Over the past decade, there has been increased interest amongst researchers, practitioners and policymakers in physical literacy for children and young people and the assessment of the concept within physical education (PE). This systematic review aimed to identify tools to assess physical literacy and its physical, cognitive and affective domains within children aged 7–11.9 years, and to examine the measurement properties, feasibility and elements of physical literacy assessed within each tool.Six databases  were searched up to 10th September 2020. Studies were included if they sampled children aged between 7 and 11.9 years, employed field-based assessments of physical literacy and/or related affective, physical or cognitive domains, reported measurement properties (quantitative) or theoretical development , and were published in English in peer-reviewed journals. The methodological quality and measurement properties of studies and assessment tools were appraised using the COnsensus-based Standards for the selection of health Measurement INstruments risk of bias checklist. The feasibility of each assessment was considered using a utility matrix and elements of physical literacy element were recorded using a descriptive checklist.The search strategy resulted in a total of 11467 initial results. After full text screening, 11 studies (3 assessments) related to explicit physical literacy assessments. Forty-four studies (32 assessments) were relevant to the affective domain, 31 studies (15 assessments) were relevant to the physical domain and 2 studies (2 assessments) were included within the cognitive domain. Methodological quality and reporting of measurement properties within the included studies were mixed. The Canadian Assessment of Physical Literacy-2 and the Passport For Life had evidence of acceptable measurement properties from studies of very good methodological quality and assessed a wide range of physical literacy elements. Feasibility results indicated that many tools would be suitable for a primary PE setting, though some require a level of expertise to administer and score that would require training.This review has identified a number of existing assessments that could be useful in a physical literacy assessment approach within PE and provides further information to empower researchers and practitioners to make informed decisions when selecting the most appropriate assessment for their needs, purpose and context. The review indicates that researchers and tool developers should aim to improve the methodological quality and reporting of measurement properties of assessments to better inform the field.CRD42017062217PROSPERO: The online version contains supplementary material available at 10.1186/s40798-021-00324-8. This systematic review identified 52 existing assessment tools related to the physical, affective and cognitive domains of physical literacy for use in children aged 7–11.9 years old.Only three explicit (self-titled) physical literacy assessments were found. While these more comprehensive assessments show promise, more studies are needed to demonstrate their methodological rigour and feasibility for use in primary school settings.This review identified a number of valid, reliable and feasible measures of elements of the physical and affective domains that could be useful in a pragmatic physical literacy assessment approach within physical education. More assessment development work is needed with regards to measuring the cognitive domain of physical literacy. Findings indicate that researchers and tool developers should aim to improve the methodological quality and reporting of measurement properties of assessments.th Century ), or equipment to measure specific elements such as manual dexterity (e.g. pegs and a pegboard [BOT-2 SF]). Furthermore, the majority of assessments required either a PE/Sports specialist/researcher to administer (80%), with only two tools (PARAGON and MUGI) being appraised as “Able to be administered by qualified teacher”.The aim of this systematic review was to identify and appraise tools to assess physical literacy and related affective, physical and cognitive elements within children aged 7–11.9 years old for use in a primary school PE setting. From 88 studies, a total of 52 unique quantitative assessments were identified and subsequently examined for validity, reliability, feasibility and physical literacy elements being measured. In contrast to Edwards et al. , our seaTo be included in this review, studies of quantitative assessments of physical literacy and related domains had to report data for at one least measurement property from the properties assessed using the COSMIN risk of bias checklist. Overall, the methodological quality of studies reporting this information was inconsistent. Studies tended to examine and report on one or two measurement properties , but rarely addressed all relevant measurement properties within the risk of bias checklist. Reliability was most frequently assessed across all domains, echoing the findings of recent reviews investigating motor skill assessments –169. TheRecent guidance from COSMIN outlines that tool development and content validity are the most important measurement properties to be considered for assessments , 62. We www.capl-eclp.ca/)  . TherefoKlingberg et al.  conducteFeasibility findings suggest that there is insufficient attention given to reporting the expertise, confidence and competence of individuals required to administer assessments, particularly in assessments within the affective and cognitive domains. Therefore, an effective assessment would need to consider who would be conducting it to determine any potential training needed, ultimately, this would be an influential factor in the overall cost of the assessment. Edwards et al. , 53 and Goss et al.  recentlyOur findings suggest that there is scope for more research developing and examining rigorous qualitative methods of physical literacy assessment for use in primary school contexts. Such methods might include interviews, verbal discussions, pupil diaries, portfolios, photographs, video, text, drawing tasks and storytelling , 48, 202(i)The use of wider search terms encompassing physical literacy elements identified 52 physical literacy or related affective, physical and cognitive assessments that can be used to inform assessment approaches in PE.(ii)An assessment of the methodological quality of included studies through the COSMIN risk of bias checklist enabled a robust, transparent and systematic appraisal of the validity and reliability standards of the identified quantitative assessments.(iii)The reporting of the feasibility of assessments provided pragmatic information that can be used by teachers, coaches and researchers to decide whether a tool is appropriate for use in PE and educational contexts.The strengths of this systematic review include:(i)Only papers published in the English language were considered. Thus, the identified assessment tools were primarily derived from the US, the UK, Australia, Canada and Western Europe and relevant assessments developed within non-English language countries may have been missed.(ii)To be included in the review, articles had to be published in a peer-reviewed journal and written in the English language. Therefore, tools developed by practitioners and used currently within schools may not have been captured.(iii)Although we used “assessment” related search terms in our search strand, we did not capture any qualitative assessments of physical literacy. Had we used more specific qualitative methods as search terms  then we might have captured more assessments better aligned with an idealist perception of assessment of physical literacy.(iv)swimming”, “dance” and “gymnastics”. Inclusion of these terms may have better captured water-based assessments and tools assessing elements such as rhythm, coordination and expressive/aesthetic movement.The developed search strand did not include sport-specific search terms such as, “(v)The physical literacy elements checklist reflects commonly identified elements and was developed by the research team through discussion in a closed meeting after an overview of international physical literacy literature was conducted , 67–69. (vi)Each assessment tool was appraised for physical literacy elements in accordance with the explicit information provided within the associated studies and manuals. It is therefore possible that some tools may assess wider elements than those appraised within our results and this should be explored in future research.The limitations of this systematic review include:There is demand amongst primary school children and wider stakeholders in England for assessments to chart progress in physical literacy . This syAdditional file 1.Additional file 2.Additional file 3.Additional file 4.Additional file 5.


Maximizing performance success in sports is about continuous learning and adaptation processes. Aside from physiological, technical and emotional performance factors, previous research focused on perceptual skills, revealing their importance for decision-making. This includes deriving relevant environmental information as a result of eye, head and body movement interaction. However, to evaluate visual exploratory activity (VEA), generally utilized laboratory settings have restrictions that disregard the representativeness of assessment environments and/or decouple coherent cognitive and motor tasks. In vivo studies, however, are costly and hard to reproduce. Furthermore, the application of elaborate methods like eye tracking are cumbersome to implement and necessitate expert knowledge to interpret results correctly. In this paper, we introduce a virtual reality-based reproducible assessment method allowing the evaluation of VEA. To give insights into perceptual-cognitive processes, an easily interpretable head movement-based metric, quantifying VEA of athletes, is investigated. Our results align with comparable in vivo experiments and consequently extend them by showing the validity of the implemented approach as well as the use of virtual reality to determine characteristics among different skill levels. The findings imply that the developed method could provide accurate assessments while improving the control, validity and interpretability, which in turn informs future research and developments. Physical skills and abilities of athletes have been examined and improved for decades applying real-time ,2 or posIn fast-paced team sports, like soccer, athletes have to face an environment that is highly unpredictable and unstable. A large field including 22 players showing constant movement makes the game dynamic and complex, resulting in almost infinite possibilities to act and react. Athletes are forced to focus their attention on relevant information sources for efficient decision-making and anticipation processes. Consequently, with pro athletes showing superior skills in these areas, knowing more about them is beneficial for various areas like talent identification and performance improvement . Sports Visual exploration enables athletes to gain environmental information. In this sense, exploratory actions entail eye, head and body movements supporting the identification of opportunities for successful acting within a 360° environment in soccer. To investigate VEA, a broad variety of studies focuses on gaze behavior of athletes using eye tracking technology . These sTaking an easily applicable approach, the potential of head movement metrics within VEA is not holistically explored. First research in this area was able to identify parameters like the frequency or excursion of head turns to be relevant . NeverthIn this regard, technology had and continues to have a major impact on sports. For example by allowing a deeper understanding of athletes’ performance in diverse sport situations and by providing decision support for coaches and athletes. Therefore, sensor- and display-based methods were developed and employed to establish meaningful objective performance measures ,18,19,20Compared to traditional media formats, VR can allow for a greater degree of presence and hence enable training experiences closer to a realistic game context . It can Even though it could be shown that inertial sensors can be used for assessing athletes exploratory behavior in different sport situations ,25, littIn this paper, we contribute the design and implementation of a dynamic virtual soccer environment, consisting of multiple virtual plays that are created using real-world tracking data. We demonstrate the use of the simulation to assess the head motion behavior of soccer players while performing a recognition and recall task. We propose an assessment strategy and pipeline consisting of six different head turn measures based on head velocity data gathered from inertial sensors integrated into an HMD. Additionally, we utilized the gained data to investigate the focus area of athletes by determining the cFOV time on relevant objects . In a user study including 28 soccer players of two different skill levels, we investigated the plausibility of the developed analysis pipeline. We further assessed the quality of the VE by measuring the experienced presence and the user experience of participants.Results show significant differences between skill levels for the head turn measures HTC, HTE, HTF, as well as HTVel and its variability. Significant differences could also be observed for the duration of centered objects. Further, we found a significantly high correlation between the HTE and the experienced presence. The findings in this work demonstrate the validity of the investigated measures and VR as a medium for assessing the exploratory performance of team athletes. Resulting implications are important for manifold team sports assessment simulations and guide further research.The human process of perception comprises interpretation and understanding of geometrical shapes or objects, registered by the visual system . RegardiVEA in sports encompasses all movements of the eye, head and body in regards to perceiving relevant environmental stimuli prior to dedicated events and actions ,34,35. ITo investigate search behavior and perception of athletes most prevalent eye tracking is used in previous studies for the quantification of performance. Therefore, different dependent variables like the mean, location, duration and total number of fixations as well as amplitude, frequency, latency or velocity of saccades are used. In a review conducted by McGuckian et al., the number of fixations and fixation duration could be identified as the most dominant measures to be applied for analysis . Even thIn contrast, there exists research that found fewer fixations for experienced or more skilled soccer players ,39,40. CIn a recent study conducted by Aksum et al., the search behavior of five players in the Norwegian premier league in an 11 vs. 11 game was investigated . They coFurther studies investigated the head activity of athletes to draw conclusions on exploratory activity. Relevant measures in these studies are the duration, excursion and frequency of a head turn. The majority of these studies uses a manual evaluation process annotating relevant actions supported by video footage to analyze the behavior of participants ,43,44. E−1 [Other research suggests the application of IMUs or MEMS to determine the VEA of athletes. Using a head-worn sensor-based method, Chalkley et al. defined a head turn as a distinct movement along the longitudinal axis that exceeds an angular velocity of 125° s−1 ,45. To v−1 , playing−1  and pass−1 . To expl−1 .In summary, previous research investigating the implications of VEA mainly employed methods that are based on simple displaying procedures like 2D video clips, images or require labor and/or cost-intensive systems like the Footbonaut. However, due to high immersion and presence, VR has great potential for the assessment of behavior. Especially when it comes to identifying and developing new objective metrics to quantify athletes’ performance, only few research is conducted. Addressing this research gap is crucial since it provides the possibility of getting deeper insights into the behavior of athletes while being able to provide a realistic 360° reproducible environment based on stereoscopic vision.For different team sports there exists previous work investigating the feasibility of VR for assessing the decision-making process of team sports athletes ,23,48. IPrevious research work also investigated the applicability of VR for improving the decision-making process of quarterbacks ,49. In aOther research work addressed anticipation skills of athletes ,51,52. MAdditionally, the anticipation of rugby players was evaluated by Bideau et al. using VR . In theiIn summary, whereas there is research conducted investigating the performance of athletes using VR, these evaluations are mainly based on simple measures  and hence do not characterize athletes’ performance in more detail. Precisely, to the best of our knowledge, there is no work that examined head motion characteristics for defining VEA of athletes in dynamic game situations using VR. To address this research gap, we developed and evaluated a new VR-based method, including 18 dynamic soccer plays, that uses different head turn-based measures, namely the head turn frequency, the duration and the excursion as well as average head turn velocity and its variability to characterize VEA of athletes. Further, athletes’ FOA is evaluated by determining the duration of relevant objects within their cFOV. The developed method gives deeper insights into athletes’ performance and consequently can be used to optimize individualized training as well as talent development and scouting processes.https://assetstore.unity.com/packages/3d/characters/soccer-players-stadiums-pack-105891, accessed on 25 May 2021) were utilized and modified, fulfilling the international football standards recommended by the International Federation of Association Football (FIFA) [To create the virtual soccer environment, real-world soccer plays were mapped on agents within the VE including the ball. Therefore, nine 6 vs. 6 soccer plays were recorded using a LPS. The positioning data was pre-processed and mapped on soccer agents and a virtual ball. Also, a realistic stadium scene was created. To do so, existing assets from the Unity asset store (l (FIFA) .Real-world recorded positioning data of 11 soccer players was used to design a realistic soccer simulation. These players performed a total of nine plays representing offensive and defensive game situations. To ensure a high level of plausibility, the structure and procedure of the plays were designed by sport experts. Each game situation consisted of two teams, including five teammates and six opponents. Every play ended with the user receiving a pass. The nine plays varied in the movement of the teammates and opponents. Furthermore, two user positions were defined. A central position closely oriented behind the striker was chosen for the offensive plays. For simulation of the defensive situations, the user was positioned close to the central defender. For data recording of these plays, we used a Kinexon LPS tracking system. The system consisted of 14 antennas placed around an outdoor soccer pitch. Data was collected at 20 Hz using UWB technology in a frequency range of 4.25–7.25 GHz.−1. To increase the number of and decrease the memorability of individual plays, the nine originally recorded plays were visually mirrored in the virtual simulation. This resulted in a total of 18 plays. Further, the appearance of the soccer agents was changed. The faces, skin colors, hairstyles, as well as jersey colors and numbers of opponents and teammates were randomly assigned for each play.To enable the data acquisition, soccer players were equipped with a sensor beacon on the back including a 9-axis IMU. Additionally, a beacon was attached to the inside of the ball. All players were briefed individually regarding their movement behavior to be performed. For each play, multiple data acquisitions were made. The most adequate dataset was selected by two sports science experts depending on the players’ behavior. Therefore, additional video footage from a bird’s eye view camera placed on a stand next to the pitch was used as a reference. For the nine different plays, 2D relative positioning data represented by x and y coordinates on the tracked soccer pitch were recorded as well as the velocity of the individual players and the ball measured in mst is the time and To animate the virtual agents representing teammates and opponents within the simulation as well as the ball, pathways were defined based on the acquired real-world staged play data . The movhttps://assetstore.unity.com/packages/3d/characters/soccer-players-stadiums-pack-105891, accessed on 25 May 2021).The moving direction was used to determine the orientation of agents. An agent’s body was centrally aligned in respect to the movement vector. To simulate appropriate locomotion of agents, four moving animations were applied. These animations varied in the behavior of the skeletal model including idle, jogging, running and sprinting. The animations were pre-recorded and part of the used assets package from the Unity asset store , a 32 GB installed RAM, and the NVIDIA GeForce RTX 2080 Ti graphics card was used.To calculate the head movement-based measures, the orientation of the HMD was recorded in 3D space for each frame. A Savitzky–Golay filter was applied for smoothing the data . It perf−1. The HTF is the equivalent time-normalized parameter, given in turns per second [The HTC describes the head turns during a specific time frame. A head turn in sports is defined as a fast rotation of the head around the vertical axis of the body, exceeding an angular velocity of 125° sr second ,25.The excursion of a specific head turn is described by the HTE. It quantifies the absolute radian measure between the beginning and end of a detected head turn in degree. Likewise, the HTD describes the duration of a head turn ,25.In this work we define the HTVel as the velocity around the vertical axis also referenced as yaw-velocity. The HTCoV is calculated using yaw-velocity. It is defined as the standard deviation in relation to the mean and therefore describes the variability of velocity. It is represented in percent. Concerning sports, we see the HTCoV as an indicator of an athlete’s volatility in head motion.For the FOA the cFOV is chosen as a reference to investigate the focus of an athlete in relation to different objects within the VE. To determine the focused object, the minima of the Euclidean distance between the rendered objects and the cFOV is used as a selection criterion for each frame. The FOA is measured in time (s) spent on predefined objects .s is the number of visual stimuli presented within the virtual environment and a is the number of stimuli recognized by the user.The RRS reflects the capability of soccer players being able to recognize and recall the number of stimuli during a play see . The RRSTo determine the presence of participants within the virtual soccer environment, the PQ as recommended by Witmer and Singer  was usedFor evaluating the user experience of participants, we used the UEQ . It incl and bad .A total of 28 soccer players  with an average age of Participants were welcomed and gave informed consent to be aware of risks associated with the conducted study. Then they were asked to give demographic information by filling out a questionnaire. Next, the study procedure was explained and the HMD was calibrated by adjusting the lens-to-eye distance and lens distance. Five introduction plays were shown, to ensure that the participants were familiar with the virtual soccer environment and the task to be performed.Following, each participant experienced the 18 unique plays in a randomized order during one trial. In total, two trials were performed. Within one play, some of the teammates were marked with labels above their heads, representing the number printed on their jersey in the respective jersey color. Before the beginning of a simulated play, participants were placed at one of the two pre-determined positions see . From thFor each play data on participants head movement was acquired before receiving the ball. After experiencing the two trials, participants were asked to rate the quality of the simulation by filling out the UEQ and PQ. For statistical analysis of significance, the two groups were compared applying a Welch’s two-sample t-test. To examine the linear correlation between individual measures, we calculated Pearson’s correlation coefficient. For all statistical measures a significance level As depicted in −1 for the inexperienced group and −1 for experienced athletes.For the number of head turns (HTC), we found a significant difference . Less experienced players rated this factor higher compared to their counterparts. No significant difference could be found for the results of the presence questionnaire between the two groups. Inexperienced athletes  ,25. One Nevertheless, results in this study are comparable to in vivo experiments and suggest that our method can objectively assess VEA of athletes, and therefore optimize the examination of perceptual-cognitive skills in sports.In our study, experienced player had a significantly lower head turn frequency. This may be caused by a beneficial attitude of orienting their body for action and observation concerning relevant events on the pitch. Consequently, they do not need of adapt their position and orientation that frequently compared to less experienced players ,61. AccoContrary to the absolute amount and frequency of head turns, the duration of head turns did not seem to significantly differ between the two groups. This indicates that even though athletes with less experience show a higher exploratory behavior, this is not influenced by the individual time a movement takes. We could observe an increase in HTD over trials which could be related to the need of habituating to motion in an immersive VR . Highly Another interesting observation is the difference in the variability of velocity between the two groups (HTCoV). More experienced players showed a significantly higher volatility. Meaning, the velocity characteristic of less experienced athletes can be described as performing more frequent spontaneous movements in comparison to their counterparts, who tend to have a higher standard deviation, but a lower average angular velocity. To the best of our knowledge, this effect has not been previously reported. Future research should further investigate this finding using in vivo soccer scenarios.Our results regarding the FOA show that low experienced players tend to focus significantly longer on opponents compared to more experienced ones. Further, the latter had a significantly higher interest in observing the ball and spent more time focusing on teammates. These findings go in line with previous in vivo experiments ,41,64. FRecently published work by Aksum et al. indicates that the search behavior of professional athletes differs between laboratory results ,65 and aOverall, we provided a new approach to determine athletes’ FOA in dynamic VR-based soccer scenarios. Its capability to distinguish different experience levels contributes by creating a more holistic view of athletes’ behavioral characteristics in dynamic game situations and hence informs future research and development. To enable a more detailed analysis for future research in VR, this approach could be optimized to allow the differentiation of more object types like the player in possession of the ball. Another alternative would be the investigation of gaze behavior using eye tracking to be able to not only provide information of the center focus area of an athlete, but additionally determine the area of interest. However, results of exploratory behavior of athletes seem not to be clear when looking at previous literature ,37,64,65Nevertheless, the applied method could provide comparable results to previous in vivo experiments. This indicates that the employed VR-based approach is an effective alternative to in vivo measurements for assessing soccer players’ FOA. Further, having a holistic view of the athlete by providing more head-based exploratory measures can be beneficial to understand the behavior of athletes in dynamic competitive situations.In our study, the findings for the RRS showed that, unexpectedly, less experienced players reached a significantly higher score of approximately ed plays . The reaed plays ,67. The Another reason for this finding could be the restriction in peripheral vision. According to previous in vivo studies, superior soccer players make more use of peripheral information than their counterparts ,65. SincIn addition, we found that the RRS strongly correlated with the HTC, HTE, HTF, and HTVel. These results revealed that a more intensified overall head activity led to a higher recognition and recall ability for unstructured visual information during the experiment. While for less experienced players this could be observed for the frequency of head turns, experienced players’ RRS also showed a strong positive correlation for HTE. Previous literature states that extensive exploratory activity within the period before receiving the ball of soccer players results in more successful actions with the ball . In thisIn summary, the assessed RRS could show significant differences between the two examined experience levels. The positive correlations found between the head activity measures applied in this work and the RRS underpin the assumption that higher exploratory activity in team sports leads to more information retrieval decisive for successful decision-making . HoweverThe employed VR simulation achieved a high score when comparing user experience results to the UEQ benchmark dataset, except for the factor dependability. The reason for the low rating might be that the task of the participants within this study was to only explore the environment and hence no direct interaction possibilities to manipulate the VE were given. For future research, this could be improved by providing intuitive interaction in such a sports scenario as foot interaction.For the UEQ we could observe significant differences for the factors novelty and stimulation between the two investigated experience levels. Reasons for such a difference may lie in the fact that higher experienced athletes are more used to technique supported assessment and training methods. Prior use of HMDs should not have influenced the results, since the experience with those devices was comparable between the two groups. Previous literature could show that athletes’ personality traits affect the perceived user experience in VEs . Hence, We could not observe significant differences in presence between the two groups. Concerning the UEQ, this is an interesting finding, since even though the experience level seems to significantly influence the perception of a simulation’s hedonic quality, the same does not apply for the perceived presence. From our perspective, this underpins the suggestion of having additional quality measures besides the factor of presence to get a holistic view of the user experience when evaluating VR simulations.The subjectively perceived presence of athletes showed a significant positive correlation with HTE and HTVel. While this could be observed for less experienced players, presence correlated significantly with HTE and HTD for more experienced athletes. From our perspective, HTE could be a relevant parameter, to objectively define presence. As stated by Usoh et al., an increased presence results in a greater similarity of comparable users’ real-world behavior in VEs. Therefore, such measures yield great potential to relate to presence . This poHowever, to the best of our knowledge, there is no research work yet which could show that users’ excursion of head turns (HTE) strongly correlates with their subjectively perceived presence for an exploration task in VR.In summary, this work contributes in various ways. We created a new analysis pipeline consisting of multiple head motion characteristics that have not been investigated in a VE before. These measures were applied within a dynamic recognition and recall task to examine the VEA of inexperienced and experienced soccer players. Further, the experienced presence and overall user experience of participants regarding the VE was evaluated. Our results show that our approach could be successfully used to distinguish between different experience levels of players and can therefore be used for VEA assessment. In team sports, this is highly relevant since it enables to design more efficient assessment processes and hence is supportive in creating a more holistic view of athletes to optimize individual performance improvement processes.We further found that the subjective measure of presence strongly correlated with the HTE of participants. Since to the best of our knowledge, the correlation between those two variables has not been examined in any previous research, we see this as an additional major contribution of this work, that needs to be further investigated.Results of the head motion characteristics showed a significant difference between the two investigated groups in terms of HTC, HTCoV, HTE, HTF and HTVel. The findings go in line with comparable in vivo studies conducted in team sports. Consequently, this makes these measures a promising tool for the assessment and training of athletes in VR. The results further strengthen the applicability of VR as an efficient immersive medium for performance analysis in sports.Another contribution of this work is the exploration of athletes’ focus of attention in VR. Therefore, an approach was chosen and evaluated that measured the focus time of soccer players on the visual ball, opponents and teammates. Significant differences were found for the two examined groups varying in experience level. This could be further improved in the future by using eye tracking.Less experienced athletes outperformed their counterparts in the recognition and recall task. One reason for this might be the lack of full natural peripheral vision caused by the used HMD. Professional soccer players tend to derive decisive information from this visual area more extensively than amateurs . This isFor the subjective experience of athletes, we found significant differences between the two groups for hedonic quality , whereas no significant variation could be observed for presence. However, in sports, motivation and the experienced stimulation of the athlete play a decisive role. Therefore, to get a holistic view on the user experience for the VE to be developed, derived from the observations made in the conducted study we recommend to not only investigate the presence of an athlete, but also consider motivational linked factors like novelty and/or stimulation.


The 10-item Body Appreciation Scale-2 (BAS-2) is a measurement for individuals to self-report the extent to which they accept and respect their bodies. Although the BAS-2 has been translated into the Malay language and found to have promising qualities, the psychometric characteristics of the English version of BAS-2 remain unknown in the Malaysian context. The present study thus administered the English version BAS-2 and selfie-editing frequency scale to 797 individuals aged 18 to 56 years old in Malaysia. The dataset that was randomly divided into two halves were submitted to exploratory factor analysis and confirmatory factor analysis respectively. Both of the factor analyses consistently support a one-factor model. The Cronbach’s alpha and McDonald omega coefficients were greater than 0.90, indicating that the BAS-2 has good internal consistency. The incremental validity is also evident. A hierarchical multiple regression showed that the BAS-2 score had a positive relationship with selfie-editing frequency after controlling for age and gender. Moreover, the measurement invariance test supported scalar invariance between genders, and an analysis of covariance did not find significant gender differences. Overall, the findings replicate past findings and regularly support the usability of the BAS-2 in the Malaysian context. The implications of the BAS-2 and future directions are also discussed. Obesity has always been a great challenge to Malaysia. According to the World Population Review , Malaysid = 0.27, 95% confidence interval (CI): 0.21, 0.33, p < 0.001). Moreover, the mean gender was found to negatively predict the gender differences. In other words, the gap in body appreciation between genders reduced when age increased.Obesity is detrimental to body satisfaction . StudiesTo achieve the above-mentioned goal, however, a measurement tool of body appreciation is needed. Avalos and colleagues  developeAlthough the Malay version of the BAS-2 shows promising psychometric qualities, little is known about the psychometric properties of the original English version of the BAS-2 in the Malaysian context. It is therefore critical to address this gap for two reasons. First, it is inadequate to generalize the findings of the Malay version of the BAS-2 in the English version of the BAS-2. Inarguably, even when a well-established measurement has been translated into many different languages, researchers are still required to examine the psychometric qualities of the translated version before employing it. This is necessary since the participants presented with items in different languages may perceive the items differently and hence the factorial structure, reliability, and validity of the measurement may be compromised .Second, Malaysia is made up of four major ethnic groups, namely Bumiputera , Chinese, Indians, and others. Malaysians residing in their multiethnic and multilingual country freely use multiple languages in formal and informal settings . MoreoveTaken together, the present study was set to examine the factorial structure (using EFA and CFA), reliability, incremental validity (using selfie-editing frequency), and tested measurement invariance of the BAS-2 using a multigroup CFA in the Malaysian context. The findings are expected to shed light on the usability of the English version of the BAS-2 in Malaysia.2(1243) = 1095.527, p = 0.999), the dataset was randomly split into two sets: exploratory and confirmatory datasets. The exploratory dataset was submitted to an EFA (n = 392) to explore the factorial structure of the BAS-2, while the confirmatory dataset was used for a CFA (n = 405) to verify the factorial solution suggested by the EFA.A total of 799 individuals currently residing in Malaysia participated in the present study voluntarily. Of the participants, 2 individuals below 18 years old were excluded resulting in 797 responses . The mean age was 22.97 (SD = 5.42) and it ranged from 18 to 56 years old. The sample consisted of Chinese (58%), Malays (27.20%), Indians (11.40%), and participants with other ethnicities (3.40%). The participants were recruited either from undergraduate courses at universities or social networking sites using convenience and snowball sampling. The data, which were collected between August and October 2020 for a larger project of body image, were approved by the Scientific and Ethical Review Committee of Universiti Tunku Abdul Rahman (Ref: U/SERC/104/2020). The variables that are irrelevant to the present study were not reported for the sake of clarity. After replacing the missing values (<2%) using the expectation–maximization technique  was empBesides, we employed Yue et al.’s  13-item 2/df), comparative fit index (CFI), Tucker–Lewis Index (TLI), root mean square error of approximation (RMSEA), and the standardized root mean square residual (SRMR). A well-fitting model should pass the recommended cutoff criteria, such as χ2/df < 3, CFI and TLI > 0.95, RMSEA ≤ 0.05, and SRMR < 0.08 .The 10-item single-factor model revealed by the EFA in Study 1 was tested using a CFA with an unweighted least squares (ULS) estimation. The model showed a good fit to the data: χ2 (35) = 57.32, p = 0.010, χ2/df = 1.64, CFI = 0.998, TLI = 0.998, RMSEA = 0.028, 90% CI = , and SRMR = 0.032.As both the EFA and the CFA results consistently support a one-factor model, we used the total sample for testing the validity and measurement invariance between the gender groups. Prior to that, we ran a CFA on the total sample to ensure the fitness of the model to the data. The result showed a good fit: χr = 0.125, p < 0.001) and selfie-editing frequency , and there was a gender difference in age  = −4.14, p < 0.001, Cohen’s d = −0.31, 95% CI ), and selfie-editing frequency  = 4.425, p < 0.001, Cohen’s d = 0.32, 95% CI ), age and gender  were entered to the first model (Model 1) followed by the BAS-2 score (Model 2). The Model 2 was statistically significant and explained 4.30% of the variance: F = 11.83, p < 0.001, ΔR2 = 0.005, ΔF = 3.93, p = 0.048. After controlling for the effect of age  and gender , the BAS-2 scores  showed a negative relationship with the selfie-editing frequency, supporting the incremental validity.A hierarchical multiple regression with selfie-editing frequency as the outcome variable was conducted to examine the incremental validity of the BAS-2. As the BAS-2 score was correlated with age  and females (n = 478) in the BAS-2 score. An analysis of covariate (ANCOVA) with age and selfie-editing frequency as the covariate variables was thus conducted to compare the BAS-2 score between the two gender groups. The results showed that both age, F = 10.28, p = 0.001, η2 = 0.01, and the selfie-editing frequency, F = 3.93, p = 0.048, η2 = 0.01, had a significant relationship with the BAS-2 score. After excluding the effects of age and the selfie-editing frequency, there was no significant difference between the males  and females  in the BAS-2 score, F = 0.01, p = 0.928.Such support for scalar invariance indicates the adequacy of the testing whether there is a difference between males  among individuals in Malaysia. In line with the literature , the EnWe first explored the factorial structure of the BAS-2 using an EFA. A parallel analysis revealed a single factor thus supporting the BAS-2 as a unidimensional scale. Next, we conducted a CFA to confirm the unidimensionality of the (English) BAS-2. In line with the literature e.g., ,20,22), ,22, 20,2In addition, we also found evidence of the incremental validity of the BAS-2. After statistically controlling for age and gender, the BAS-2 still showed a significant and negative relationship with selfie-editing frequency. The results are in line with the impression management theory  that regOur findings benefit the literature by providing another piece of evidence to the usefulness of the English version of the BAS-2. The replication also sheds light on the qualities of the BAS-2 in the Southeast Asian context. Similarly, the findings have practical implications for body image research in Malaysia. As English is widely used across different age groups  and contexts  in Malaysia, the English BAS-2 can be used for different Malaysian populations. In the same vein, the BAS-2 can be employed in cross-cultural studies on body image. For instance, researchers may first investigate the measurement invariance of the BAS-2 across countries e.g., ,35) and  and 35])The present study replicates the findings of Swami et al. , implyinThe present study demonstrates that the English BAS-2 is a psychometrically valid tool for assessing the level to which individuals in Malaysia appreciate their bodies. Both the EFA and the CFA support that the BAS-2 is a unidimensional measurement with good internal consistency, incremental validity, and measurement equivalence between genders. As obesity has become a critical issue in Malaysia, the BAS-2 would be useful for researchers and practitioners to advance the research and interventions related to body image in the Malaysian context. There is also the potential for the use of the BAS-2 in cross-cultural studies to provide valuable insights into the antecedents and consequences of body appreciation in different cultural settings.


Dirofilaria immitis as the first reported autochthonous Dirofilaria immitis infection in Austria. There was no history of periods abroad. Echocardiography showed suspected D. immitis in the right cardiac chamber with increased pulmonary pressure and ascites. Surgical removal of the heartworms was performed. Twenty adult heartworms were removed by transvenous jugular approach under general anesthesia and stored in 4% formalin. Five out of 20 specimens were examined via light and stereomicroscopy and feline heartworm infection was confirmed. Amplification of a 203 bp or 724 bp fragment of the cytochrome c oxidase subunit I gene was unsuccessful. After surgery the cat developed acute renal failure but recovered quickly. One year later, the cat underwent a control examination including echocardiography and blood work. There were no more D. immitis detectable at echocardiography. Lung pressure was mildly increased. Complete blood count and creatinine were unremarkable. The Knott’s test and Dirofilaria-Antigen-test produced negative results. The cat did not show any clinical signs during the follow-up period. The aim of this case report is to highlight the growing risk of acquiring infection with D. immitis not only for Austrian dogs, but also for cats. This case report represents the first report of autochthonous D. immitis infection in Austria. Moreover, even if the prognosis in cats with caval syndrome due to feline heartworm disease is guarded to poor, surgical removal of the filariae can be a successful treatment option.This case report is about a seven-year-old male neutered European Shorthair cat infected by  Dirofilaria immitis belongs to filarioid nematodes and represents the underlying agent for feline heartworm disease (FHWD) and heartworm associated respiratory disease (HARD). D. immitis infects mainly dogs but also cats, ferrets, wild carnivores and humans, and more than 70 different species of culicid mosquitos can act as vectors [D. immitis infection has been reported mainly in temperate, tropical and subtropical areas of the world. The largest endemic area in Europe can be found in the Po River Valley in northern Italy, where the prevalence in non-preventive-treated dogs ranges up to 80% [D. immitis emerges in new countries due to globalization and increased travel as well as the import of infected dogs. In addition, climate change and the adaptability of vectors play major roles in the spreading of D. immitis [D. immitis cases in dogs more than doubled, and it is suspected that Austria is facing pre-endemic status [Aedes vexans and the Culex pipiens complex are already known to act as potential vectors for Dirofilaria parasites. One main reason for the delayed introduction and establishment of D. immitis is the lack of microfilaraemic dogs as a consequence of less common kennelling or outdoor keeping of dogs in Austria [Feline heartworm disease can be quite a challenging diagnosis for veterinarians due to its unique nature and physiopathology . Dirofil vectors ,3. D. imp to 80% . D. immi immitis . Betweenc status . In Aust Austria . PrevaleD. immitis. Compared to dogs, only a low number of L3 larvae develop to the adult stage, which also takes about seven to nine months. What is more, microfilariae (L1 larvae) are able to develop in only 20% of cats with mature female and male worms. Unlike in cats, significant microfilaraemia that can last for years develop in dogs. The lifetime of adult heartworms in cats up to four years old is shorter than in dogs, and adult D. immitis in cats are also smaller. Moreover, about 25% of cats are naturally resistant to infestation with D. immitis [Cats represent imperfect hosts for  immitis . Cats wi immitis . On the  immitis . Further immitis .Severe pathological and life-threatening changes despite low parasite load of one to six adult worms per cat can be found early in cats . After iTo diagnose FHWD, a multimodal approach is necessary. A combination of diagnostic tools like thoracic radiographs, serum antibody tests, echocardiography and serum antigen tests are recommended. Necropsy is the gold standard for detecting adult worms ,10,11. MIn contrast to dogs, adulticidal therapy is not recommended because FHWD self-cures in most cases within 18–48 months. Surgical removal of the adult filariae can be performed in symptomatic cats. It is important to remove intact worms to avoid anaphylaxis. Monthly administration of macrocyclic lactones is strongly recommended in endemic areas ,15.To our knowledge, there are no reports of FHWD in Austria. In this case report, we describe a clinical case of autochthonous heartworm infection in a cat in Austria.A male neutered European Shorthair cat, seven years of age, 6 kg weight, was referred to the Veterinary Hospital Parndorf in the province of Burgenland, Austria for echocardiography in March 2020 . Prior tOn clinical examination the cat showed calm and attentive behaviour, slightly pale mucous membranes, preserved skin elasticity, increased breathing, a systolic heart murmur Grade IV/VI best heard on the right hemithorax, moderate vesicular breath sounds, weak femoral pulse and lymph nodes within normal limits.The pretreatment by the referral vet included Benazepril 0.4 mg/kg once daily and Furosemide 1.6 mg/kg twice daily with no improvement of clinical signs. The referral vet also took thoracic and abdominal radiographs. The thoracic radiographs showed a diffuse bronchointerstitial pattern of the pulmonary parenchyma with enlarged pulmonary arteries. The abdominal radiographs revealed decreased delimitation of the abdominal organs—most likely due to ascites.D. immitis.Echocardiographic exams were performed by a single experienced operator with GE vivid™ S6, equipped with a microconvex GE 7s probe. The right atrium showed severe dilatation, and several double lined hyperechoic echoes close the tricuspid valve were seen . The susAfter a period of reflection, the owner opted for a surgical attempt. Surgical removal of the suspected heartworms was scheduled two days after first presentation.®  and Idexx Catalyst DX® . The cat showed a severe hyperchromic, macrocytic regenerative anaemia. What is more, the cat showed a mildly increased count of leucocytes with mildly increased neutrophils, lymphocytes and monocytes. Creatinine was 2.4 µmol/L which was in the upper reference interval. The Combo+ Snaptest®  for infection with feline immunodeficiency virus (FIV) and feline leukemia virus (FeLV) showed a positive result for FeLV. No antigen testing for D. immitis was done before surgery due to the owner’s cost restrictions.Before anaesthesia, blood analysis  and the skin incision was also closed with the same suture material in a routine manner.The cat was placed in left lateral recumbency for surgery. The right jugular vein was incised for a transvenous approach to the vena cava. A pair of flexible alligator forceps with 40 cm length—which usually finds use in endoscopy—was used to remove the suspected heartworms guided by echocardiography and C-arm. By use of this technique, which was described by Glaus et al., 1995  the succDirofilaria specimens were stored in formalin for a year. DNA extraction of the middle piece of three specimens was performed with the DNeasy Blood and Tissue kit  according to the manufacturer’s instructions. Briefly, tissue was homogenized in 180 µL buffer and three 2.8 mm ceramic beads  with a TissueLyser II  for three minutes. Overnight digestion with 20 µL of Proteinase K was done at 56 °C. Buffer and ethanol were added and centrifuged in a Minispin column. After two washing steps, the DNA was collected with an elution buffer. Additionally, DNA was extracted with the QIAamp DNA FFPE Tissue kit  according to the manufacturer’s guidelines. Tissue was rehydrated with 200 µL of 99.9% alcohol and subsequent centrifugation. The supernatant was discarded and 200 µL of 70% alcohol was added following centrifugation and discarding of the supernatant. Remaining alcohol was removed through evaporation and tissue was digested overnight with 180 µL buffer and 20 µL proteinase K at 56 °C. After incubation at 90 °C for one hour buffer and ethanol were added and centrifuged in a Minispin column. After two washing steps, the DNA was collected with an elution buffer. Amplification of the extracted DNA was performed with two different PCR protocols. Primers H14FilaCOIFw and H14FilaCOIRv targeted a 724 bp fragment and primers DI COI-F1 and DI COI-R1 targeted a 203 bp fragment of the mitochondrial cytochrome c oxidase subunit I gene and are published along with the PCR conditions elsewhere [® Long PCR Master Mix . PCR products were separated in 2% agarose gels stained with Midori Green Advanced DNA stain  by electrophoresis. Amplification of a 203 bp or 724 bp fragment of the cytochrome c oxidase subunit I gene was unsuccessful.lsewhere ,18. To iD. immitis. Using light microscopy  and stereo microscopy  five specimens were analysed of which three were female and two were male. Female specimens were 212 to 250 mm long and 0.74 to 1.08 mm wide. Male specimens were 97 to 116 mm long and 0.63 to 0.66 wide; however, in one specimen, the tail was missing. The cuticle was smooth and lacking significant longitudinal cuticular ridges A, showinAfter surgery, the cat’s creatinine increased to 5.1 mg/dL and the haematocrit decreased to 12.8%—but showed still high regeneration with a reticulocyte count of 158.7 G/L. It was suspected that the cat had an episode of acute kidney failure due to the removal of the heartworms. The therapy included buprenorphine 10 µg/kg three times a day, amoxicillin–clavulanic acid 20 mg/kg twice daily, doxycycline 5 mg/kg twice daily, spironolactone 2 mg/kg twice daily, pimobendan 0.25 mg/kg twice daily, and calcium carbonate to lower the phosphorus level. Fortunately, the cat’s medical condition improved, and it was sent home three days after surgery with a creatinine of 3.2 mg/dL and a stable haematocrit of 12%.The prescribed treatment included pimobendan 0.25 mg/kg twice daily, clopidogrel 1.5 mg/kg once daily and milbemycin 4 mg/kg monthly. Further control examinations were performed at the referral vet.The cat was presented 16 months after surgery for a control examination including thoracic radiographs and echocardiography at the Veterinary Hospital in Parndorf, Burgenland. The owner reported that the cat was not showing any clinical signs despite of infrequent, spontaneous coughing and receiving the prescribed medication daily. Clinical examination remained unremarkable. The thoracic radiographs showed a moderate bronchointerstitial lung pattern without enlarged pulmonary arteries . This brmax 1.1 m/s (probably suggesting mild pulmonary hypertension). Comparing the two echocardiograms the cat’s hemodynamic status significantly improved , a mild mitral insufficiency and a pulmonary artery flow of Vimproved  with incimproved . LA/Ao cComplete blood count and creatinine were repeated, and CBC showed no abnormalities with a haematocrit of 30.5% and creatinine of 1.9 mg/dL .®  showed a negative result. Felichek-3® (Bionote), a chromatographic immunoassay showed negative results for feline heartworm antibodies as well as feline immunodeficiency virus antibody and feline leukaemia virus antigen.What is more, the Knott’s test to detect microfilaria was negative. In addition, the Heartworm-Snap-TestD. immitis in this cat.At this time, in July 2021, there was no sign of reinfection with Dirofilaria immitis has shown a rapidly increasing prevalence over the past few years, especially in Central Europe. FHWD can be detected in the same areas as canine heartworm disease at up to 20% of the rate in unprotected dogs [D. immitis and D. repens has increased over the past few years and Hungary now also belongs to one of the endemic areas in Europe [2 [D. immitis in shelter dogs and mosquitoes, 205 mosquito species were trapped in Austria and 115 dogs were tested for D. immitis infection. Forty-six of these mosquitoes were found in Burgenland. In none of these 205 mosquitoes has DNA of D. immitis been found to date but several dogs in a local shelter, all originating from Hungary, tested positive for D. immitis [ted dogs ,19. The n Europe . In a sturope [2 ,23,24. I immitis .D. immitis in echocardiography [D. immitis is operator-dependent and is reported between 88% and 100%. False positive results can be caused by right ventricular chordae tendineae [At initial presentation, the cat showed dyspnoea, ascites and double hyperechoic parallel lines in the echocardiography, which is the typical presentation for iography . The senendineae .Angiostrongylus chabaudi was assumed. At necropsies, immature nematodes of A. chabaudi can be found in the pulmonary arteries without evidence of L1 in faeces [As a differential diagnosis, n faeces .A. chabaudi was first described in 1957 in a wild cat in Central Italy. More case reports of cats with A. chabaudi in Greece, Romania, Italy, Bulgaria, Bosnia-Herzegovina and Germany do exist but it is not known yet if angiostrongylosis caused by A. chabaudi is clinically relevant or not. Pathological lesions like granulomatous pneumonia, hyperplasia of pulmonal arteries and thrombosis are reported [A. chabaudi being detectable in echocardiography. In dogs, Angiostrongylus vasorum cannot be seen in echocardiography, so it also seems unlikely that A. chabaudi can be seen in echocardiography [reported . In our iography .Aelurostrongylus abstrusus and Troglostrongylus brevior. The most common signs of aelurostrongylosis are dry or productive cough, dyspnoea, tachypnoea as well as weight loss, anorexia and fever. Pleural effusion or pneumothorax caused by A. abstrusus can lead to death. Secondary pulmonary hypertension is caused by the local inflammation triggered by parasite stages. Clinical presentation of cats with T. brevior is similar, although the nematode seems to be more pathogenic in kittens and young animals. Due to the paucity of clinical studies on this disease, knowledge on the radiographic features of troglostrongylosis is still poor [A. abstrusus and T. brevior being detectable in echocardiography, what makes these differentials unlikely.Another differential diagnosis with emphasis on the radiographic changes are infections with ill poor ,32. To oD. immitis are found two months post infection. False positive test results as consequence of clearing the infection can be found as well as false negative results in asymptomatic cats. Running antigen and antibody tests can improve the sensitivity compared to running one test alone [The cat also showed right atrial as well as right ventricular enlargement, which underlined our suspected diagnosis of FHWD. These findings seem to appear quite rarely in cats and are commonly observed in dogs . What isst alone ,34. In oD. immitis. Therefore, the result should be recorded as “no antigen detected” [D. immitis. They postulate that this is not necessarily related to a relationship with heartworm infection but might be due to common predisposing factors, such as outdoor roaming. Contrary to this study, no apparent correlation with FeLV and FIV infection was noted in a study of 2011 [Usually, the worm burden is low and infections with only male or female adults reduce the sensitivity of the antigenic reaction. Detection of antigen cannot confirm the presence of immature stages of the parasite. A negative antigenic test cannot be the basis for ruling out an infection with etected” ,10. In t of 2011 ,20,34. I of 2011 . No furtThe cat showed also severe hyperchromic, macrocytic regenerative anaemia. Anemia is described in cats and dogs with caval syndrome due to haemolysation .D. immitis. It is associated with poor tissue perfusion and hyporexia of these organs. In necropsy of dogs with caval syndrome tubular necrosis and haemosiderosis was found [In this case, we decided to remove the adult nematodes surgically. Acute death of cats can occur when even only one worm is present ,10. In mas found ,35,38.DNA extraction of formalin fixed tissue is challenging, and usually only short fragments can be amplified. A study comparing two DNA extraction kits showed better results with the QIAamp DNA FFPE Tissue kit , which is designed for DNA extraction from formalin fixed paraffin embedded tissue but is recommended for the use of tissue that has been fixed in formalin no longer than 24 h. In this study, up to 171 bp sequences could be amplified from historic formalin fixed tissue, albeit with low purity . ConsideWolbachia. Wolbachia spp. plays an important role in the survival of filarioid nematodes and gets amino acids for bacterial growth in turn. In dogs, pre-treatment with doxycycline before adulticidal therapy helps to reduce pulmonary pathology. In cats, this benefit has not yet been evaluated. That is the reason why doxycycline is not recommended as an adjunctive therapy in cats at the moment [After surgery, the cat was treated with doxycline 5 mg/kg twice daily orally to target e moment ,34. Clope moment ,10,15.To prevent reinfection, the owner was advised to give milbemycin 4 mg/kg monthly following surgery. Monthly chemoprophylaxis is recommended from eight weeks of age year-round to kill L3 and L4 larvae. Ivermectin and milbemycin oxime, both administered orally, as well as topical moxidectin and selamectin can all be used for the prevention of FHWD .Considering the lack of clinical signs and detectable abnormalities at clinical, sonographic and laboratory examination at 16 months post-surgery, the cat can be considered fully recovered. Coughing can be a long-term effect of HARD. Parasite death can be associated with severe pulmonary thromboembolism and eosinophilic inflammatory response in the lungs, causing HARD. Chronic, histologic evident myofibrocyte proliferation can be observed up to 18 months after infection .In a study with asymptomatic cats with HWD, it was quite impossible to predict the outcome if the infection was diagnosed early. Three cats in this study died suddenly after 38–40 months post-diagnosis. In addition, if the duration of infection from diagnosis to death exceeds 1000 days, it is too long to implicate HWD as cause of death. Another retrospective study of symptomatic cats showed a median survival time of 1.5 years overall ,44. Our D. immitis worldwide due to climate change, globalization and increased travel of infected dogs is the reason Austria is facing the pre-endemic status [D. immitis infection. Austrian veterinarians should be aware of the zoonotic potential of D. immitis. Increased and more intensive communication about prevention with owners living in close owner-pet-relationships is necessary. FHWD should be considered as a differential diagnosis if cats are living in border regions of surrounding countries. Macrocyclic lactones should not be used only for deworming  but also for prevention of HWD.The spreading of c status ,6. This D. immitis worldwide due to climate change, globalization and increased travel of infected dogs is the reason Austria is facing pre-endemic status [D. immitis infection in Austria. In our case, a cat was infected with D. immitis. Furthermore, considering that the cat is not the natural reservoir of the parasite, it must be deduced that in the same area there were dogs infected by D. immitis and not diagnosed. Increased and more intensive communication about prevention with owners living in close owner-pet-relationships is necessary. FHWD should be considered as a differential diagnosis if cats are living in border regions of surrounding countries. Macrocyclic lactones should not be used only for deworming  but also for prevention of HWD.The spreading of c status . This ca


This study aimed to describe and assess the current evidence in systematic reviews on cupping therapy for various conditions. We searched PubMed, EMBASE, Cochrane Database of Systematic Reviews, China National Knowledge Infrastructure, and six Korean databases for systematic reviews of trials on cupping treatments for any condition published prior to March 2021. We used a bubble plot to graphically display the clinical topics, the number of articles, the number of participants in the total population, confidence, and effectiveness. Thirteen systematic reviews that met the inclusion criteria were included in the evidence map, and 16 bubbles were created. The findings from six reviews showed potential benefits of cupping for conditions such as low back pain, ankylosing spondylitis, knee osteoarthritis, neck pain, herpes zoster, migraine, plaque psoriasis, and chronic urticaria. Cupping has been applied in a variety of clinical areas, and systematic reviews in a few of these areas have demonstrated statistically significant benefits. The evidence map provides a visual overview of cupping research volume and findings. Evidence mapping can facilitate the transfer of knowledge from researchers to policymakers and promote research on musculoskeletal pain  and skin disease (plaque psoriasis). Cupping has been used with traditional and alternative medicine to treat a variety of conditions in China, Korea, and East Asia. In Taiwan, 12.8% of participants in a previous study reported undergoing cupping therapies in the past year , especiaCupping, whether it is performed dry or wet, is a technique in which cups made of plastic, bamboo, or glass cups are used in suctioning the skin over acupuncture points, painful areas, or reflex zones . For dryThe usage of cupping therapies to improve health outcomes has been increasing continuously, resulting in cupping being the subject of investigation in many primary studies and systematic reviews (SRs). However, previous research has covered a variety of conditions, populations, and settings. Several SRs have investigated the therapeutic effect of cupping therapy for low back pain , neck paEvidence maps are new synthesis tools that involve searching systematically and characterizing existing research on a topic of interest for the identification of knowledge gaps and future research needs . We condThis evidence map study aimed to present a visual overview of the distribution of evidence available on cupping therapy for various conditions, along with a concomitant narrative that will aid stakeholders in interpreting the state of the current evidence for informed policy and clinical decision making.There are no official standardized methods for evidence mapping . The metThe following electronic databases were systematically searched for in literature published from their dates of inception to 16 March 2021: PubMed, EMBASE, the Cochrane Database of Systematic Reviews (CDSR), one Chinese database ), and six Korean medical databases (Research Information Service System (RISS), DBpia, Korea Med, Oriental Medicine Advanced Search Integrated System (OASIS), Korean Studies Information Services System (KISS), and Korean Medical Database (KM base)). In addition, the reference lists of the potentially eligible articles were searched manually to further identify additional eligible papers.The search terms used were “systematic review” or “meta-analysis” and “cupping therapy”, and the database-specific filters were used to search for SRs without language restrictions .Only SRs focusing on cupping therapy, which compiled primary research studies of any clinical indications, were included. We defined SRs as self-identified review articles that included the phrase “systematic review” in the title or the main text and/or review articles that reported the sources systematically searched for in the identified studies. SRs are studies in which the findings of studies are systematically selected from the medical literature and are summarized for each type of intervention.Individuals with any conditions were included.SRs of the effectiveness of cupping for any clinical indication were eligible for inclusion. All trials were included regardless of the type of cupping and control intervention. Trials that used cupping as an adjunctive treatment were also included.SRs that report patient health outcomes were included and those of provider outcomes, study designs, or intervention features unrelated to patient health outcomes were excluded.SRs that summarize the assessments of interventions of any duration with any follow-up period were included.Formal SR articles with and without a meta-analysis related to any type of cupping therapy for any type of medical condition were eligible for inclusion. Articles that were not performed using systematic methods such as reviews, comments, and overviews, were excluded. Two reviewers (TYC and JHJ) independently screened all the titles and abstracts and read the full text of articles to exclude irrelevant SRs. Disagreements were resolved through discussion and consensus, and an additional reviewer (MSL) was consulted. The originals and updates of SRs by the same author group were always available, but only the most recent version was considered. In the case of multiple publications, they were considered as one review, and data were extracted from all the available publications. If multiple reviews of similar clinical topics were identified, the most pertinent and best-performed SR was used for the inclusion of evidence maps selected based on the results of the AMSTAR 2 assessment.The Assessing the Methodological Quality of Systematic Reviews (AMSTAR)-2 tool was used to critically appraise the quality of reporting for each included SR. A validated 16-item instrument was also used for the appraisal of the SRs based on critical flow and bias using ratings of “yes”, “partial yes”, or “no” [Information regarding the population, intervention, comparison and outcomes (PICO) process, the numbers of randomized controlled trials (RCTs) included in each SR, summary effect estimates for the main outcomes, overall risk of bias of the included RCTs, publication bias, and conclusions as quoted from the original article, were extracted. The information for each intervention was extracted separately if the SR was designed as an overview or an umbrella review. All articles were read by two independent reviewers (TYC and JHJ), and the data were extracted from the articles according to the predefined criteria for the data extraction and methodological quality assessments. Disagreements were resolved by consensus, and when necessary, an additional reviewer (MSL) participated in the discussion.We used topics of investigation of the included SRs to categorize them. The results of evidence mapping were presented using characteristic tables of included SRs and a graphical display of bubble plots. Each bubble in the chart represents the included evidence for clinical topics as assessed by the SR investigating the effectiveness of cupping.The outcomes, populations, or clinical indications were focused in the reviews. The SRs were grouped into clinical topics by one reviewer, and the grouping results were discussed and reviewed by the team. The decisions to not combine potentially related topic areas were due to the lack of overlapping between studies included in the reviews and differences in the reported outcomes or the review’s conclusion. When SRs contained various diseases, each disease was analyzed separately and used multiple times in the bubble plot. The evidence map used R software .This chart displays the information in four dimensions:(1)X-axis: effect estimateThe clinical effectiveness of cupping therapy was evaluated based on the effect estimates and the overall risk of bias reported in the selected SRs. Clinical effectiveness was classified as “effective” when the effect estimates were significantly positive with a low overall risk of bias, “potentially effective” when the effect estimates were significantly positive with a high overall risk of bias, or “unclear” when the effect estimates were negative or the overall risk of bias was unclear.(2)Y-axis: number of articlesThe literature size was defined as the number of RCTs in the selected SRs on the topic. Although reviews often differ in their inclusion criteria, all reviews are likely to include studies of well-established research design, such as an RCT, and provides a broad estimate of the research volume.(3)Bubble size: number of participants in the total populationThe size of each SR bubble was proportional to the number of participants in the total sample size for the effects of cupping.(4)Color: strength of the findingsConfidence was determined based on the results of the AMSTAR 2 assessment and was classified into the following four categories: yellow circles correspond to “high confidence”; green circles correspond to “moderate confidence”; blue circles correspond to “low confidence”, or red circles corresponded to “critically low confidence”.To provide more details from the included SRs, a concomitant narrative synthesis was expanded upon the visual evidence map. Such details included descriptions of the findings, the features of cupping therapy, and the types of diseases.n = 1), China (n = 9), and Korea (n = 3). The information of the excluded 10 SRs information is presented in The electronic database search identified 107 potentially relevant studies. After duplicate publications were removed, the titles and abstracts of 85 papers were screened. The full texts of 37 articles were reviewed for eligibility and 23 SRs were included in the review. According to the results of the AMSTAR 2 assessment, only the best performed SRs were selected for further inclusion . Finallyn = 7), ankylosing spondylitis (n = 2), knee osteoarthritis (n = 3), neck pain (n = 4), cervical spondylosis (n = 1), lateral femoral cutaneous neuritis (n = 1), scapulohumeral periarthritis (n = 1), herpes zoster (n = 4), facial paralysis (n = 1), acne (n = 1), cervical spondylosis (n = 1), stroke rehabilitation (n = 1), hypertension (n = 2), migraine (n = 1), plaque psoriasis (n = 2), chronic urticarial (n = 1), and obesity (n = 1).The effectiveness, literature size, and confidence level for cupping therapy in the included SRs were identified and evaluated. A few SRs covered several types of diseases, which were assessed separately in our evaluation. The medical conditions studied in the RCTs of the included SRs were back pain , and the number of primary studies (y-axis). The details of the included SRs were provided in All included SRs concluded that cupping did not improve the outcomes of interest; however, the number of existing studies was small in all of the identified topic areas. The evidence mapping results showed that only a restricted number of cupping therapies were assessed with inconclusive clinical evidence, indicating the necessity of additional primary research in this area .The evidence map visualizations show the presence and absence of evidence for cupping therapy based on 13 published SRs and identified the evidence gaps relating to the details of the cupping therapy in particular. The studies included in our evidence map provide a very extensive and broad overview of the evidence on cupping therapy published between 2010 and 2020. Our evidence map also highlights the areas where meta-analyses have reported positive or unclear results, in the meantime showing the research concentration and volume. This evidence mapping process shows a range of evidence on cupping for any condition. Cupping has been clinically utilized and evaluated for a wide range of clinical conditions. Several identified SRs have addressed a very broad topic such as low back pain even though they included a large number of RCTs. Additionally, evidence on the role of cupping for specific clinical conditions is also very limited due to the small number of published studies.Even though evidence maps can provide only a broad overview of research areas, our review concluded that more rigorous research on the clinical effectiveness of cupping is needed across various clinical topic areas. The duration and frequency of the cupping interventions in the cited studies have yet to be evaluated and need to be studied further. Furthermore, such inconclusive evidence also warrants more research.The findings of seven reviews showed evidence of potential benefits of cupping for conditions including neck pain, knee osteoarthritis, plaque psoriasis, chronic urticarial, ankylosing spondylitis, herpes zoster, and migraine. Many studies have provided evidence concerning the effectiveness of cupping in treating certain clinical indications. Cupping therapy is a traditional method and is currently used in the treatment of a broad range of medical and health conditions. Nevertheless, the mechanism of action of cupping remains unclear and is yet to be fully understood .Evidence maps are one of many tools and information sources to support evidence. It is similar to systematic review methods that are reproducible and transparent. However, while SRs target specific research questions, evidence mapping focuses on the nature, volume, and characteristics of the research to identify, describe and summarize what is known . The creThis evidence map has described the research focus, which was reported in the existing SRs, and identified the gaps in evidence to pinpoint areas that should be prioritized in future research. However, this evidence map is unable to answer more refined questions, such as the most adequate cupping therapy for specific applications and the differences between health services. To further advance our evidence-based knowledge of cupping, we should collect more data on the effectiveness of cupping across and within each clinical condition and patient population through meta-analyses across primary studies. Additionally, the large number of topic areas that were classified as having unclear evidence warrants additional primary studies. More studies have been published in some of the topic areas included in the unclear evidence category, and the currently available SRs need to be updated. As there might be other efficient ways of drawing evidence maps, further research should also include developing evidence maps of other research designs.In conclusion, cupping has been applied in a variety of clinical areas, and for a few of these, SRs have demonstrated statistically significant results. This evidence map provides a very broad overview of the evidence base, indicating the areas in which research has been conducted. The evidence map provides a visual overview of the cupping research volume and content. Evidence mapping can facilitate the transfer of knowledge from researchers to policymakers and promote research on musculoskeletal pain  and skin disease (plaque psoriasis).


Social presence is an important construct in online group learning. It influences the way how social interaction unfolds online and affects learning and social outcomes. However, what precisely social presence is has been under debate, as presently a plethora of different definitions and measures exist preventing the development of a coherent research field regarding social presence and its defining role in online group learning. To solve the issue, we went back to the original social presence theory as devised by the communication researchers Short et al.  to show  Quite a number of educational researchers investigating online distance education consider social presence an important construct in online group learning (OGL). Group learning refers to the “instructional use of small groups so that students work together to maximize their own and each other’s learning”  tools and electronic platforms for OGL in terms of the degree to which these CMC tools and electronic platforms can transfer the same face-to-face interpersonal communication, group learning, and group dynamics when learning and working together in an online setting. Social presence influences the way how the social interaction in OGL groups unfolds online, which, in turn, affects the learning outcomes  reformulated their social presence definition to enable an operationalization in line with their conceptualization of social presence; (2) departed from their technological determinism of social presence; (3) identified two other constructs, namely, sociability and social space. With respect to the first point, we reformulated social presence as the psychological phenomenon in which, to a certain extent, the other persons are perceived as physical “real” persons in technology-mediated communication enabled by CMC tools and electronic platforms  of Gunawardena and Zittle . It has What is made clear here is that the different measures for social presence make it hard or even impossible to compare the various findings of empirical research using one of these measures because they differ in the number of dimensions as well as what these dimensions are and because the measures do not necessarily assess “realness” of the other person but rather correlates of it (which were then referred to as dimensions). And even if the same dimension is considered , items still may assess a different thing—do the four items of the intimacy dimension of the Wei et al.  measure Kehrwald  stressedIn order to get structure in the conceptual chaos surrounding social presence and its measurement, it seemed to us that the best way is to go back to the original theory of social presence as devised by Short et al.  as to diTo recapitulate, Short et al.  defined The social psychology of telecommunications that the degree of social presence is dependent on the degree to which the other person is perceived as a “real” person. For example, on page 73, they stated that for telephone, even when immediacy communication behaviors vary by an interlocutor, the “degree to which he is perceived as a ‘real person’—the Social Presence afforded by the telephone — will be the same.” On page 74, they pointed to a study of Champness . They, apparently, saw such three-dimensional representation as the highest form of fidelity of physical realness of the other. Nowadays, 3D holographic representation of a person has already become a reality . The benefit of CMC is that it can be buffered and stored, meaning that it makes delayed (asynchronous or time-deferred) communication possible. CMC is also mainly text-based, as the usual CMC tools are email, online forums, and instant messaging. Delayed communication allows online distance learning to happen independently of time and place  is high on sociability because they possess many types of social affordances; hence, they are deemed “social media.” The kind of social affordances found in these social media encompass, among others, possibilities for self-expression, personalizing, the upload of videos and photos for sharing, commenting on messages of other persons, blogging, grouping, and the use of a variety of emoticons when instant messaging. However, while indeed the availability of these affordances explains why social media has become so popular (Gao et al., Hedonic affordances determine the hedonicity of an electronic platform which is yet another medium attribute; and in the case of an electronic OGL platform, a third medium attribute is educability (Kreijns and Kirschner, Social presence is an evocative and popular notion. There have now been decades of research into the concept and its many applications in different domains. Yet, this has not produced a clear understanding of the concept and caused a situation that brings much confusion preventing the development of a coherent research field regarding social presence and its defining role in OGL. Subsequently, there have been numerous calls for more rigor in social presence research (Biocca et al., The purpose of this paper was to disentangle social presence theory as devised by Short et al. . We founPotential consequences of this are, at best, an inconvenience for emerging scholars who are not steeped in the literature, at worst, effectively obstructing cumulative research of a concept that may be pivotal for understanding interpersonal effects in OGL contexts that are increasingly technologically mediated.Although our work is not the first of its kind, the goal of this paper was to provide something the previous work has not, a possibility to integrate and incorporate the myriad of ways social presence has been defined in the past. For example, Lowenthal’s  continuuInstead of merely showing what is out there and pointing to the deficiencies of the literature, we aimed to provide a way out, a framework through which we can better understand past research. Through this, we avoid the tendency of defiling or invalidating this large body of research and instead provide one step toward resolution. We found that definitions and measurement of social presence can be allocated in a space between three interrelated constructs, sociability, social presence, and social space. With this framework at hand, we can better understand the many correlates and effects that have been attributed to social presence but that may, in fact, be better attributed to sociability or social space.As an example, let us consider the elusive connection of social presence to learning achievement. This connection is claimed by many (Wei et al., Although we aimed to provide a comprehensive review of the issues surrounding the definition and measurement of social presence, it remains possible that we have missed exemplary single studies or even lines of research that operate with coherent definitions and rigorous measures. However, we are confident that we have captured a large part of the most well-known and well-cited social presence research and, given the prevalence of issues in our reviewed sample, we find it unlikely that research we may have missed has fared significantly better in terms of defining and measuring social presence.Importantly, our paper focused on the educational domain, more specifically, the realm of online distance learning, where OGL plays a large role. There are, of course, other areas of research that work with the concept of social presence, for example, VR, robotics, and conversational agents (see, e.g., Oh et al., Finally, our proposed solution of differentiating three central constructs appears sensible in light of the original definition of Short et al.  and the Aiming for conceptual clarity, researchers concerned with social presence are encouraged to distinguish between the three major variables delineated in this paper. Thus, we recommend referring to sociability when we wish to talk about the capacity of CMC tools and electronic platforms when it comes to giving expression to one’s social presence and how one is perceiving or experiencing the other person’s social presence so to foster socio-emotional aspects of the learning experience. If, on the other hand, we consider the extent to which there is a network of interpersonal relationships in the OGL-group, we should refer to the term social space, which considers sense of community, group climate, mutual trust, social identity and group cohesion. Lastly, let’s only talk about social presence when we want to invoke the unique psychological phenomenon that we perceive other social persons as being physical “real” persons while using CMC tools and electronic platforms. Only then can we escape from the confounding situation surrounding social presence and build a coherent and cumulative research line.