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Introduction: Organ motion (OM) and volumetric changes pose challenges in radiotherapy (RT) for locally advanced cervical cancer (LACC). Magnetic Resonance-guided Radiotherapy (MRgRT) combines improved MRI contrast with adaptive RT plans for daily anatomical changes. Our goal was to analyze cervico-uterine structure (CUS) changes during RT to develop strategies for managing OM., Materials and Methods: LACC patients received chemoradiation by MRIdian system with a simultaneous integrated boost (SIB) protocol. Prescription doses of 55-50.6 Gy at PTV1 and 45-39.6 Gy at PTV2 were given in 22 and 25 fractions. Daily MRI scans were co-registered with planning scans and CUS changes were assessed.Six PTVs were created by adding 0.5, 0.7, 1, 1.3, 1.5, and 2 cm margins to the CUS, based on the simulation MRI. Adequate margins were determined to include 95 % of the CUSs throughout the entire treatment in 95 % of patients., Results: Analysis of 15 LACC patients and 372 MR scans showed a 31 % median CUS volume decrease. Asymmetric margins of 2 cm cranially, 0.5 cm caudally, 1.5 cm posteriorly, 2 cm anteriorly, and 1.5 cm on both sides were optimal for PTV, adapting to CUS variations. Post-14th fraction, smaller margins of 0.7 cm cranially, 0.5 cm caudally, 1.3 cm posteriorly, 1.3 cm anteriorly, and 1.3 cm on both sides sufficed., Conclusion: CUS mobility varies during RT, suggesting reduced PTV margins after the third week. MRgRT with adaptive strategies optimizes dose delivery, emphasizing the importance of streamlined IGRT with reduced PTV margins using a tailored MRgRT workflow with hybrid MRI-guided systems., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 Published by Elsevier B.V. on behalf of European Society for Radiotherapy and Oncology.)

Multiple sclerosis (MS) is a chronic autoimmune disorder that affects the central nervous system and can result in various symptoms, including muscle weakness, spasticity, and fatigue, ultimately leading to the deterioration of the musculoskeletal system. However, in recent years, exosuits have emerged as a game-changing solution to assist individuals with MS during their daily activities. These lightweight and affordable wearable robotic devices have gained immense popularity. In our study, we assessed the performance of an elbow exosuit on eight individuals with MS using high-density electromyography to measure biceps muscle activity. The results demonstrated that our prototype significantly reduced muscle effort during both dynamic and isometric tasks while increasing the elbow range of motion. In addition, the exosuit effectively delayed the onset of muscle fatigue, enhancing endurance for people with MS and enabling them to perform heavy duty tasks for a longer period.

Background: Radiotherapy (RT) plays an important role in the treatment of patients with previously irradiated locally recurrent rectal cancer (LRRC). Over the years, numerous technologies and different types of RT have emerged. The aim of our systematic literature review was to determine whether the new techniques have led to improvements in both outcomes and toxicities., Methods: A computerized search was performed by MEDLINE and the Cochrane database. The studies reported data from patients treated with carbon ion radiotherapy (CIRT), intensity-modulated photon radiotherapy (IMRT), and stereotactic radiotherapy (SBRT)., Results: Seven publications of the 126 titles/abstracts that emerged from our search met the inclusion criteria and presented outcomes of 230 patients. OS was reported with rates of 90.0% and 73.0% at 1 and 2 years, respectively; LC was 89.0% and 71.6% at 1 and 2 years after re-RT, respectively. Toxicity data vary widely, with emphasis on acute and chronic gastrointestinal and urogenital toxicity, even with modern techniques., Conclusion: data on toxicity and outcomes of re-RT for LRRC with new technologies are promising compared with 3D techniques. Comparative studies are needed to define the best technique, also in relation to the site of recurrence.

Purpose: Radical resection (R0) represents the best curative treatment for local recurrence (LR) rectal cancer. Re-irradiation (re-RT) can increase the rate of R0 resection. Currently, there is a lack of guidelines on Re-RT for LR rectal cancer. The Italian Association of Radiation and clinical oncology for gastrointestinal tumors (AIRO-GI) study group released a national survey to investigate the current clinical practice of external beam radiation therapy in these patients., Material and Methods: In February 2021, the survey was designed and distributed to members of the GI working group. The questionnaire consisted of 40 questions regarding center characteristics, clinical indications, doses, and treatment techniques of re-RT for LR rectal cancer., Results: A total of 37 questionnaires were collected. Re-RT was reported as an option for neoadjuvant treatment in resectable and unresectable disease by 55% and 75% of respondents, respectively. Long-course treatment with 30-40 Gy (1.8-2 Gy/die, 1.2 Gy bid) and hypofractionated regimen of 30-35 Gy in 5 fractions were used in most centers. A total dose of 90-100 Gy as EqD2 dose (α/β = 5 Gy) was delivered by 46% of the respondents considering the previous treatment. Modern conformal techniques and daily image-guided radiation therapy protocols were used in 94% of centers., Conclusion: Our survey showed that re-RT treatment is performed with advanced technology that allow a good management of LR rectal cancer. Significant variations were observed in terms of dose and fractionation, highlighting the need for a consensus on a common treatment strategy that could be validated in prospective studies., (© 2023. The Author(s).)

Bimanual object manipulation involves using both hands to interact with objects in the environment, and the process requires the central nervous system to process sensory feedback and translate it into motor commands. Although there have been significant advancements in haptics and robotics, the kinematic strategies involved in bimanual coupled tasks are still not fully understood. This study aimed to investigate the dynamic interaction between hands during the manipulation of a shared object using two impedance-controlled exoskeletons programmed to simulate bimanual coupled manipulation of virtual objects. Twenty-six participants (right-handed and left-handed) were asked to use both hands to grab and place simulated objects in specific locations. The virtual objects were rendered with four different dynamic properties, affecting the manipulation strategies used to complete the tasks. The results showed that force asymmetries were related to movement direction and handedness preference, with right-handers exhibiting asymmetries related to movement direction and left-handers showing better control of the force applied between their hands. This is possibly due to their constant exposure to objects designed for right-handed use. Additionally, the haptic properties of the virtual objects influenced task performance in terms of timing and failure for all participants. This study demonstrates the potential of advanced technologies to provide realistic simulations of multi-joint movements involving the entire upper extremities. The findings have implications for the development of training programs for bimanual object manipulation tasks and the design of virtual environments that can enhance the learning process.

Haptic feedback is the sensory modality to enhance the so-called "immersion", meant as the extent to which senses are engaged by the mediated environment during virtual reality applications. However, it can be challenging to meet this requirement using conventional robotic design approaches that rely on rigid mechanical systems with limited workspace and bandwidth. An alternative solution can be seen in the adoption of lightweight wearable systems equipped with Neuromuscular Electrical Stimulation (NMES): in fact, NMES offers a wide range of different forces and qualities of haptic feedback. In this study, we present an experimental setup able to enrich the virtual reality experience by employing NMES to create in the antagonists' muscles the haptic sensation of being loaded. We developed a subject-specific biomechanical model that estimated elbow torque during object lifting to deliver suitable electrical muscle stimulations. We experimentally tested our system by exploring the differences between the implemented NMES-based haptic feedback ( NMES condition), a physical lifted object ( Physical condition), and a condition without haptic feedback ( Visual condition) in terms of kinematic response, metabolic effort, and participants' perception of fatigue. Our results showed that both in terms of metabolic consumption and user fatigue perception, the condition with electrical stimulation and the condition with the real weight differed significantly from the condition without any load: the implemented feedback was able to faithfully reproduce interactions with objects, suggesting its possible application in different areas such as gaming, work risk assessment simulation, and education.

Background: In our department, we provided guidelines to the radiation oncologists (ROs) regarding the omission, delay, or shortening of radiotherapy (RT). The purpose was to reduce the patients' exposure to the hospital environment and to minimize the departmental overcrowding. The aim was to evaluate the ROs' compliance to these guidelines., Methods: ROs were asked to fill out a data collection form during patients' first visits in May and June 2020. The collected data included the ROs' age and gender, patient age and residence, RT purpose, treated tumor, the dose and fractionation that would have been prescribed, and RT changes. The chi-square test and binomial logistic regression were used to analyze the correlation between the treatment prescription and the collected parameters., Results: One hundred and twenty-six out of 205 prescribed treatments were included in this analysis. Treatment was modified in 61.1% of cases. More specifically, the treatment was omitted, delayed, or shortened in 7.9, 15.9, and 37.3% of patients, respectively. The number of delivered fractions was reduced by 27.9%. A statistically significant correlation ( p = 0.028) between younger patients' age and lower treatment modifications rate was recorded., Conclusion: Our analysis showed a reasonably high compliance of ROs to the pandemic-adapted guidelines. The adopted strategy was effective in reducing the number of admissions to our department.

Background: The recovery of upper limb mobility and functions is essential for people with cervical spinal cord injuries (cSCI) to maximize independence in daily activities and ensure a successful return to normality. The rehabilitative path should include a thorough neuromotor evaluation and personalized treatments aimed at recovering motor functions. Body-machine interfaces (BoMI) have been proven to be capable of harnessing residual joint motions to control objects like computer cursors and virtual or physical wheelchairs and to promote motor recovery. However, their therapeutic application has still been limited to shoulder movements. Here, we expanded the use of BoMI to promote the whole arm's mobility, with a special focus on elbow movements. We also developed an instrumented evaluation test and a set of kinematic indicators for assessing residual abilities and recovery., Methods: Five inpatient cSCI subjects (four acute, one chronic) participated in a BoMI treatment complementary to their standard rehabilitative routine. The subjects wore a BoMI with sensors placed on both proximal and distal arm districts and practiced for 5 weeks. The BoMI was programmed to promote symmetry between right and left arms use and the forearms' mobility while playing games. To evaluate the effectiveness of the treatment, the subjects' kinematics were recorded while performing an evaluation test that involved functional bilateral arms movements, before, at the end, and three months after training., Results: At the end of the training, all subjects learned to efficiently use the interface despite being compelled by it to engage their most impaired movements. The subjects completed the training with bilateral symmetry in body recruitment, already present at the end of the familiarization, and they increased the forearm activity. The instrumental evaluation confirmed this. The elbow motion's angular amplitude improved for all subjects, and other kinematic parameters showed a trend towards the normality range., Conclusion: The outcomes are preliminary evidence supporting the efficacy of the proposed BoMI as a rehabilitation tool to be considered for clinical practice. It also suggests an instrumental evaluation protocol and a set of indicators to assess and evaluate motor impairment and recovery in cSCI.

Position sense refers to an aspect of proprioception crucial for motor control and learning. The onset of neurological diseases can damage such sensory afference, with consequent motor disorders dramatically reducing the associated recovery process. In regular clinical practice, assessment of proprioceptive deficits is run by means of clinical scales which do not provide quantitative measurements. However, existing robotic solutions usually do not involve multi-joint movements but are mostly applied to a single proximal or distal joint. The present work provides a testing paradigm for assessing proprioception during coordinated multi-joint distal movements and in presence of kinaesthetic perturbations: we evaluated healthy subjects' ability to match proprioceptive targets along two of the three wrist's degrees of freedom, flexion/extension and abduction/adduction. By introducing rotations along the pronation/supination axis not involved in the matching task, we tested two experimental conditions, which differed in terms of the temporal imposition of the external perturbation: in the first one, the disturbance was provided after the presentation of the proprioceptive target, while in the second one, the rotation of the pronation/ supination axis was imposed during the proprioceptive target presentation. We investigated if (i) the amplitude of the perturbation along the pronation/supination would lead to proprioceptive miscalibration; (ii) the encoding of proprioceptive target, would be influenced by the presentation sequence between the target itself and the rotational disturbance. Eighteen participants were tested by means of a haptic neuroergonomic wrist device: our findings provided evidence that the order of disturbance presentation does not alter proprioceptive acuity. Yet, a further effect has been noticed: proprioception is highly anisotropic and dependent on perturbation amplitude. Unexpectedly, the configuration of the forearm highly influences sensory feedbacks, and significantly alters subjects' performance in matching the proprioceptive targets, defining portions of the wrist workspace where kinaesthetic and proprioceptive acuity are more sensitive. This finding may suggest solutions and applications in multiple fields: from general haptics where, knowing how wrist configuration influences proprioception, might suggest new neuroergonomic solutions in device design, to clinical evaluation after neurological damage, where accurately assessing proprioceptive deficits can dramatically complement regular therapy for a better prediction of the recovery path., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 D'Antonio, Galofaro, Zenzeri, Patané, Konczak, Casadio and Masia.)

Background: Several daily living activities require people to coordinate the motion and the force produced by both arms, using their position sense and sense of effort. However, to date, the interaction in bimanual tasks has not been extensively investigated., Methods: We focused on bimanual tasks where subjects were required: (Experiment 1) to move their hands until reaching the same position - equal hand position implied identical arm configurations in joint space - under different loading conditions;(Experiment 2) to produce the same amount of isometric force by pushing upward, with their hands placed in symmetric or asymmetric positions. The arm motions and forces required for accomplishing these tasks were in the vertical direction. We enrolled a healthy population of 20 subjects for Experiment 1 and 25 for Experiment 2. Our primary outcome was the systematic difference between the two hands at the end of each trial in terms of position for Experiment 1 and force for Experiment 2. In both experiments using repeated measure ANOVA we evaluated the effect of each specific condition, namely loading in the former case and hand configuration in the latter., Results: In the first experiment, the difference between the hands' positions was greater when they were concurrently loaded with different weights. Conversely, in the second experiment, when subjects were asked to exert equal forces with both arms, the systematic difference between left and right force was not influenced by symmetric or asymmetric arm configurations, but by the position of the left hand, regardless of the right hand position. The performance was better when the left hand was in the higher position., Conclusions: The experiments report the reciprocal interaction between position sense and sense of effort inbimanual tasks performed by healthy subjects. Apart for the intrinsic interest for a better understanding of basic sensorimotor processes, the results are also relevant to clinical applications, for defining functional evaluation and rehabilitative protocols for people with neurological diseases or conditions that impair the ability to sense and control concurrently position and force.

Prostate cancer (PCa) is one of the most common malignancies in men both in western and developing countries. Radiotherapy (RT) is an important therapeutic option. New technologies (including 3D, intensity modulated RT, image-guided RT and, volumetric modulated arc therapy) have been introduced in the last few decades with progressive improvement of clinical outcomes. However, in many developing countries, the only treatment option is the traditional two-dimensional (2D) technique based on standard simulation. The guidelines for 2D field definition are still based on expert's opinions. The aim of the present study was to propose new practical guidelines for 2D fields definition based on 3D simulation in PCa. A total of 20 patients were enrolled. Computed tomography-simulation and pelvic magnetic resonance images were merged to define the prostate volumes. Clinical Target Volume (CTV) was defined using the European Organisation for Research and Treatment of Cancer guidelines in consideration of the four risk categories: Low, intermediate, and high risk with or without seminal vesicles involvement, respectively. Planning Target Volume (PTV) was defined by adding 10 mm to the CTV. For each category, two treatment plans were calculated using a cobalt source or 10 MV photons. Progressive optimization was achieved by evaluating 3D dose distribution. Finally, the optimal distances between field margins and radiological landmarks (bones and rectum with contrast medium) were defined. The results were reported in tabular form. Both field margins (PTV D 98% >95%) needed to adequately irradiate all patients and to achieve a similar result in 95% of the enrolled patients are reported. Using a group of patients with PCa and based on a 3D planning analysis, we propose new practical guidelines for PCa 2D-RT based on current criteria for risk category and CTV, and PTV definition.

Assessing proprioception is important for understanding and treating sensorimotor impairments. Many daily tasks require bimanual manipulation of objects, but state of the art methods for the assessment of proprioception are far away from bimanual activities, and instead evaluate sensorimotor integrity in oversimplified and often unimanual goal-directed tasks. Here, we developed a new device and method to assess proprioception and force production by simulating a realistic bimanual behavior. Twelve healthy participants held a physically coupled object - a sensorized box - and matched target orientations about the three principal axes without and with added weights. Our preliminary findings indicate that bimanual proprioception during orientation matching depends on the axis of rotation. For example, in rotations about the lateral axis of the body, underestimation and overestimation of the target angle depends on its orientation in a body-centered reference frame: participants tended to underestimate targets that required rotation far away from the body and overestimated angles that required rotation towards the body. We also found that for the same rotation axis, the larger were the rotations, the higher was the force applied. Moreover, we also found that fatigue causes undershoot in orientation matching. In the future, this tool could be adopted for assessment and treatment of sensorimotor deficits in bimanual functional tasks.

Proprioceptive deficits are frequent and disabling symptoms of neurological diseases such as Multiple Sclerosis (MS). These deficits are poorly understood partly because of the limited sensitivity and reproducibility of clinical measures. However, their assessment is crucial in planning and evaluating rehabilitative treatments. Therefore, we designed a device and a protocol for assessing proprioceptive deficits by evaluating the position and force control performance. We focused on bimanual tasks, as most daily life activities require the combined use of both hands while MS induces coordination problems and often affects the two arms differently. Specifically, without being able to see their arms, subjects had (1) to reach with their hands a target positions holding objects of equal or different weights; (2) to exert equal isometric forces with the two hands in upward direction against rigid constraints at the same or different heights. For a first proof of concept of the feasibility we enrolled seven MS subjects with different levels of upper limb impairment and seven sex and age matched controls. We found that the ability to exert symmetric forces with both arms was significantly altered in all MS subjects, while position control decreased only for higher level of impairment. These preliminary findings suggest that in people with MS the ability to exert bilaterally required levels of force might be affected earlier compared to the ability to control hand position.

Myoelectric Computer Interfaces (MCIs) are a viable option to promote the recovery of movements following spinal cord injury (SCI), stroke, or other neurological disorders that impair motor functions. We developed and tested a MCI interface with the goal of reducing abnormal muscular activations due to compensatory strategies or undesired co-contraction after SCI. The interface mapped surface electromyographic signals (sEMG) into the movement of a cursor on a computer monitor. First, we aimed to reduce the co-activation of muscles pairs: the activation of two muscles controlled orthogonal directions of the cursor movements. Furthermore, to decrease the undesired concurrent activation of a third muscle, we modulated the visual feedback related to the position of the cursor on the screen based on the activation of this muscle. We tested the interface with six unimpaired and two SCI participants. Participants were able to decrease the activity of the targeted muscle when it was associated with the visual feedback of the cursor, but, interestingly, after training, its activity increased again. As for the SCI participants, one successfully decreased the co-activation of arm muscles, while the other successfully improved the selective activation of leg muscles. This is a first proof of concept that people with SCI can acquire, through the proposed MCI, a greater awareness of their muscular activity, reducing abnormal muscle simultaneous activations.

In daily life it is necessary to learn skills that can be applied in different tasks and different contexts. Usually these skills are acquired by observation or by direct physical training with another expert person. The critical point is to know which is the best possible way to achieve this knowledge acquisition. In this work we have proposed a collaborative environment where subjects with different levels of expertise have to interact through the use of a robotic platform. A motor skill learning algorithm has been designed in order to allow the less skilled subjects-naïves-to explore the virtual environment and to exploit the advantages of working with a skilled partner. Results show that the correct trade - off between exploration and exploitation, provided by the implemented algorithm applied during the dyadic training, allows a group of naive subjects to learn the task and generalize better the acquired skills respect to subjects trained without the proposed algorithm.