Here, we suggest a fundamentally different, inherently probabilistic model of axon growth, one that is grounded in the stochastic dynamics of actin networks. This perspective is motivated and supported by a synthesis of results from live imaging of a specific axon growing in its native tissue in vivo, together with single-molecule computational simulations of actin dynamics. In particular, we show how axon growth arises from a small spatial bias in the intrinsic fluctuations of the axonal actin cytoskeleton, one that produces net translocation of the axonal actin network by differentially modulating local probabilities of network expansion versus compaction. We discuss the relationship between this model and current views of axon growth and guidance mechanism and demonstrate how it offers explanations for various longstanding puzzles in this field. We further point out the implications of the probabilistic nature of actin dynamics for many other processes of cell morphology and motility.The mechanism of axon growth and guidance is a core, unsolved problem in neuroscience and cell biology. For nearly three decades, our view of this process has largely been based on deterministic models of motility derived from studies of neurons cultured  Macroscopic features of organisms, such as their morphology and physiology, tend to be remarkably consistent and predictable, but the cellular and subcellular machines that make those features show tremendous fluctuation and variability in their moment-to-moment activity –5. One oin vivo.In this Commentary, we will consider the implications of this challenge for the mechanism of axon growth and guidance in the developing nervous system. The function of a nervous system depends on its pattern of wiring, where the ‘wire’ that carries information from one neuron to those downstream in its neural circuit is called an axon. However, those wires do not start out having their complex final shapes, they have to grow . Each stin vivo at multiple levels of resolution. After reviewing some of the key data, we will discuss how the observations of this axon, called TSM1 (twin sensillae of the margin 1), suggest a new and unexpected model for the mechanism of axon growth and guidance. In brief, we will see how the stochastic fluctuations of individual actin filaments produce dynamic redistribution of the global actin network in the axon at a multi-micrometre scale and how this in turn produces directed axon growth. To come to that endpoint, we will start by examining the large features of the TSM1 axon and work our way down to the small ones, start with a description of the morphology and actin distribution of this axon in vivo, then focus down on biochemical processes that produce that cell biology, and then focus further on the single-molecule biophysics that underpin the entire mechanism. We then synthesize these findings in a coherent model for the mechanism of growth of TSM1. Finally, we show how this model uncovers an underlying simplicity that may reconcile some of the divergent views in the field of axon growth and explain some longstanding mysteries. In the body of this Commentary, we will focus our attention exclusively on the dynamics of the actin cytoskeleton. At the end, however, we will briefly extend our discussion to consider some of the ways that the microtubule cytoskeleton may fit into the story to modulate the actin-based processes that are presented here in more detail . Th. Th52]. Caenorhabditis elegans [The pattern of overall compaction versus expansion of the total actin network with changing Arp2/3 activity that was observed in the simulations closely matches what was observed experimentally from loss and gain of Abl activity in TSM1 growth cones ,51 and o elegans . Moreove elegans . This pr elegans . It alsoThe analysis above focuses on Arp2/3, but what about the other branch of Abl signalling, via Ena? Surprisingly, simulations suggest that the effects of Ena on large-scale actin organization should be minimal . This was unexpected, but direct experimental quantification of actin distribution in TSM1 upon decrease or increase of Ena activity validates the prediction, demonstrating that altering Ena activity does not produce statistically significant effects on actin distribution in the growth cone. Instead, the key effect of Ena is evidently on the linkage of that actin to the plasma membrane, that is, on the efficiency with which filopodia are produced in response to accumulation of actin. It seems that the complementarity of Abl effects on Ena versus Arp2/3 is likely a mechanism to ensure that growth cone morphology remains stable even as Abl activity is altered to vary the properties of the growth cone actin network . It is i. 7in vivo? Can we do so in a way that is true to the inherently probabilistic nature of single-cell biology, as reflected in the choices made by an individual pioneer growth cone? And what are the implications of variability and stochasticity for the mechanism, and the fidelity, of neural wiring?Can we, then, bring together cell biology, biochemistry and biophysics to account for the guided growth of the TSM1 pioneer axon We have seen here that the morphological feature that we call ‘the TSM1 growth cone’, a local domain of dynamic filopodia, is an emergent property generated by the presence of a local accumulation of actin in the axon shaft. The actin network in the axon fluctuates stochastically in length, but a small spatial bias favours fluctuations that advance the actin along its genetically pre-specified trajectory. The actin mass as a whole thus advances, and in so doing, it advances the morphological domain that is competent to support filopodial formation and maintenance, i.e. the growth cone. In essence, net advance occurs by locking-in those stochastic fluctuations of actin that happen to occur in a direction favoured by external, environmental factors, in this case guidance cues laid out by the genetic programme of axon wiring, together with the physico-chemical properties of the underlying substratum. In this picture, for clarity of exposition, we emphasize the actin in the core of the axon shaft, but in reality, that central actin mass is continuous with the actin network throughout the axon, including the filopodia, and the global fluctuations of the entire actin network contribute to the growth and guidance event.The dimensions and cohesion of the actin network, in turn, are controlled by cytoplasmic signalling pathways such as that defined by Abl tyrosine kinase, among many others. At any given time and place, those signalling pathways integrate information from a complex constellation of chemical guidance cues and receptors, as well as physical features of the internal and external environment, transforming those spatial cues into patterned intracellular modulation of a few elementary processes of actin dynamics—actin polymerization, branching, severing, bundling and capping, together with myosin contractility. Thus, the summed effects of cytoplasmic signalling pathways produce spatial modulation of the detailed kinetic parameters that control actin dynamics. In response to that patterned modulation, the quantitative logic of actomyosin biophysics, and particularly the interplay between the distribution of actin filament lengths and myosin contractility, probabilistically modifies the dynamic architecture of the actin network to promote net forward translocation of the actin mass. In particular, we propose that preferential shortening of actin filaments in the leading part of the actin peak locally fragments the actin mass into smaller subnetworks. This favours local expansion of the actin mass, causing its leading edge to advance. Meanwhile, in the rear of the growth cone, preferential lengthening of individual filaments and/or enhanced myosin II contractility locally promotes consolidation of that portion of the actin mass, effectively compacting it into a cohesive unit that, in the process, pulls itself forward towards the centre of the growth cone. It is the combination of expansion in the front and compaction from the rear that produces the net forward motion of the actin. By this model, in other words, the spatial bias in the fluctuations of actin network density is what drives translocation of the axonal actin peak into a single leading filopodium, transforming that filopodium into the future axon shaft and thus advancing the effective tip of the axon. It is noteworthy that this model does not require formation of specific anchorage points in the environment to provide foci for traction . It was We note that the very same mechanism that extends the axon can also account for growth cone turning. The axonal actin network fluctuates not just along the axon shaft but also out the flanking filopodia. Locking-in fluctuations that preferentially populate an oblique filopodium, rather than a leading one, make that oblique projection the focus of future projection outgrowth—the new growth cone—and the axon has now turned. Note also that for turning of TSM1, as for its growth, there need not be a unique site at which a deterministic, instructive turning signal is received. Rather, guidance information can be distributed over the entire growth cone, and averaged over time and space, to progressively promote the guided advance of the axon.C. elegans [Drosophila optic system [The key property of the view presented here is that it is irreducibly probabilistic, at every step in the mechanism. Motion of the growth cone derives from stochastic fluctuations of the actin distribution, both in terms of its net position and of its mesoscopic level of fragmentation. That fluctuating fragmentation, in turn, arises from the stochastic properties of actin turnover. Efforts to account for these data by a deterministic model foundered in all cases on the probabilistic behaviour that was observed at every stage of the experimental and computational analyses of TSM1. It has come to be recognized in many systems that cytoskeletal cell biology and biophysics are in their essence inherently probabilistic in nature, not just noisy to measure, but noisy in their essence, and indeed have evolved to use ‘noise’—random fluctuation—as a central element in their mechanism, just as we see here ,100–103. elegans , and stoc system . Single-in vivo [et al. [in vivo appear as protrusive, filopodial structures when growing laterally across the midline or longitudinally after exiting the floor plate but transiently assume a lamellar structure when they stop moving at the floor plate exit point to reorient their polarity [Aplysia bag cell growth cone that has been the primary paradigm for adhesive growth cones [The model of growth cone mechanism described above, built on the stochastic fluctuations of actomyosin networks, sounds very different from the typical view of how axons grow ,10–12. Ain vivo ,105. Evith cones  is actuath cones ,107. Stain vivo represents yet a third paradigm, one distinct from both of the adherent mechanisms described earlier. It is clearly different from the traction-based mode of adhesive growth first proposed for lamellipodial growth cones as it lacks the structural features on which that mode is predicated. However, it also appears to be distinct from the PEC mode of adherent, two-dimensional motility. PEC, like TSM1 probabilistic actin reorganization, posits that net motion is generated by reorganization of internal components, not by pulling on external traction points. PEC-associated growth, however, is thought to be driven by microtubules invading the leading edge of the growth cone to promote membrane advance, while the role of actin is to limit invasion by microtubules and guide their spatial distribution [in vitro [in vivo, the fluctuation and spatial redistribution of actin is itself the driver of axon advance and turning: inhibiting actin dynamics halts axon growth immediately [in vitro versus the mechanism of TSM1-like extension in vivo. Nonetheless, it remains possible that elements of the TSM1-like mechanism might also contribute in the PEC context. For example, in an adherent environment that predisposes to the PEC mechanism, one could plausibly imagine that the initiating protrusive event could be driven by stochastic actin rearrangement like that seen in TSM1, separate from later steps in the motility cycle. To determine the relationship between the TSM1 mode of in vivo growth and the more familiar modes of two-dimensional motility in vitro it will be essential to perform equivalent experiments and analyses in the different experimental contexts so that direct comparisons can be made. The morphology observed for TSM1 matches well with those seen in live imaging studies performed in vivo in several organisms [Along the continuum of growth cone modes, it appears that the model we present here of probabilistic actin reorganization ribution ,35. In tin vitro ,28. By cediately . This isediately . Moreoveediately . These prganisms ,108,109,rganisms , suggestThe three general models of axon growth also differ in how they incorporate the role of force in growth cone advance. More purely adhesive models emphasize the importance of external traction forces for physically pulling the growth cone forward . PEC-sty. 8in vivo environment? The mechanism that we have described reveals an unforeseen simplicity beneath this apparent complexity. The number of external influences and internal signalling components is vast, but all of that complexity converges on just half a dozen elementary steps in actomyosin dynamics. The outcome in any individual case will depend on the specific nature of the many contributing factors, but they all converge on the same machinery, one responding, in part, to the interaction between the distribution of lengths of the individual actin filaments and the contractility of myosin. That interaction is modified by ancillary processes such as stabilization, bundling, and capping of filaments, but these fit into the picture in ways that also can readily be understood. In detail, each contributing factor will have its own special features—polymerization of actin by Ena/VASP proteins [The mechanism we describe has been inferred based on the signalling properties of a single signalling pathway, defined by Abl tyrosine kinase. But how does a growth cone integrate and respond to the complex cocktail of biochemical signals and biophysical constraints provided by the proteins  will havproteins ; severinproteins ; and theproteins —but the in vivo [3 at any given instant. Suddenly, the statistical fluctuations of guidance cues and signalling pathway activity become tools of guidance rather than problems. The growth cone simply averages over time and space, reinvestigating the local concentration of guidance signals in any single voxel many, many times as it slowly advances along its trajectory. This allows accurate and precise measurement of even extremely small differences in the concentrations of guiding molecules. Variability and fluctuation, therefore, are the very essence of the mechanism of growth and guidance of TSM1. They are not ‘bugs’ in the machinery; they are the machinery [The saltatory, episodic nature of axon advance that we have described has crucial implications for the specificity and fidelity of guidance. For example, we have long wondered how a growth cone can navigate in response to the vanishingly shallow gradients of guidance information present in vivo . The mecachinery –117. It achinery . We suggachinery –120. FinWe have shown that growth and guidance occur by a mechanism that favours fluctuations that tend in a direction appropriate to the eventual trajectory of an axon ,122, butin vivo. These are critical subjects for future investigation.In this Commentary, we have discussed only the intrinsic dynamics of the actin cytoskeleton but that does not mean that actin and myosin alone determine axon growth and guidance. It is apparent that the adhesive and biophysical properties of the substratum influence axon growth in some contexts ,128, andin vivo.The principles of actin organization and dynamics that we have discussed in this Commentary should apply not only to growth cones and their motility, but generally to cellular structures that are built on actin networks, or are moved by them. There are numerous systems in cell biology in which an actin network grows or shrinks in response to biochemical signals, or in which there must be regulation of the range of action of a mechanical force or the range of transmission of a signal. Many of these could, in principle, be modulated by simple variations on the concepts presented here, and it will be interesting to investigate the range of applicability of these ideas ,132,133.


Over recent decades, the burden of diseases has shifted from communicable to non-communicable diseases with low- and middle-income countries (LMICs) bearing a huge part of this burden. The shift in the burden of diseases, especially the share in LMICs is thought to be driven by rapid population ageing, accompanied by a rise in physical and mental health challenges, injuries, in particular road traffic accidents, and comorbidities that occur in these countries  is a group of 19 LMICs with a population over 345 million people . In SSFADespite all these efforts, the provision of physiotherapy services in SSFA is far from meeting the needs of populations not only from a quantitative point of view but also from a qualitative one. Recently, the World Health Organization (WHO) expressed deep concern that rehabilitation needs are largely unmet globally and that in many countries more than 50% of people do not receive the rehabilitation services they require. In some African countries, between 62.5% and 82.5% of people who need physiotherapy services do not benefit from them  material support for installation, (2) reduction or cancellation of taxes, (3) financial premium for installation, among others. Secondly, telerehabilitation and the use of affordable mobile health technologies are promising opportunities to overcome the scarcity of physiotherapists in remote or rural areas , as a universal call to action to end poverty, protect the planet, and ensure that by 2030 all people enjoy peace and prosperity. Goal 3 aims to ensure healthy lives and promote well-being for all, at all ages, which is essential to sustainable development. Incorporating physiotherapy services into the package of essential services, along with disease prevention, health promotion, treatment and palliative care would be an essential part of achieving target 3 of the SDGs.Despite its utmost importance, evidence-based practice (EBP) is not well developed and implemented in SSFA. I conducted a literature search in PubMed/Medline, Web of Science, Science Direct, Google Scholar, and ResearchGate databases from inception to 15 June 2023. The search strategy combined keywords ‘physiotherapy’, ‘rehabilitation’, ‘physical therapy’, ‘Africa’. Articles were included if they fulfilled the following criteria: (1) at least one of the authors was a physiotherapist; (2) at least one of the authors’ affiliations was located in SSFA; (3) in the case of multiple authors of a publication including physiotherapists with affiliations located in different SSFA countries, the publication was attributed to the author with the highest rank in authorship. To date, in SSFA around 150 scientific publications on physiotherapy have been published and are available in electronic databases, most of which are observational studies. I found two randomised controlled trials in Burundi and in Benin . Thanks to North–South collaborations, physiotherapists from several countries in the region are undertaking PhD studies and are publishing their work. This trend needs to be reinforced not only through South–South collaborations but also through the effective integration of physiotherapist researchers into the body of researchers in their countries and their full integration in the academic body of the physiotherapy training programmes in the region. This will contribute to raising the level of training of physiotherapists and promote high-quality physiotherapy research in the region, including health policy and systems research.Considering the aforementioned, I call for urgent action in the following five areas:Regarding the health and demographic trends in the region, there is an urgent need for the training of more practising physiotherapists.Physiotherapy must be brought closer to communities and patients’ homes by supporting the installation of physiotherapists in disadvantaged, rural or remote areas, and by promoting telerehabilitation and the use of mobile technologies in physiotherapy.Physiotherapy should be incorporated into universal health coverage so that no one needing rehabilitation is left behind.Solid networks and partnerships in physiotherapy should be established within the region including with non-French speaking countries.It is also of utmost importance to strengthen research capacity and expand the availability of robust EBP in physiotherapy in the region.Sub-Saharan French-speaking Africa needs to respond to the WHO rehabilitation 2030 call for action. Urgent and concerted actions are needed to expand the quantity and the quality of rehabilitation services in the region. There is also an urgent need to establish and/or strengthen networks and partnerships not only within the region but also with high-income countries to establish and expand strong scientific evidence adapted to local socioeconomic and cultural realities.


Nesting sites are one of the main factors driving the presence or absence of hedgehogs in an area, along with food availability and the presence of predators. However, little attention has been paid to them in the literature beyond the study of the hibernacula (winter nests) in northern latitudes, with only a few studies conducted in summer and none of those being in their southern range. Here, we analyse, for the first time in detail, the environmental characteristics of where hedgehogs chose to establish their nests in two urban parks in Alicante (Spain). Our results show that there is a sex difference in the structures selected for nesting. Males used a greater variety of structures than females, which were more selective and showed a preference for certain structures that offered a higher degree of shelter. Both sexes used a similar number of nests; however, the males’ nests were more widely dispersed, and they changed nests more often than females, who reused the same nest more frequently. The location of the nests was also influenced by the different topographies and management of both urban areas, stressing the importance of good management of urban green areas in the conservation of this species.Erinaceus europaeus) in an area, along with food availability. However, little attention has been paid to them in the literature. This study aimed at analysing, for the first time, the environmental characteristics of nesting sites chosen by hedgehogs, their spatial distribution and the effect of sex and season on them in two types of urban parks in southeastern Spain. A total of 31 hedgehogs were equipped with GPS devices, and 130 hedgehog nests were located and described. Both sexes had a similar number of nests; however, the spatial distribution of the male nests was larger, and they changed nests more frequently than females. The environment around the nests and hosting structures used also differed between the sexes, with males using a higher variety of nesting structures available and females being more selective. The differences in topography and habitat composition of the two urban parks also affected hedgehog nesting ecology, especially in reference to artificial elements like cat feeders. Further studies of nest locations at a microhabitat level are needed to contribute to a better understanding of a hedgehog’s requirements, fostering the design of more effective conservation strategies.Appropriate nesting sites are needed for the presence of European hedgehogs ( Erinaceus europaeus) in an area [Species distribution is determined by a set of factors that are vital for the species’ survival. Among them, nest sites (understood as resting places not only for breeding), food availability and the presence of predators seem to be the main variables limiting the presence of European hedgehogs  is a medium-sized nocturnal insectivorous mammal found naturally from the Iberia Peninsula northwards into Scandinavia. Although timings may differ in relation to climate, sex, body size and condition, hedgehogs typically hibernate between November and April, making winter nests for hibernation particularly important and therefore becoming the focus of many studies ,7,8. HowThe European hedgehog is a species of conservation concern in Europe due to their reported population declines ,12. One The aim of this study was to characterise for the first time the key elements of habitat use for nesting in urban populations of European hedgehogs at the southern range of this species distribution. In order to do so, we studied hedgehogs in two areas representative of two types of urban habitats used by this species in the region: The campus of the University of Alicante was used as an example of an intensively gardened park, and Mount Benacantil was used as an urban forest with more natural vegetation. In the present study, we analysed: (1) the number of nests and the frequency of use depending on sex, season and location; (2) the spatial distribution of the nests and their distance to artificial structures; (3) the structures in which the nests were located and the habitat around them; and (4) the nests’ characteristics and nesting materials used.We selected two areas representative of two types of urban habitats used by hedgehogs in the region.Salsola oppositifolia and Rhamnus lycioides as the predominant bushy species, and Stipa tenacissima, Brachypodium retusum and wide-open spaces of bare soil  with an intense and almost continuous human presence, located in the urban area of San Vicente del Raspeig . Half surrounded by buildings and roads, the landscape is completely flat. The vegetation is green and lush, thanks to its artificial irrigation, with bushes and garden plants that provide several good shelters between areas of pavement and wide-open grass . In contare soil . As in sare soil .Fieldwork was conducted between the 12 December 2016 and 15 March 2017 (winter period) and between 3 June 2017 and 28 September 2017 (summer period) on the campus of the University of Alicante and between 25 March 2017 and 8 October 2017 (spring–summer period) in the urban forest of Mount Benacantil.Hedgehogs were captured by hand at night with the aid of spotlights. Once captured, all animals were sexed according to the urogenital distance ,21 and w™ 4 [From a known population of monitored hedgehogs , a sample of 31 hedgehogs  weighing >600 g was equipped with tracking devices to study their movements and habitat use. Each device was a pack that included a global positioning system (GPS) and a very high frequency (VHF) transmitter that was attached to a mid-dorsal patch of clipped spines ,24 using™ 4  (<5% of ™ 4 ). The atTo ensure the hedgehogs’ tolerance to the tagging process, a hedgehog was tagged for a trial period of three days. Subsequently, all hedgehogs were monitored for 1 week–10 days, except for one hedgehog that retained the device for 16 days due to some difficulties in relocating it. At the end of the monitoring period, the hedgehogs were caught again thanks to the VHF transmitters that continuously broadcast a signal. They were weighed, and all devices were removed by cutting off the tip of the spines below the dental composite material ,28.Hedgehog nests are usually well concealed and very difficult to find. To overcome this problem, the GPS devices were programmed to operate continuously, capturing positions every 3 min during the initial phase of the survey. However, as repeated daytime locations yielded no valuable data, a modified schedule was implemented to conserve the transmitter’s battery life. Accordingly, the GPS devices were set to record locations between two hours before sunset and two hours after sunrise, thus ensuring the location of the nests. As the time of sunrise and sunset varied throughout the study, the GPS devices were programmed week by week in order to adjust them to the desired time. We could only access data and, thus, the location of the nests, once the device was detached from the hedgehog and the data was downloaded.All the nests were visited, and both the habitat around the nest and the nest itself were characterised. We calculated the number of nests used by each hedgehog and the number of times each nest was used during the monitoring days. From the nest coordinates, we calculated the distances  between the nests of each hedgehog used on consecutive days. We also calculated the MCPs (minimum convex polygons), including all the nests used by each hedgehog as a measure of their spatial spread, using QGIS 3.26.1.The nests were examined when possible, but only if a hedgehog was found inside the nest, actively using it at the time of the visit. The nests were classified into four structural categories: well-structured , poorly structured , unstructured  and burrow . The dimensions of the well-structured and poorly structured nests were measured: the length, width and height (cm) and nesting materials found in all the nests were described.For each nest location, we recorded the main structure that hosted the nest, the complementary structure (if present), the minimum height and length (cm) of the main hosting and complementary structures and the distance to the ground of the lower part of the structure at its most distal part to determine the presence or absence of immediate shelter. The principal structure was defined as the main structure hosting the nest of the hedgehog. It was divided into four different categories according to the nature of the structure itself: artificial structure , shrub-like plants , sturdy plants  and herbaceous plants . The complementary structure was defined as a plant structure that was not part of the main structure but whose presence provided additional shelter. It was divided into two categories: live plants  and leaf litter . A shelter was considered to be present when the hedgehog was fully hidden within the hosting structure immediately upon entering it, either by the main structure alone or through a combination of the main structure and a complementary one. The presence of immediate shelter was recorded when the distance between the ground and the lower part of the hosting structure at its most distal part was less than 10 cm, while an absence was recorded when the gap under the structure was greater than 10 cm.A value of slope (°) was assigned to each nest using the Digital Slope Model layer—MDP05 (5 m mesh)—downloaded from the CNIG page .To evaluate the potential effect of the presence of some artificial structures on a nest’s habitat use, the distance to four types of structures was calculated for each nest location using QGIS 3.26.1: distance to the nearest path, distance to the nearest road, distance to the nearest cat feeder and distance to the nearest streetlight. Only accessible paths and roads were taken into account when estimating the distances to those structures, and only the minimum real distance to the feeders was used .The habitat’s characteristics were measured for all the nests located, using a 5-metre radius around the central point of each nest, following the methodology used in the SEMICE project   with a sWe analysed whether the number of nests used by an individual, the number of times that each nest was used, their spatial spread  and the distance to artificial structures  varied according to sex, locality (university or urban forest) or season (spring–summer or winter). Given that the hedgehogs from the urban forest were not monitored in winter, the effect of the season was analysed using only data from the university campus. When both localities were compared, only data from spring–summer were used. In models that included repeated data from the same hedgehog, generalised mixed models with individual identification as a random effect were used. This included all models at the university because an individual may contribute data for both seasons, while for the urban forest, it included the models for the nest distances to artificial structures and times occupied. These models were fitted with function glmmTMB from the R package glmmTMB . In the The number of nests and number of times occupied may be affected by the number of days that an individual was monitored; thus, to take into account this effect, the number of monitoring days was included as a covariate in the models for these variables. Only hedgehogs with more than 1 nest were used in the models for the mean distances between consecutive nests, and only the hedgehogs with more than 2 nests were used in the MCP models. Since the number of recorded nests could affect the MCP values and the distance between them, the number of nests was included in these models as a covariate. First, the models that included the interaction of sex and season (university data) or sex and place (comparison of study sites), including the mentioned covariates, if necessary, were fitted and then were simplified, removing variables using the AIC as a criterion .2 of an ANOVA were used when testing for the differences of coordinates between levels of each categorical variable [We used factorial analysis of mixed data (FAMD) to investigate the gradients of the environmental variables related to nest placement. The FAMD allows continuous and categorical data to be integrated into the same analysis. Thus, it allowed us to investigate the association between the categorical variables describing the location of the nest  and the continuous variables relating to the cover of soil around the nests. We used the R package FactoMineR  to perfovariable .p = 0.05.The nest coordinates in the selected dimensions, resulting from this analysis, were used as dependent variables in linear mixed models (glmmTMB package) to test the fixed effects of locality, season and hedgehog sex on nest location and environment. In this analysis, the hedgehog’s identity was used as a random effect. The significance level for statistical analyses was set at A total of 130 nests (59 at the university and 71 in the urban forest) belonging to 31 hedgehogs were found. The results from the university campus showed that the number of nests per hedgehog and the distance between the consecutive nests did not vary between seasons or sexes . The valThe interaction between sex and season was significant for the number of times a nest was occupied; thus, females used the same nest more times during summer and changed nests more often in winter, while the season had no effect on males’ nest occupations. The distance from a nest to the nearest cat feeder did not vary between seasons or sexes. On the contrary, males tended to locate their nests farther from paths and streetlights but closer to roads than females .p = 0.031).All nests studied in the urban forest were found during the spring–summer period, limiting the analysis of the seasonal effects in this location. With respect to the sex’s effect, the distances between consecutive nests did not differ between the sexes, but the spread of the nests (MCP) was found to be greater for males . The average slope for the nesting sites in the urban forest was 25°, reaching maximum values of 36.5° for female and 41.5° for male nests.Pittosporum or bamboo, and dry grass. However, 27.7% of the nests also included man-made objects, such as torn plastic bags, pieces of fabric, chocolate wrappers and even an umbrella.We examined a total of 15 nests in both study areas that were actively used by a hedgehog at the moment of its location . A totalSalsola oppositifolia (p < 0.001). In both study areas, the diversity index of the nesting sites used by males appears to be higher than by females; however, this difference is only significant for the university .Almost all the nests in the urban forest were located under shrub-like plants, mainly itifolia . Nest loitifolia . The divThe FAMD identified seven dimensions with eigenvalues > 1. We selected to interpret the first five dimensions on the basis of presenting strong correlations with more than one continuous variable that, after inspection of the scatter plots , were noAccording to the linear mixed models , nest loOur results have revealed differences between male and female hedgehogs regarding their various aspects of nest use, spatial spread and location in relation to habitat’s characteristics. These differences are likely related to the promiscuous mating system of the species ,32,33 anThe distances between consecutive nests did not differ between sexes; however, in the urban forest, we estimated that the males presented a larger nest spread, as measured by the minimum convex polygon (MCP) of the nests, compared to the females. We could not test the sex effect at the university campus due to limited data; however, we observed a trend for the male nest MCP being larger in spring–summer compared to winter. Both of these patterns align with expectations due to the larger home range of males and their active search for mating partners . The comHedgehogs spend the entire day sleeping in their resting nests . Good prThe diversity of plants or structures used by females for nest placement was found to be lower compared to males in both study areas. However, this difference reached statistical significance only at the university campus, where it was more pronounced. At the university campus, we identified a total of 23 distinct types of nest locations, while in the urban forest, we found only 12 types. This suggests that the presence of gardens and artificial structures on the campus provides a wider array of potential nesting places . HedgehoThe FAMD ordination of nesting sites and their environment clearly revealed a distinction between the two urban study areas, which was statistically significant in the first four dimensions, likely indicating variations in nesting sites’ availability and habitats. The first dimension primarily separates nesting in artificial structures lacking shelter at their entrance from nesting under plants, which typically provide shelter. Nesting in artificial structures is primarily found at the university, although nesting under plants remains predominant there. Interestingly, this analysis revealed differences between the sexes in Dimensions 2 and 3, providing evidence of variations in the average nest selection environments between males and females. Dimension 2 depicts a gradient ranging from nesting in sturdy plants with a complementary structure and ample grass-like plant cover in the surrounding area  to nesting beneath shrub-like plants in an area dominated by large shrubs . Interestingly, and consistently across both locations, females nested more often in the former and males in the latter. Dimension 3 is exclusively correlated with the surrounding habitats of the nests and represents a gradient ranging from areas characterised by paved soil and small shrubs  to areas dominated by large shrubs . In this gradient, there is also a consistent difference between the sexes across the two locations, with the majority of female nests situated in areas with a higher abundance of small shrubs and, in the case of the university, more paved soil.Salsola oppositifolia, which was the dominant shrub species in that area. This raises the question of why female nests were more frequently located in sturdy plants at the university campus, while in the urban forest, they were able to utilise mostly shrubs. The answer is likely related to the variability in shape and density of the shrubs, as not all of them would be equally suitable for female nests. All plants used by females at the university and included in the category of shrub-like plants, such as Pittosporum, Lavandula or Cupressus, are quite compact. In contrast, as well as these same species, the males made nests in other shrub-like plants  that were never used by the females. Those bushes, unlike others, have less dense branching structures and seem to provide a lower level of protection that may not be suitable for females.Within the group of sturdy plants where the females established their nests at the university, ivy dominated, followed by pampas grass. Both plant species, unlike many shrubs, are difficult-to-access structures, meaning that they provide highly concealed protection for hedgehogs, with large surfaces around them  and/or thick walls of plant tissue . These types of plants were absent in the urban forest, where all female nests were found within shrub-like plants, primarily Brachypodium retusum, while at the university campus, it was predominantly composed of leaf litter (66.7% of the cases). Therefore, at the university campus, leaf litter seems to contribute to the increased suitability of some shrub-like plants besides being a component of the structure and inner lining of the nest. In addition, leaf litter is known to be an important source of food, as it provides a habitat for their natural prey, such as snails, slugs and insects [The presence or absence of an immediate shelter, which allows hedgehogs to quickly hide when entering the structure that includes the nest, seems to be important, given that the great majority of used sites (89.2%) offer this type of shelter. Among the shrub-like plants, immediate shelter was present and directly provided by the principal structure in 96% of the cases. Of the remaining 4%, in 26.3% of the cases, shelter was provided by the presence of the secondary structure, which could contribute to increasing its suitability. The nature of the secondary structures varied greatly between localities. In the urban forest, for 93.3% of nests, the secondary structure was composed of live plants, mainly  insects .The artificial structures were the only ones that lacked immediate shelter in most cases, with only 18.2% of the used sites having shelter. These structures also did not have a complementary structure that could contribute to hiding the hedgehog. As a consequence, the hedgehog was not immediately protected by the structure when entering and, thus, had to go deeper. We recorded only two cases of artificial structures used by females: a nest box specifically designed for hedgehogs, and therefore likely to be more suitable than the average artificial structures, and an office trailer, whose size and shape could have contributed to being selected by females. But overall, artificial structures were used mainly by males, which supports the idea that males are less selective of nesting sites.The type of sites used for the nest and the characteristics of its surrounding environment are expected to be related, as some types of structures are more likely to be found in particular habitats. An example of this effect may be the tendency of females to place nests in sites with greater cover of paved soil than males, especially at the university. This could be a consequence of the females selecting  shrub-like plants for their nests, as there is a negative relation between the cover of large shrubs and paved soil. On the other hand, females showed a tendency to choose sites with greater grass-like plant cover around. This result may originate from the selection of nesting sites with greater availability of food items nearby since the amount of time spent by females searching for natural prey in lawns has been shown to be greater than that spent by males in urban areas where cat feeders are available ; likewisThe contrasting topography of the university campus (flat) and the steep urban forest located on a mountain may affect the cost of movement  and helpDifferences in the management of the urban parks studied may have also contributed to increasing the dependency on cat feeders in the urban forest. The artificial irrigation employed at the university could enhance the availability of invertebrates, whereas, in the dry and arid urban forest, hedgehogs may rely more on supplementary food from cat feeders. The different distributions of artificial structures between the study areas may also help to explain some of the contrasting patterns found. Roads at the university campus are close to the periphery as it is designed as a pedestrian area, while in the urban forest, there is a road running roughly through the centre. The males placed nests closer to roads at the university campus but farther away in the urban forest. This sex and locality interaction could be attributed to the distinct road distribution. The males’ tendency for longer exploratory movements and larger home ranges ,9,10,24 Erinaceus concolor in Israel [Finally, our results showed that the nests described here are looser and smaller than those described at northern latitudes ,8,35. Man Israel  reaffirmOur study has shown differences in the nest distribution and habitat use between male and female hedgehogs in urban habitats. Females showed a preference for well-concealed structures with the presence of immediate shelter, while males were able to use a greater variety of nesting sites and tended to locate their nests further apart than females. Females tend to reuse the same nest more often than males. These results suggest that females are more selective than males when choosing the structures hosting their nests. There are also differences between the sexes in the distance of nests to some artificial elements present in the urban habitat that may act as barriers, sources of perturbations or, contrarily, attraction points. Females nested closer to paths and streetlights at the university, while males were closer to roads. Opposite results were found in the urban forest, where a road ran through the centre and where female nests were closer to roads than those of males, which is evidence that the distribution of elements in urban areas is important. Different topographies and garden management also affected the dependence of hedgehogs on supplementary food, with the nests closer to the cat feeders in the urban forest.Nests in both study areas were found to be relatively flimsy, consisting merely of grass and dry leaves, with poor compaction, and significant changes in nest characteristics were not detected across the seasons. This contrasts with the results from northern latitudes, where winter nests are thicker and far better constructed than spring–summer nests, pointing out that in southern latitudes, the selection of good hosting structures seems more important than the nest construction itself.Differences in nesting ecology between the two urban parks observed are likely to be related to their different topography and habitat characteristics and availability, highlighting the importance of studying hedgehogs’ nest site selections at the microhabitat level. However, our study has some limitations because, despite having analysed more than a hundred nests, they were built by just 31 hedgehogs, which were monitored for a limited period of time. Consequently, the sample sizes of some combinations of sex, season and study site were limited, and we were unable to fully explore the effects of these factors. Future studies with larger sample sizes and in other habitats are needed to confirm or not the generality and strength of the patterns we have found. This type of study would contribute to a better understanding of hedgehogs’ nesting requirements, fostering the design of more effective conservation strategies for hedgehogs and the appropriate management of green urban areas for this species and other wildlife.Currently, based on our results, we can highlight certain practices that would enhance the suitability of garden habitats for hedgehogs’ nests. These include: (1) using plants with a dense structure, where branches begin close to the ground to provide good shelter for the hedgehogs; (2) maintaining lawn areas as naturally as possible ; and (3)


Organ donation has a crucial impact on patient care and survival, of which the worldwide gap between organ demand and supply is currently one of the most challenging issues. Brain-dead patients are the main source of organs that can be donated, but donation requires the consent of family members—a choice that is often complex and stressful and leads to refusal of consent. This mini-review aims to provide an overview of the current knowledge on the impact of certain psychosocial factors on the decision-making process with regard to organ donation by family members. In particular, the influence of several aspects is emphasized, such as sociodemographic factors, knowledge of the organ donation process, religious beliefs, concerns that are related to the choice to donate, and mode of communication. Consistent with this evidence, we emphasize the need to examine these aspects further through interventions and guidelines that improve the organ donation application process and ensure a positive experience for the family that has to make the decision. EgyptiaThe first successful living donor transplant of a human organ occurred only in 1954, when a boy in the US donated a kidney to his twin broche, who suffered chronic kidney failure . SubsequAccording to the Italian Organ Donor Association , the sciRefusal can be issued by an individual during his lifetime or later by eligible family members. In 2021, the refusal rate was 28.6%, resulting in the exclusion of 730 potential donors.According to the European Parliament, organ donation is the act of giving organs or parts of them, without compensation, for transplantation into another person . With thThe European overview reveals substantial differences in the overall rates and specific types of donation between countries, although organ transplantation from deceased donors remains the most common form of transplantation throughout the EU . In thisDespite a global decrease (−17.6%) in transplants that were performed in 2020 compared with 2019 due to the COVID-19 pandemic, a comparison of transplantation rates between the 6 WHO regions has shown that the most active region is the Americas, with 54,084 transplants (55.0 per million population), followed by Europe, with 36,181 transplants (42.7 per million population) .The elaborate procedure of organ donation revolves around the generosity of donors or their families, and to be successful, it needs proper interaction between the health care providers that are involved—donor hospitals constitute the springboard; thus, defining standardized evaluation criteria of their potential could promote efforts toward improving performance .Considering the gap between the demand and supply of donor organs as a major global concern , the chaBuilding on available evidence , several2.We performed a literature search of studies on organ donation and transplantation, focusing on the psychological factors that are involved in the decision-making process. The studies were selected, based on the following topics: psychological impact of the request to donate organs, development of organ donation process over the years, mode of communication in the hospital setting, and the experiences of family members who consented to or refused organ and tissue donation.Global databases, such as PsychInfo, PubMed, and Google Scholar, were queried, using the following keywords: organ donation, communication, brain death, loss experience, guidelines, organ and tissue donation request, and family. Through a manual search, more relevant articles were selected, including systematic reviews, research reports, and case reports. Most of the studies were published between 2012 and 2022 .3.3.1.Sociodemographic factors, such as age, gender, ethnicity, education level, monthly income, and cause of death, influence the propensity of a potential donor/family member to consent to organ donation . In part3.2.Several studies have focused on family members’ understanding of the meaning of brain death , their kBrain-dead people are often the main source of organs ; thus, fConversely, the lack of deep knowledge of brain death, coupled with the emotionally stressful impact of such news, can foster illusory hopes in a family member . AcceptiConcerns over respecting and maintaining the dignity of the body of a brain-dead loved one  and over3.3.Religious, cultural, and social beliefs are important factors in the decision-making process for family members who are asked to donate their loved ones’ organs . Religio3.4.The decision-making process activates internal conflict that assumes the form of an ethical dilemma. Through donation, family members may feel that the death of their loved one was not in vain . Yet, faSolidarity  and the Knowing the deceased person’s wishes helps a family in the decision to donate organs . A familThoughts regarding the burial of a loved one are another concern in the choice to donate organs . Family 3.5.Brain death can occur suddenly and unexpectedly. Family members are often asked to make the decision to donate organs quickly, at an already complicated time . Yet, coThe location where the communication takes place, the participants, and verbal and nonverbal expressions are important communication-related factors .Family members need clear and comprehensive information  and empaSeveral studies  emphasizA follow-up meeting could provide clarification to families and give updates on the health of the recipients of their family members’ organs .4.Several groups  have exaWith regard to other sociodemographic factors, a higher level of education and higher income are significantly associated with a positive attitude toward organ donation , whereasAnother psychosocial factor that influences decision-making in organ donation is knowledge of the donation process . Such knGiven that brain-dead people are often the main supply of organs , it woulReligious beliefs, as a system of values, have a significant impact on the choice of organ donation . AccordiThe world’s greatest religions  highlight different understandings of the body, death, and organ transplantation.The Christian faith seems to approve of organ transplantation, which is seen as a personal choice. Jehovah’s Witnesses, distinct from mainstream Christianity, show a different and more complex conception, compounded by the rejection of blood transfusion. The possibility of free choice on the issue of organ transplantation for Jehovah’s Witnesses came in the 1980s, while retaining the blood bond .The Jewish faith embraces a complex debate: avoiding any unnecessary interference with the copre after death is one of the most significant principles because it allows for proper burial. At the same time saving lives is one of the major commandments. “Goses” is an Alachic term describing a sick person at risk of death within 3 days. In this case, the Jewish faith seems to reject interference-for example, medically intervening to prepare him or her for organ donation-so as not to hasten death .Similarly complex appears the Buddhist conception in which selfless giving corresponds to a central principle. However, the concept of brain death is controversial because in some Buddhist traditions spiritual “consciousness” can remain in the body for days after the exhalation of the last breath. Interfering with the dying process could therefore negatively interfere with the person’s rebirth.Confucianism requires respecting the body (hair and skin) from birth to death because they are considered gifts from the parents. Donating organs would therefore not be respectful to the parents .The conception of the body and organ donation in Hinduism appears to be different. Physical integrity is not necessary for the reincarnation of the soul, a founding belief for Hindus. Helping those who suffer and donating (Daan) is part of virtuous acts (Niyama) .As discussed, one of the most intricate aspects is the complex emotional management of grief and the urgency of making a decision regarding organ donation, which is governed by many intervening factors. Two of the most frequent concerns are the time that given to the family for making a decision and the appropriate timing for interviewing families about organ donation by a deceased relative . A shortUltimately, the literature suggests that a first prerequisite for donation is to first inform the population about the possibility of donation in general. Organ donation protocols should aim at organizing times, spaces, and methods of communication to ease the stress, pain, and pressure that family members experienced at the time of communication.Several studies  show thaSome authors  divide tThese data are consistent with a review  that higMost of the considered literature converges on the retrospective  and revi5.This review has identified psychosocial factors that are significantly involved in the organ and tissue donation decision-making. Knowing the wishes and beliefs of loved ones is a central factor that facilitates the decision-making process and relieves family members of an emotionally and ethically onerous choice. Therefore, though research on this issue is virtually non-existent, studies on the emotional reactions and adjustment of family members involved in the donation process are highly recommended and needed.It would also be desirable to raise awareness and promote public education on organ donation to overcome false myths and misconceptions, given that more knowledge on this topic is associated with a greater propensity to donate. In particular, future studies should address new ways of communicating with the patient’s family, an aspect that has been poorly examined in Italy. Further research should determine the impact of various educational and communication strategies with patients’ families. These findings support the need to develop an efficient protocol for organ and tissue donation, providing specific training for health care workers who are involved in the donation process and psychological support for donor families.CM, CV, and VnC performed the bibliographic search. All authors contributed to the composition of the manuscript.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The underrepresentation of women in academia is often explained by the presence of gender stereotypes and the perception that women fit the role of an academic to a lesser extent. Based on social role theory and role congruity theory, this study investigates and estimates the perceived role fit of women and men academics in the social sports sciences.n = 792) includes individuals who study or work in sports economics, sport management, or sport sociology . The questionnaire included items that reflect attributes of an ideal-typical academic as well as women and men academics in four dimensions, i.e., leadership, research methods, media visibility, and research topics. In the first step, these items were used to estimate a total role fit index for both women and men academics, as well as indices for all dimensions. In a second step, regression analyses were used to examine how respondents' individual characteristics  are related to their perceived role fit indices and the differences in the perceived role fit.Data were collected with a quantitative online survey. The sample . The results suggest that women in the social sports sciences are perceived as a better fit for the role of an academic. In contrast to role congruity theory, women's leadership fit is higher than men's fit in this dimension (0.79 vs. 0.72). Regarding the associations of individual characteristics, professors seem to perceive a lower role fit for both genders than students. Furthermore, the difference between the perceived role fit of men and women is smaller for women respondents. Having a woman role model leads to a higher fit of women academics in the leadership dimension. In 2019, only 29.3% of the world's researchers were women  What is the perceived role fit of women and men academics in the social sports sciences? (2) Which individual characteristics are related to the perceived role fit? And (3) Which individual characteristics are related to the difference in perceived role fit for women and men academics? Theoretically grounded in social role theory and role congruity theory, the research questions are analyzed using a dataset gathered from a quantitative online survey targeted at people at different academic career stages in the social sports sciences. Investigating and understanding the role fit of women (and men) academics is important to recruit and retain more women in the social sports sciences since women are already minorities in the sports sciences , post-doc researchers, and professors in sports economics, management, and sociology. The link to the survey was distributed in two ways: firstly, the survey was promoted after seven conferences in the three disciplines. More specifically, conference participants were requested to participate in the survey via email and Twitter. Secondly, academics in the three disciplines were contacted via email and were asked to participate themselves and share the link with their students and faculty colleagues. These emails were sent to more than 300 academics in Australia, Austria, Canada, Germany, the United Kingdom (UK), and the US.Data were gathered with a quantitative online survey from June 2022 to January 2023. The survey was programmed on the platform n = 792 participants. Overall, 38.8% of respondents studied or worked in the field of sports economics. Half of the respondents (50.3%) studied or worked in sport sociology. In contrast, two-thirds of respondents' study program or work was related to sport management. Respondents' ages ranged between 18 and 80 years, with an average age of 27 years. Most respondents were undergraduate or graduate students (65%), while 15.4% were PhD students and 14.1% were professors. More than half of the respondents (59.1%) were men, and more respondents had a man professor as a role model (35.9%) than a woman professor as a role model (32.4%). The vast majority of respondents studied or worked in Germany (60.6%), followed by the US (17.8%) and Canada (7.8%).The final sample size includes The questionnaire was designed as part of a larger research project. At the beginning of the questionnaire, respondents were informed about the purpose of the study, data treatment and data publication, ethical conduct, and voluntary participation. The perception of role attributes of an ideal-typical academic, as well as the perception of women and men academics in the social sports sciences, was assessed with three identical scales. Each item was measured with a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). The three scales were presented to participants in a randomized order. Such explicit measures are traditionally used for investigating attributes of women and men and gender stereotypes by asking participants to rate how likely or desirable certain attributes are for persons in general, a man, or a woman . All other countries are included in the dummy variable Other_Country. Finally, respondents' science attitude index was measured with three items based on Young et al.  were subtracted from the respective item values of the ideal-typical academics scale (xi). For example, if a respondent strongly agrees (5) that academics in the social sports sciences should be authoritarian and disagrees (2) that women academics in the social sports sciences are authoritarian, the result of this first step is 3 for the first item. Similarly, the difference is calculated for all other items. Afterward, the Euclidean distance was calculated. Therefore, the results for all items were added and then divided by the highest squared distance, which is possible. For a 5-point Likert scale, the maximum difference per item is 4, resulting in 256 as the highest possible squared distance for 16 items ([4*4]*16). This step is necessary to adjust the values to a range between 0 and 1 *4. Furthermore, the absolute differences between the perceived men's role fit index and the women's role fit index were calculated .Furthermore, the role fit indices for the four dimensions for both women and men academics were calculated by only subtracting the respective items of a dimension and calculating the Euclidean distance as explained above. The sum from the first step was divided by 64 instead of 256 because the maximum possible squared distance for four items is . However, multicollinearity was not an issue in this study. All individual variables displayed in The results of the regression analyses are displayed in For the career stages, the group of students serve as the reference category. There are significant negative effects on the total role fit index of both women and men academics for PhD students, Post-docs, and professors , again indicating that both genders seem to be equally matching the role of an academic. With a role fit of over 0.80 for the dimensions of research methods and research topics, both women and men academics appear to be rated competent with respect to science- and discipline-specific topics and skills. These findings are contradictory to previous research suggesting that women are perceived as having less analytical skills . Even though Germany is ranked better in the total gender gap index, Canada has a smaller gender gap in economic participation and education  is less present in the disciplines of the social sports sciences or that they have started to decrease. Furthermore, individual characteristics, such as the career stage, gender, and the country in which one studies or works, were found to be related to the perception of the role fit and the difference between women's and men's role fit.Based on social role theory Eagly,  and roleThe results of this study can contribute to the body of literature in several ways: firstly, this study investigates gender stereotypes by measuring the perception of stereotypically masculine and feminine attributes in the social sports sciences, a field which is associated with masculinity Burton, , but whiThe study provides some implications for both researchers in the field of gender stereotypes in academia and researchers who study or work in the social sports sciences. The study shows the importance of investigating gender stereotypes and role (in)congruities in different disciplines. It is not possible to generalize findings from other disciplines, even if many circumstances seem comparable. Practically, academics in the social sports sciences need to reflect their own stereotypes, especially when they are involved in performance evaluations or hiring decisions. Workshops within the faculties or at conferences might be a good start. It may be advantageous to increase and encourage communication between the disciplines of the social sports sciences, e.g., by organizing a joined conference, since academics in different disciplines perceive different role fits. Since the majority of academics within the field are men and the results suggest that men tend to perceive a better fit of men academics, it is especially important that men are actively encouraged to reconsider their view on role fit. Furthermore, the regression results indicate that women's role models may be helpful because they showcase that women's social role has developed and that they have had the skillset to become a full professor. While previous studies found that women role models are especially important for women (Lockwood, The study has some limitations, which can guide future studies. The dataset reflects cross-sectional data and is limited to the time of data collection. Longitudinal studies would enrich the state of knowledge by seeing if and how the role fit changes during people's academic career. The online survey was designed to measure the perception of role fit, not the actual behaviors directed toward gender. A mixed-methods approach might be valuable to get a deeper understanding of a potential bias between the perception and behaviors. Furthermore, the items in the role attributes scale cannot measure all aspects that might be important in the four dimensions. Given that this study is the first that estimates a role fit index and that multi-dimensional approaches were described as beneficial (Haines et al., The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving humans were approved by Ethics Commitee of Bielefeld University. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.LL performed the data cleaning and data analysis under the advice of PW, drafted the introduction, theory and literature review, method, results, discussion, and conclusion. KS and PW checked the overall manuscript for coherence, language, and format. All authors were part of the conceptualization of the study and the design of the questionnaire, contributed to the data collection, revised the manuscript critically, and agreed on the final version of the manuscript.


Neck pain is one of the leading causes of years lived with disability, and approximately half of people with neck pain experience recurrent episodes. Deficits in the sensorimotor system can persist even after pain relief, which may contribute to the chronic course of neck pain in some patients. Evaluation of sensorimotor capacities in patients with neck pain is therefore important. No consensus exists on how sensorimotor capacities of the neck should be assessed in physiotherapy. The aims of this systematic review are: (a) to provide an overview of tests used in physiotherapy for assessment of sensorimotor capacities in patients with neck pain; and (b) to provide information about reliability and measurement error of these tests, to enable physiotherapists to select appropriate tests.Medline, CINAHL, Embase and PsycINFO databases were searched for studies reporting data on the reliability and/or measurement error of sensorimotor tests in patients with neck pain. The results for reliability and measurement error were compared against the criteria for good measurement properties. The quality of evidence was assessed according to the modified GRADE method proposed by the COSMIN group.A total of 206 tests for assessment of sensorimotor capacities of the neck were identified and categorized into 18 groups of tests. The included tests did not cover all aspects of the sensorimotor system; tests for the sensory and motor components were identified, but not for the central integration component. Furthermore, no data were found on reliability or measurement error for some tests that are used in practice, such as movement control tests, which apply to the motor component. Approximately half of the tests showed good reliability, and 12 were rated as having good (+) reliability. However, tests that evaluated complex movements, which are more difficult to standardize, were less reliable. Measurement error could not be evaluated because the minimal clinically important change was not available for all tests.Overall, the quality of evidence is not yet high enough to enable clear recommendations about which tests to use to assess the sensorimotor capacities of the neck.The online version contains supplementary material available at 10.1186/s40945-023-00170-9. Neck pain is the second most common musculoskeletal problem . It is oManagement of patients with neck pain is a major challenge in physiotherapy, mainly because these patients form a very heterogeneous group in terms of the nature of symptoms, symptom distribution, and underlying pain mechanisms . As neckDeficits of sensorimotor capacities (SC) may be one of the factors contributing to neck pain, in particular the persistence or recurrence of neck pain . The senGiven that many tests exist for assessment of SC of the neck, the challenge is to choose the most appropriate test for use in a specific situation. From a scientific perspective, knowledge about the quality of a test, i.e. measurement properties, is important when making this decision. The quality of a test depends on three criteria: reliability, validity and responsiveness .This systematic review investigates the domain reliability. Reliability is the degree to which measurements are free from measurement error. The domain reliability includes three measurement properties: reliability, , measurement error (which is the systematic and random error of a patient’s score that is not attributed to true changes in the construct to be measured), and internal consistency . InternaThe aim of this systematic review is to include all tests assessing any aspect of SC of the neck. Therefore, since many different tests are described in the literature, this review focusses only on reliability. Of course, when deciding which test to use, it would also be important to consider the different aspects of validity.The concepts of reliability and measurement error are related, but focus on different purposes. Reliability focusses on the variability between patients or measurements and is influenced by the variation in the population where the test is used. On the other hand, measurement error is a relevant parameter for measurement of change over time, and it is not affected by population variability . In clinThe aims of this systematic review are: (a) to provide an overview of tests used in physiotherapy to assess SC in patients with neck pain; and (b) to provide information about the reliability and measurement error of these tests, to enable physiotherapists to select appropriate tests.A meta-analysis of studies investigating the reliability and measurement error of tests assessing SC of patients with neck pain in a physiotherapy setting.The databases CINAHL, Embase and PsycINFO were searched up to July 2020 and for Medline up to May 2021. Blocks of search terms were developed for: (a) construct of interest (sensorimotor capacities), (b) population (patients with neck pain), (c) the sensitive PubMed filter developed by Terwee et al.  for the Two reviewers (SE and either RH or MT) screened the titles and abstracts independently, based on the predefined inclusion and exclusion criteria listed in Fig. Full-text screening was performed independently by two researchers (SE and RH) using the same predefined criteria Fig. . After eData extraction was conducted using REDCap electronic data capture tools hosted at the University of Applied Sciences and Arts Western Switzerland (HES-SO) Valais  by SE anThe intraclass correlation coefficients of studies that used the same device and similar instructions for the corresponding test were quantitatively pooled. When pooling was not feasible, the study results were qualitatively summarized, by reporting the lowest and highest values. Because of the large number of tests applied for different directions of movement of the neck  test directions were summarized with reliability or measurement error values that led to the same conclusion regarding the criteria for good measurement properties, with the lowest and highest value. Tests directions with very different values (i.e. when the conclusion about the appropriateness of the reliability or the measurement error for this direction would be different from that for other directions) were reported separately.2 > 0.5), and imprecision . The score was not downgraded for indirectness, due to the restrictive inclusion criteria used in the current study [The overall results for the reliability and/or measurement error of single studies or of summarized or pooled studies were compared against the criteria for good measurement properties. In a next step, the quality of evidence was graded according to the modified GRADE method proposed by the COSMIN group . The quant study . DetaileIn total 11,704 studies were found using the search strategy in four databases . First, 3741 duplicates were removed. The remaining 7963 studies were screened for title and abstract, and 7803 were excluded based on the predefined criteria. Of the 160 full-text studies, 118 were excluded. The reasons for exclusion are listed in Fig. A final total of 42 studies, investigating a total of 206 tests for the assessment of SC in patients with neck pain, were included in the systematic review Table .Fig. 2FlTests were categorized into 18 different groups . Based on the classification of Riemann & Lephart , tests fAccording to the COSMIN criteria the following 12 tests were rated as good: craniocervical flexion test (test-retest reliability), neck flexor muscle endurance test (inter-rater and test-retest reliability), neck extensor muscle endurance test (inter-rater and test-retest reliability), sternocleidomastoid muscle strength (test-retest reliability), maximal voluntary isometric contraction (test-retest reliability), isometric strength with the help of different devices (test-retest reliability), flexion-relaxation ratio (test-retest reliability), active range of motion test with the help of different devices (inter-rater and test-retest reliability), figure of eight test (inter-rater and test-retest reliability), zigzag test (inter-rater and test-retest reliability), smooth pursuit neck torsion test (test-retest reliability), and rod and frame test (test-retest reliability). An overview of the ratings of all tests is shown Table Regarding measurement error, the criteria for good measurement error were rated as unknown for all included tests, because the minimal clinically important change was not reported. The quality of evidence was rated very low to high Table . ReasonsThis systematic review included 42 studies evaluating 206 tests, with the aim of investigating the reliability and measurement error of tests for SC in patients with neck pain. The main findings are, firstly, that tests for the sensory and motor components of the sensorimotor system were found, but not for the central integration component. Furthermore, no data were found on reliability or measurement error in patients with neck pain for some tests that are used in practice, such as the movement control tests, which would belong to the motor component; secondly, approximately half of the tests, particularly tests that are easier to standardize with regard to test position or movement direction, showed good reliability; and, finally, tests evaluating more complex movements, which are more difficult to standardize, were less reliable.In general, all included muscle endurance tests, had good (relative) reliability values according to the criteria for good measurement properties proposed by COSMIN, except for the scapula muscle endurance test in standing position. The execution of this test is much more complex and more difficult to standardize than other tests. Furthermore, scapula movements, compensatory movements, muscle recruitment etc. are more difficult to assess compared with neck movements where the movement directions follow the sagittal, frontal, or transversal plane in a more stable way. Similarly, regarding reliability of the isometric muscle strength tests, tests involving the judgement of movements or muscle recruitment around the scapula have lower values for reliability than tests for isometric activity of the head into flexion, extension, lateral flexion, or rotation. Again, this may be because scapula positions are more difficult to standardize, and isometric contractions of the scapula muscles are more difficult to assess regarding compensatory movements than isometric muscle activity of the muscles of the cervical spine.The test of fast cervical rotations showed very low reliability, possibly due to the very complex characteristics of these movements, which make it difficult to standardize the test. The tests assessing active range of motion (AROM) of the cervical spine showed that assessment of rotation is more difficult compared with the other movement directions. This is particularly evident when the rotation is assessed as a single movement  and when AROM is assessed with the help of a smartphone. In the current analysis, the values were less reliable for Android phones than for iPhones , this review shows that tests that require a substantial subjective rating (e.g. judgement of muscle recruitment or movement patterns) lead to lower reliability compared with more objective criteria (e.g. time). The current results are in line with a recent systematic review by Selistre and colleagues , investiThe two recent systematic reviews on measurement properties of tests for the SC of the neck included studies with participants with and without neck pain , 31. BotThe major strength of this study is that it included all available tests for assessment of all aspects of sensorimotor control of the neck. However, the study also has a number of limitations. Many tests were performed only on healthy participants or in a mixed group of participants with and without neck pain. Several studies were excluded, including all studies assessing tests for movement control of the neck, as the authors did not report separate data for the patient group. Secondly, the quality of evidence was low to very low regarding reliability for all included studies. It was necessary to downgrade the level of evidence, mainly because of high risk of bias, inconsistency, and low precision. In the assessment of risk of bias, the item “patient stability” is one of the items that was particularly rated as doubtful in many cases. COSMIN recommends that patient stability should only be rated as very good if the study explicitly describes that the patients’ condition did not change between measurements. As this information was often missing, the current review had to rate the patient stability item as doubtful, even though the time interval between measurements was adequate. A further limitation of this review is that the included studies did not report data on interpretability and feasibility of the different tests, which would be important information for the recommendation of specific tests. Finally, this review did not assess aspects of validity, which would certainly also be important for the selection of appropriate tests.Better studies are needed on reliability, measurement error and validity of tests in patients with neck pain, because the quality of evidence of the existing research is mainly low or very low, and the reliability of some tests (e.g. for movement control) was not evaluated in patients with neck pain at all.Despite the large number of tests available, the quality of evidence is not yet high enough to conclusively inform clinicians which test to use to assess SC in patients with neck pain.For clinical practice, this systematic review shows that tests with objective criteria and a thorough standardization should be chosen to ensure higher reliability.Measurement error could not be evaluated because the minimal clinically important change was not available for all tests.Additional file 1. Search strategy (for Medline). Search strategy for MedlineAdditional file 2. Risk of bias Reliability. Items of the assessment of risk of bias for reliabilityAdditional file 3. Risk of bias Measurement error. Items of the assessment of risk of bias for measurement errorAdditional file 4. GRADE Downgrading Reliability. Reasons for downgradingAdditional file 5. GRADE Downgrading Measurement error. Reasons for downgrading


During the last few decades, the field of rehabilitation has experienced substantial development, growth, and acceptance. Rehabilitation addresses the impact of a health condition on a person’s everyday life by optimizing their functioning and reducing their experience of disability. Rehabilitation expands the focus of health beyond preventative and curative care to ensure people with a health condition can remain as independent as possible and participate in education, work and meaningful life roles . A definEnsure healthy lives and promote well-being for all at all ages [We also have now a better understanding of the growing global need, demand, and recognition of rehabilitation around the world. For example, it has been estimated that 2.41 billion people in the world could benefit from rehabilitation services. This means that at least one in every three persons in the world needs rehabilitation at some point during the course of their disease or injury . Now morall ages .Notwithstanding the foregoing arguments, there continues to be a high unmet need for rehabilitation globally, with some low- and middle-income countries reporting unmet needs up to 50% of those who could benefit from rehabilitation. Rehabilitation services are not accessible to many people around the world , 8. HealThe field of health policy and systems research (HPSR) seeks to understand and improve how societies organize themselves in achieving collective health goals, and how different actors interact in the policy and implementation processes to contribute to policy outcomes , 10. By In 2022 the WHO Rehabilitation Program established the World Rehabilitation Alliance (WRA)  to strenIn this context the co-authors of this editorial on behalf of their respective academic journals express their full support for the WRA mission in general and for the specific objectives of the research workstream. In concrete terms we, commit that our journals, as much as possible, will implement one or more of the following actions: (1) invite researchers in the field of HPSR for rehabilitation to submit their manuscripts to our Journals for peer review and possible publication, (2) create a special journal section, series, or designation dedicated to HPSR for rehabilitation, (3) appoint editorial board members with expertise in HPSR for rehabilitation, and (4) disseminate research articles among funding agencies and policymakers. These actions by our academic journals will help the WRA achieve its goal of strengthening rehabilitation services for all.