to do so, revealing their self-serving reward. Although third-party reward is not as thoroughly investigated as punishment, earlier results suggest reward to be less efficient than punishment in terms of promoting social norms15.Similar to punishment, in third-party reward game, previous studies find that when third-party have to reward at their own expense, the demand for costly reward is substantially lower if they can also withhold punishment as a form of costless rewardWhile third-party reward and punishment are of high research interest, they are mostly studied separately from one another. In addition, “costly” and “profit-seeking” reward and punishment, namely, the interest relationships between first-party and third-party, also lack overall analysis. Therefore, this study extends prior research by applying two unified frameworks that combine reward and punishment with “costly” and “profit-seeking” interest relationships. Observers make third-party decisions under either alignment or conflict framework: under the alignment framework, the interests of first-party and third-party are positively correlated, that is, both win or both lose; whereas under the conflict framework, the interests of first-party and third-party are conflicting, that is, one gains at the cost of the other. Third-party can reward, punish or stay indifferent to pro-social or anti-social behaviors, and their decisions are largely dependent upon their interest relationship with the first-party.Our experimental results provide solid evidence for third-party’s self-serving reward and punishment. When an anti-social behavior is observed, due to consideration for personal interests, third-party punish lightly when their interests align with first-party, showing their reluctance for “costly” punishment; in contrast, they punish harshly when interests are conflicting, demonstrating “profit-seeking” punishment. When a pro-social behavior is observed, third-party reward generously under the alignment framework, providing evidence for self-serving reward; however, under the conflict framework, contrary to our expectation of third-party rewarding reluctantly, they reward altruistically at the expense of their own interests.We devise a three-stage experiment that combines a revised small-stake dictator game with a large-stake third-party reward and punishment game. First, subjects are randomly divided into three-people groups and are assigned the role of Player I, II or III. Each role follows a set of instructions strictly without knowing the experimental content of the other two roles.STAGE 1—The first stage is a small-stake dictator game. Player I is asked to decide the value of X (0 or 1), which determines the payoffs of Player I and II in stage 1. Player I needs to make this allocation decision under one of the two payoff frameworks, either alignment or conflict. Under the alignment framework, the interests of Player I and Player II are positively correlated; under the conflict framework, Player I and Player II have conflicting interests. Specific calculation formulas of Player I and II’s payoffs , which determines the payoffs of Player III and I in Stage 2. Player III’s decision is also put under one of the two payoff frameworks: under the alignment framework, the payoffs of Player III and Player I are positively correlated; whereas under the conflict framework, Player III and Player I have conflicting interests. Specific calculation formulas of Player III and I’s payoffs . The hypotheses are as follows:16, we predict that third-party tend to reward altruistic first-party generously and be harsh on those who act selfishly, even when reward or punishment is costly. Based on this prediction, we come up with Hypothesis In all the treatments, Player III needs to decide on a Y-value based on Player I’s previous allocation decision. Based on numerous past studies that probe into third-party reward and punishmentWhen the interests of third-party and first-party are positively correlated, third-party will decide on higher Y-values when first-party act pro-socially as opposed to anti-socially. When the interests of third-party and first-party are in conflict, third-party will decide on lower Y-values when first-party act pro-socially as opposed to anti-socially.However, in benchmark groups, as X-values are randomly assigned by computers, third-party’s decisions do not include reward or punishment factors. In treatment 5 and 7, when the interests of third-party and first-party are positively correlated, third-party will decide on a Y-value that maximize both parties’ gains no matter X-value equals to 0 or 1. In treatment 6 and 8, when the interests of third-party and first-party conflict with one another, third-party will feel empathetic for first-party and be relatively generous at their own expense. Comparing our predictions of the main treatment groups with that of the benchmark groups, we formulate Hypothesis When the interests of third-party and first-party are positively correlated, and X-value, either decided by Player I or assigned by the computer, is pro-social, third-party will decide on similar or greater Y-values in main treatments than in benchmark groups, maximizing both parties’ interests; however, when X-value is anti-social, Y-values will be higher in benchmark groups. When the interests of third-party and first-party are in conflict, and X-value is pro-social, Y-values will be higher in benchmark groups; when X-value is anti-social, Y-value will be higher in main treatment groups.28 explore second-order free-riding, showing third-party’s unwillingness to shoulder the cost of punishment. Kriss et al.23 reveals that third-party punish reluctantly: they choose to avoid the opportunity to punish when they can do so without explicitly revealing that this is their preference. On the contrary, in39, third-party fully utilize their power to punish in profitable treatments, gaining more payoff during this process. Based on these previous findings, in our study, since third-party’s payoffs are determined by their own reward and punishment behaviors, we expect to find that third-party’s behaviors are no longer “pure” responses to pro-sociality or anti-sociality, but may deviate from social anticipation for “legitimate” third-party actions. They may shirk or fully utilize their power to reward or punish in order to gain more personal interests. Specifically, under the alignment framework, when a pro-social behavior is observed, Player III may choose Y-value that is close to 10, maximizing both parties’ interests; however, when an anti-social behavior is observed, Player III may punish reluctantly or may even avoid the opportunity to punish. Similarly, under the conflict framework, Player III may severely punish Player I’s anti-social behaviors but reluctantly reward pro-social behaviors, or may even avoid the opportunity to reward. Driven by personal interests, third-party may deviate from the level of reward or punishment considered “legitimate” by society. This social anticipation for legitimate reward and punishment can be reflected by Player IIs’ estimations of Y-values as they remain unknown of Player I and III’s decisions throughout the entire experiment and are relatively detached. The discrepancy between Player IIIs’ actual decisions and Player IIs’ estimations sheds light on third-party’s self-serving reward and punishment. We formulate Hypothesis Past studies have revealed third-party’s tendency to shirk the responsibility of reward and punish when doing so benefits their personal interests. Szolnoki and PercWhen the interests of third-party and first-party are positively correlated, and first-party act pro-socially, third-party’s decisions will be similar to social anticipation, maximizing both parties’ interests; however, when first-party act anti-socially, Y-values decided by third-party will exceed social anticipation. When the interests of third-party and first-party are in conflict, no matter first-party act pro-socially or anti-socially, Y-values decided by the third-party will be higher than social anticipation.39. Thus, we expect to find that, in stage 2, due to alignment or conflict of interests, Player III may interpret Player I’s small deed and amplify its implication to justify a certain level of reward or punishment, and gain more payoff in this process. As a result, the X-values that Player Is decide in stage 1 differ by only 1, but Player Is’ payoffs in stage 2 may differ by a very large amount.Stage 1 is a small-stake dictator game. Player I makes a small-stake decision in stage 1, deciding X-value equals 0 or 1. Stage 2 is a large-stake third-party reward or punishment game. According to previous studies, besides third-party’s responsibility to reward altruism and punish selfishness, they also tend to obtain more personal interests in the process of giving reward and punishmentA small difference in decisions by first-party in stage 1 may result in a large difference in payoffs in stage 2. Specifically, payoffs received by pro-social first-party when the interests of first-party and third-party align will be significantly higher than that received by anti-social first-party when interests conflict.(1) Decision III(2) Decision III. Player III’s decision in stage 2 is a third-party response to Player I’s previous decision and includes self-serving preference. (3) Estimation I. Player I’s estimation of third-party’s response is strongly biased as Player I himself is the first-party being observed. (4) Estimation II. Player II’s estimation of third-party’ response is relatively objective as Player II remains uninvolved and ignorant of Player I and III’s previous decisions. Therefore, estimation II can reflect social anticipation for third-party reward and punishment.Based on the above hypotheses, we make predictions about the data results. There are four different Y-values that are particularly important to us: Below in Table When the interests of Player III and I are aligned, and Player I’ pro-social behavior is observed, we expect to find all four Y-values to be close to 10. On the contrary, when Player I’s anti-social behavior is observed, society calls for punishment, but due to concern for individual interest, Player III may decide on a Y-value larger than social anticipation, showing Player III’s self-serving punishment; and Estimation I may be even larger, revealing Player I’s tendency to shirk punishment. Decision III will be larger in benchmark groups than in main treatment groups as third-party punishment only exists in the latter.When the interests of Player III and I are in conflict, and Player I is pro-social, Player III may decide on a Y-value larger than social anticipation, rewarding I reluctantly whereas Player I, seeking more reward, may estimate a Y-value lower than social anticipation. Decision III will be lower in the main treatment groups as it involves third-party reward. When Player I is anti-social, society calls for punishment, and Player III may punish even more harshly as he can benefit from punishment, whereas Player I may estimate a lower Y-value to shirk punishment. Decision III will be larger in the main treatment groups.Our main results were drawn from the data collected from the first round of each treatment in which subjects had no clue of what was going to happen next, and their decisions were largely intuitive, eliciting their true beliefs. When the experimental procedures were repeated in the second and third round, subjects grew familiar with the experimental procedure and might develop different strategies. We present these secondary results in the “Additional Analysis–The Learning Effect” section in Methods, exploring how the mentality and strategy of subjects change over time.41. Since only Player I made decisions in stage 1 but Player II could benefit from this decision, Player I believed that Player II was free-riding. Thus, they would rather sacrifice a little bit of personal payoff to discourage free-riding.We first looked into Player Is’ decisions in stage 1. When Player I and II were put under the alignment framework, 91.2% chose to act pro-socially and reach a win–win. Still, 8.8% of participants behaved irrationally and reduced both their and the opponent’s payoff. We believed this phenomenon was caused by free-riding aversion42, in the standard dictator game, dictators on average gave 28.35% of the pie, and 36.11% of dictators gave nothing to recipients. Comparing the data, we can find that in our study, the proportion of anti-social Player I who gave nothing to Player II is close to the proportion of dictators who shared nothing in the standard dictator game.When Player I and II were put under the conflict framework, 66.1% conducted pro-social behaviors while 33.9% acted anti-socially. This indicates that when interests conflict, the majority chose to sacrifice a little of personal gain to benefit others, yet a significant portion deprived their counterparts of any profit to maximize personal gain. It is worth noting here that our design of the conflict framework is a revised version of the standard dictator game used in numerous studies, in which a dictator divides a pie of $10 between himself and a recipient. According toOur primary interest is in Player III’s rewarding or punitive behaviors under alignment or conflict payoff framework. Below Fig. In Fig. These experimental results are consistent with Hypothesis Our findings verify Hypothesis To further probe into third-party reward and punishment, we conducted Mann–Whitney U Test on Decision III in benchmark groups and main treatment groups. In benchmark groups, as X-values are randomly assigned, Decision III does not involve third-party reward or punishment. By comparing Decision III in main treatment groups and benchmark groups, we aim to reveal third-party reward and punishment. We only found a significant difference when Player III and I were under conflict framework and Player I was pro-social  at Beijing Foreign Studies University (BFSU) in September and October 2022. The Ethical Review Committee of the Behavioral and Experimental Social Science Laboratory at Beijing Foreign Studies University approved the study (Reference No. 2022L009). The computerized experiment was designed using the software program Z-treeThe study was carried out in accordance with the relevant guidelines and regulations of Beijing Foreign Studies University for studies with human participants. A total of 483 subjects were recruited via a web-based recruitment system that draws on a large pool of potential student subjects in BFSU. The number of subjects who participated in each treatment is listed below in Table Among all the subjects, a total of 83% of the subjects were female, and the median age was 20. 64% of the subjects were economic majors, and others majored in information management, languages, education, international relations and journalism. For social income, 54% had a weekly income between RMB 300 to RMB 700, 25% had a weekly income lower than RMB 300 and 21% had a weekly income over RMB 700.All subjects gave their informed consent before participation. After that, subjects received written instructions that were subsequently read aloud to promote understanding. Then, subjects completed the experimental procedure following instructions shown stage-by-stage on computer screens.  Screenshots of the experimental stages are provided in the To analyze the results, we applied the Mann-Whitney U test, ANOVA and LSD. The Mann-Whitney U test, also known as the Wilcoxon Rank Sum Test, is a non-parametric statistical test used to compare two samples or groups. It assesses whether two samples are likely to derive from the same population, and essentially asks whether these two populations have the same shape with regard to their data. In this study, we employed the Mann-Whitney U test to test: (1) the difference between third-party’s decisions when the first-party they face is either pro-social or anti-social; (2) the difference between third-party’s decisions in main treatment groups and in benchmark groups; (3) the difference between third-party’s decisions and society’s anticipation of reward and punishment that should be exerted on first-party. The results of the Mann Whitney U test showed accordingly: (1) third-party’s decisions differed significantly in the face of either pro-social or anti-social first-party; (2) third-party’s decisions differed significantly in response to X-values made by first-party or randomly assigned by computers, demonstrating third-party reward and punishment; (3) Third-party’s decisions significantly deviated from social anticipation, revealing both self-serving reward and altruistic reward. We also used one-way ANOVA, which is a statistical tool analyzing the differences among means of different groups. We probed into the differences between payoffs of Player Is in different scenarios, and we applied Fisher’s LSD to create confidence intervals for all pairwise differences, providing solid evidence for the amplification effect. We also used one-way ANOVA and LSD to test the difference between Decision III, Estimation I, Estimation II and Decision IIIThank you for participating in this experiment! We will pay a participation fee of 10 RMB for you. Please read the following instructions carefully, and if you have any questions, feel free to ask us. Please do not communicate with others during the experiment. Thank you for your cooperation.Matching rules: Before the experiment begins, you will be randomly assigned an ID number  to represent your Player role. You will randomly form a group of three people with other 2 participants with different roles to complete this experimental task.Payoff rules: The payoff you receive will be converted from your tokens earned during the experiment. Your payoff is converted following the rule: This experimental task consists of several stages. In order to ensure the smooth running of the experimental task, the rules of each stage will be informed in turn.In this stage, only Player I will make a decision that will determine the payoffs of Player I and fellow Player II in stage 1. Player I needs to decide on the value of X (0 or 1). Player II can only accept, not reject.Stage 1 payoff rules:In this stage, the group composition of Player I, Player II and Player III remains the same as in stage 1. We will inform Player III of the decision made by fellow Player I in stage 1.In this stage, only Player III will make a decision that will determine the payoffs of Player III and fellow Player I in stage 2. Player III needs to decide on the value of Y (an integer between 0 and 10). Player I can only accept, not reject.Stage 2 payoff rules:In this stage, the group composition of Player I, Player II, and Player III remains the same as in stage 1. Player I and Player II need to make the following estimations.Player I: We will not inform Player I of the decisions made by Player III in stage 2. At this point Player I needs to estimate the Y-value of Player III’s decision in stage 2. The closer the estimated Y-value of Player I is to the true value, the more tokens will be rewarded. The specific bonus rule is as follows:Assuming that Player I’s estimation of Y-value is G and Player III’s actual decision of Y-value is T, Player I receives a Player II: We will not inform Player II of the decisions made by Player I and Player III in stage 1 and 2 respectively. At this point, Player II needs to make two estimations as follows:First, Player II needs to estimate the decision made by Player I in stage 1. If the estimation is accurate, Player II will be rewarded with 5 tokens. If the estimation is incorrect, Player II will receive 0 token.Second, Player II needs to estimate when the X-value of Player I’s decision in stage 1 is 0 or 1 respectively, the Y-value of Player III’s decision in stage 2. The closer the estimated Y-value of Player II is to the true value, the more tokens will be rewarded. The specific bonus rule is as follows:Assuming that Player II’s estimation of Y-value is G and Player III’s actual decision of Y-value is T, Player II receives a The total payoff of this experiment task is:Total Total Total Stage 3 payoff rules:In this stage, the computer will generate a random X-value (0 or 1) which will determine the payoffs of Player I and fellow Player II in stage 1.Stage 1 payoff rules:In this stage, the group composition of Player I, Player II and Player III remains the same as in stage 1. We will inform Player III of the random X-value (0 or 1) generated by the computer and the payoffs of Player I and Player II in stage 1.)In this stage, only Player III will make a decision that will determine the payoffs of Player III and fellow Player I in stage 2. Player III needs to decide on the value of Y (an integer between 0 and 10). Player I can only accept, not reject.Stage 2 payoff rules:In this stage, the group composition of Player I, Player II, and Player III remains the same as in stage 1. Player I and Player II need to make the following estimations.Player I: We will not inform Player I of the decisions made by Player III in stage 2. At this point Player I needs to estimate the Y-value of Player III’s decision in stage 2. The closer the estimated Y-value of Player I is to the true value, the more tokens will be rewarded. The specific bonus rule is as follows:Assuming that Player I’s estimation of Y-value is G and Player III’s actual decision of Y-value is T, Player I receives a Player II: We will not inform Player II of the random X-value (0 or 1) generated by the computer and Player III’s decision in stage 1 and 2 respectively. At this point, Player II needs to make two estimations as follows:First, Player II needs to estimate the random X-value (0 or 1) generated by the computer in stage 1. If the estimation is accurate, Player II will be rewarded with 5 tokens. If the estimation is incorrect, Player II will receive 0 token.Second, Player II needs to estimate when the random X-value (0 or 1) generated by the computer in stage 1 is 0 or 1 respectively, the Y-value of Player III’s decision in stage 2. The closer the estimated Y-value of Player II is to the true value, the more tokens will be rewarded. The specific bonus rule is as follows:Assuming that Player II’s estimation of Y-value is G and Player III’s actual decision of Y-value is T, Player II receives a The total payoff of this experiment task is:Total Total Total Stage 3 payoff rules:In the section of Third-party Reward and Punishment in Results, we analyzed the distribution of Decision III. While Fig. We also looked into the experimental results of the second and third round. As subjects got familiar with the experimental content and accumulated experiences, their strategies and decisions differed from that of the first round. Below Fig. For Player I’s behaviors, third-party reward and punishment proved to be an efficient way to promote pro-social behaviors. In Fig. As to third-party’s behaviors, they exhibited a stronger tendency for self-serving reward and punishment in the second and third round. After knowing the entire experimental content, they generally decided on higher Y-values. Meanwhile, the discrepancy between Decision III and Estimation II significantly narrowed as Player II gave more and more accurate estimation for third-party responses. We found significant difference between Decision III and Estimation II in the second and third round when stage 2 was under alignment framework and Player I was pro-social(Mann–Whitney Supplementary Information.