{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T19:28:12Z","timestamp":1790796492488,"version":"4.1.0"},"reference-count":50,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2025,12,21]],"date-time":"2025-12-21T00:00:00Z","timestamp":1766275200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Illustrious Professional College of Physiotherapists of the Community of Madrid","award":["1-10-2025"],"award-info":[{"award-number":["1-10-2025"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Introduction. The proliferation of immersive virtual reality (VR) technologies has transformed the way individuals interact with digital environments, offering unprecedented opportunities in fields ranging from entertainment and education to healthcare and mental health interventions. Immersive VR is increasingly being implemented in motor and cognitive programs in neurorehabilitation, where patient safety and treatment adherence are critical. Despite its relevance, the conceptualization and measurement of cybersickness (CS) remain fragmented across disciplines, with various assessment tools developed in isolation, targeting different symptom domains, populations, and use contexts. Aim. The aim of this systematic review is to identify, categorize, and critically appraise all existing instruments and scales developed to measure CS associated with immersive VR use. The secondary objectives involve examining the psychometric properties of the identified instruments to provide robust evidence for clinicians in assessing CS associated with VR, thereby supporting future scale development and standardization. Additionally, a further objective is to evaluate the specific applicability of these instruments and scales for measuring CS within neurorehabilitation settings, given the growing use of immersive VR in clinical practice with neurological populations. Methods. This systematic review was conducted in accordance with the Guideline for reporting systematic reviews of outcome measurement instruments (PRISMACOSMIN). The review protocol was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO). Data extraction was performed independently by the two reviewers, and discrepancies were resolved by consensus or consultation with a third reviewer. To assess the psychometric robustness of existing CS assessment instruments used in virtual reality settings, we applied the methodology proposed by the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) initiative for systematic reviews of patient-reported outcome measures (PROMs). The evaluation was structured across three steps: Assessment of risk of bias; Quality of measurement properties and Summary of evidence; and Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. Results. Nine assessment instruments were included in this review. Following our analysis, the CSQ-VR and VRNQ received a Grade A recommendation, as they met sufficient criteria for both internal consistency and structural validity with high methodological quality. Few instruments have reported validations in specific clinical populations related to neurorehabilitation, including individuals with neurological conditions such as brain injury, multiple sclerosis (MS), migraine-associated vestibulopathy, vestibular disorders or cognitive impairment, indicating a critical gap in scale generalizability across clinical contexts. Conclusions. Despite the increasing use of immersive VR, few CS assessment tools have been designed and validated, reaching the CSQ-VR and VRNQ a Grade A recommendation. Among the nine identified assessment instruments, only the SSQ, MSAQ, CSQ-VR, VRNQ MSSQ and SEQ have been employed in samples with neurological disorders. There is a critical need for standardized CS VR-specific tools with robust psychometric properties to ensure safe and effective implementation in neurorehabilitation settings.<\/jats:p>","DOI":"10.3390\/jcm15010046","type":"journal-article","created":{"date-parts":[[2025,12,22]],"date-time":"2025-12-22T16:19:26Z","timestamp":1766420366000},"page":"46","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["Cybersickness Evaluation in Immersive Virtual Environments: A Systematic Review with Implications for Neurological Rehabilitation"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0009-0004-8913-1513","authenticated-orcid":false,"given":"Mar\u00eda","family":"Fern\u00e1ndez-Ca\u00f1as","sequence":"first","affiliation":[{"name":"International Doctorate School, Universidad Rey Juan Carlos, 28922 Alcorc\u00f3n, Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1808-0526","authenticated-orcid":false,"given":"Rosa Mar\u00eda","family":"Ortiz-Guti\u00e9rrez","sequence":"additional","affiliation":[{"name":"Departamento de Fisioterapia, Universidad Complutense de Madrid, 28040 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5889-1841","authenticated-orcid":false,"given":"Patricia","family":"Mart\u00edn-Casas","sequence":"additional","affiliation":[{"name":"Departamento de Fisioterapia, Universidad Complutense de Madrid, 28040 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8809-2952","authenticated-orcid":false,"given":"Cecilia","family":"Estrada-Barranco","sequence":"additional","affiliation":[{"name":"Departamento de Fisioterapia, Universidad Europea de Madrid, 28670 Villaviciosa de Od\u00f3n, Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Selena","family":"Marcos-Ant\u00f3n","sequence":"additional","affiliation":[{"name":"Departamento de Ciencias de la Salud, Universidad Villanueva, 28034 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-8820-7560","authenticated-orcid":false,"given":"Aitor","family":"Bl\u00e1zquez-Fern\u00e1ndez","sequence":"additional","affiliation":[{"name":"International Doctorate School, Universidad Rey Juan Carlos, 28922 Alcorc\u00f3n, Madrid, Spain"},{"name":"Asociaci\u00f3n de Legan\u00e9s de Esclerosis M\u00faltiple, 28915 Legan\u00e9s, Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8836-7135","authenticated-orcid":false,"given":"Sof\u00eda","family":"Laguarta-Val","sequence":"additional","affiliation":[{"name":"Departamento de Fisioterapia, Terapia Ocupacional, Rehabilitaci\u00f3n y Medicina F\u00edsica, Universidad Rey Juan Carlos, 28922 Alcorc\u00f3n, Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9253-8884","authenticated-orcid":false,"given":"Carmen","family":"Jim\u00e9nez-Antona","sequence":"additional","affiliation":[{"name":"Departamento de Fisioterapia, Terapia Ocupacional, Rehabilitaci\u00f3n y Medicina F\u00edsica, Universidad Rey Juan Carlos, 28922 Alcorc\u00f3n, Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1118-4234","authenticated-orcid":false,"given":"Roberto","family":"Cano-de-la-Cuerda","sequence":"additional","affiliation":[{"name":"Departamento de Fisioterapia, Terapia Ocupacional, Rehabilitaci\u00f3n y Medicina F\u00edsica, Universidad Rey Juan Carlos, 28922 Alcorc\u00f3n, Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,12,21]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"545","DOI":"10.3233\/NRE-130995","article-title":"A telerehabilitation program by virtual reality-video games improves balance and postural control in multiple sclerosis patients","volume":"33","author":"Arroyo","year":"2013","journal-title":"NeuroRehabilitation"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"513","DOI":"10.3233\/NRE-131001","article-title":"Kinect Xbox 360 as a therapeutic modality for children with cerebral palsy in a school environment: A preliminary study","volume":"33","year":"2013","journal-title":"NeuroRehabilitation"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"5697","DOI":"10.3390\/ijerph10115697","article-title":"A telerehabilitation program improves postural control in multiple sclerosis patients: A Spanish preliminary study","volume":"10","year":"2013","journal-title":"Int. J. Environ. Res. Public Health"},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Slater, M., and Sanchez-Vives, M.V. (2016). Enhancing our lives with immersive virtual reality. Front. Robot. AI, 3.","DOI":"10.3389\/frobt.2016.00074"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"752","DOI":"10.1038\/nrn3122","article-title":"Virtual reality in neuroscience research and therapy","volume":"12","author":"Bohil","year":"2011","journal-title":"Nat. Rev. Neurosci."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"82","DOI":"10.1089\/cyber.2017.29099.gri","article-title":"Neuroscience of virtual reality: From virtual exposure to embodied medicine","volume":"22","author":"Riva","year":"2019","journal-title":"Cyberpsychol. Behav. Soc. Netw."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1145\/333329.333344","article-title":"A discussion of cybersickness in virtual environments","volume":"32","author":"LaViola","year":"2000","journal-title":"ACM SIGCHI Bull."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"101","DOI":"10.1007\/s10055-016-0285-9","article-title":"Review on cybersickness in applications and visual displays","volume":"20","author":"Rebenitsch","year":"2016","journal-title":"Virtual Real."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Davis, S., Nesbitt, K., and Nalivaiko, E. (2014, January 2\u20133). A systematic review of cybersickness. Proceedings of the 2014 Conference on Interactive Entertainment, Newcastle, Australia.","DOI":"10.1145\/2677758.2677780"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"2201","DOI":"10.1152\/jn.00477.2018","article-title":"Estimating the sensorimotor components of cybersickness","volume":"120","author":"Weech","year":"2018","journal-title":"J Neurophysiol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"2003","DOI":"10.1007\/s10055-023-00787-y","article-title":"CAVE and HMD: Distance perception comparative study","volume":"27","author":"Combe","year":"2023","journal-title":"Virtual Real."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"20552076231178619","DOI":"10.1177\/20552076231178619","article-title":"Virtual reality for healthcare: A scoping review of commercially available applications for head-mounted displays","volume":"9","author":"Helou","year":"2023","journal-title":"Digit. Health"},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Baashar, Y., Alkawsi, G., Wan Ahmad, W.N., Alomari, M.A., Alhussian, H., and Tiong, S.K. (2023). Towards wearable augmented reality in healthcare: A comparative survey and analysis of head-mounted displays. Int. J. Environ. Res. Public Health, 20.","DOI":"10.3390\/ijerph20053940"},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Fregna, G., Schincaglia, N., Baroni, A., Straudi, S., and Casile, A. (2022). A novel immersive virtual reality environment for the motor rehabilitation of stroke patients: A feasibility study. Front. Robot. AI, 9.","DOI":"10.3389\/frobt.2022.906424"},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Casile, A., Fregna, G., Boarini, V., Paoluzzi, C., Manfredini, F., Lamberti, N., Baroni, A., and Straudi, S. (2023). Quantitative comparison of hand kinematics measured with a markerless commercial head-mounted display and a marker-based motion capture system in stroke survivors. Sensors, 23.","DOI":"10.20944\/preprints202307.1645.v1"},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Demeco, A., Zola, L., Frizziero, A., Martini, C., Palumbo, A., Foresti, R., Buccino, G., and Costantino, C. (2023). Immersive virtual reality in post-stroke rehabilitation: A systematic review. Sensors, 23.","DOI":"10.3390\/s23031712"},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Fregna, G., Paoluzzi, C., Baroni, A., Cano-de-la-Cuerda, R., Casile, A., and Straudi, S. (2023). Head-mounted displays for upper limb stroke rehabilitation: A scoping review. J. Clin. Med., 12.","DOI":"10.3390\/jcm12237444"},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Patsaki, I., Dimitriadi, N., Despoti, A., Tzoumi, D., Leventakis, N., Roussou, G., Papathanasiou, A., Nanas, S., and Karatzanos, E. (2022). The effectiveness of immersive virtual reality in physical recovery of stroke patients: A systematic review. Front. Syst. Neurosci., 16.","DOI":"10.3389\/fnsys.2022.880447"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"203","DOI":"10.1207\/s15327108ijap0303_3","article-title":"Simulator sickness questionnaire: An enhanced method for quantifying simulator sickness","volume":"3","author":"Kennedy","year":"1993","journal-title":"Int. J. Aviat. Psychol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1186\/1743-0003-1-8","article-title":"Virtual reality and physical rehabilitation: A new toy or a new research and rehabilitation tool?","volume":"1","author":"Keshner","year":"2004","journal-title":"J. Neuroeng. Rehabil."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Saredakis, D., Szpak, A., Birckhead, B., Keage, H.A.D., Rizzo, A., and Loetscher, T. (2020). Factors associated with virtual reality sickness in head-mounted displays: A systematic review and meta-analysis. Front. Hum. Neurosci., 14.","DOI":"10.3389\/fnhum.2020.00096"},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Streiner, D.L., Norman, G.R., and Cairney, J. (2015). Health Measurement Scales: A Practical Guide to Their Development and Use, Oxford University Press. [5th ed.].","DOI":"10.1093\/med\/9780199685219.001.0001"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"111422","DOI":"10.1016\/j.jclinepi.2024.111422","article-title":"Guideline for reporting systematic reviews of outcome measurement instruments (OMIs): PRISMA COSMIN for OMIs 2024","volume":"173","author":"Elsman","year":"2024","journal-title":"J. Clin. Epidemiol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"539","DOI":"10.1007\/s11136-010-9606-8","article-title":"The COSMIN checklist for assessing the methodological quality of studies on measurement properties: A Delphi study","volume":"19","author":"Mokkink","year":"2010","journal-title":"Qual. Life Res."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1147","DOI":"10.1007\/s11136-018-1798-3","article-title":"COSMIN guideline for systematic reviews of patient-reported outcome measures","volume":"27","author":"Prinsen","year":"2018","journal-title":"Qual. Life Res."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1159","DOI":"10.1007\/s11136-018-1829-0","article-title":"COSMIN methodology for evaluating the content validity of patient-reported outcome measures: A Delphi study","volume":"27","author":"Terwee","year":"2018","journal-title":"Qual. Life Res."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"651","DOI":"10.1007\/s11136-011-9960-1","article-title":"Rating the methodological quality in systematic reviews of studies on measurement properties: A scoring system for the COSMIN checklist","volume":"21","author":"Terwee","year":"2012","journal-title":"Qual. Life Res."},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"GRADE Working Group (2004). Grading quality of evidence and strength of recommendations. BMJ, 328, 1490.","DOI":"10.1136\/bmj.328.7454.1490"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"66","DOI":"10.1016\/j.apergo.2017.12.016","article-title":"Virtual reality sickness questionnaire (VRSQ): Motion sickness measurement index in a virtual reality environment","volume":"69","author":"Kim","year":"2018","journal-title":"Appl. Ergon."},{"key":"ref_30","first-page":"115","article-title":"A questionnaire for the assessment of the multiple dimensions of motion sickness","volume":"72","author":"Gianaros","year":"2001","journal-title":"Aviat. Space Environ. Med."},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Weech, S., Kenny, S., and Barnett-Cowan, M. (2019). Presence and cybersickness in virtual reality are negatively related: A review. Front. Psychol., 10.","DOI":"10.3389\/fpsyg.2019.00158"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"415","DOI":"10.1177\/0018720811403736","article-title":"Validating an efficient method to quantify motion sickness","volume":"53","author":"Keshavarz","year":"2011","journal-title":"Hum. Factors"},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Kourtesis, P., Collina, S., Doumas, L.A.A., and MacPherson, S.E. (2019). Validation of the Virtual Reality Neuroscience Questionnaire: Maximum duration of immersive virtual reality sessions without the presence of pertinent adverse symptomatology. Front. Hum. Neurosci., 13.","DOI":"10.3389\/fnhum.2019.00417"},{"key":"ref_34","first-page":"16","article-title":"Cybersickness in virtual reality questionnaire (CSQ-VR): A validation and comparison against SSQ and VRSQ","volume":"2","author":"Kourtesis","year":"2023","journal-title":"Virtual Real."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"507","DOI":"10.1016\/S0361-9230(98)00091-4","article-title":"Motion sickness susceptibility questionnaire revised and its relationship to other forms of sickness","volume":"47","author":"Golding","year":"1998","journal-title":"Brain Res. Bull."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"439","DOI":"10.1089\/g4h.2019.0045","article-title":"Development of a classifier to determine factors causing cybersickness in virtual reality environments","volume":"8","author":"Reuter","year":"2019","journal-title":"Games Health J."},{"key":"ref_37","unstructured":"Gil-G\u00f3mez, J.A., Gil-G\u00f3mez, H., Lozano-Quilis, J.A., Manzano-Hern\u00e1ndez, P., Albiol-P\u00e9rez, S., and Aula-Valero, C. (2013, January 5\u20138). SEQ: Suitability evaluation questionnaire for virtual rehabilitation systems. Application in a virtual rehabilitation system for balance rehabilitation. Proceedings of the 7th International Conference on Pervasive Computing Technologies for Healthcare and Workshops, Venice, Italy."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1080\/00140139.2020.1820083","article-title":"Exploratory factor analysis and validity of the virtual reality symptom questionnaire and computer use survey","volume":"64","author":"Larranaga","year":"2021","journal-title":"Ergonomics"},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"Stanney, K.M., Fidopiastis, C., and Foster, L. (2020). Virtual Reality Is Sexist: But It Does not Have to Be. Front. Robot. AI, 7.","DOI":"10.3389\/frobt.2020.00004"},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Pau, M., Arippa, F., Leban, B., Porta, M., Casu, G., Frau, J., Lorefice, L., Coghe, G., and Cocco, E. (2024). Cybersickness in People with Multiple Sclerosis Exposed to Immersive Virtual Reality. Bioengineering, 11.","DOI":"10.3390\/bioengineering11020115"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"311","DOI":"10.1162\/pres.1992.1.3.311","article-title":"Cybersickness: Perception of Self-Motion in Virtual Environments","volume":"1","author":"McCauley","year":"1992","journal-title":"Presence Teleoperators Virtual Environ."},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"Espinosa-Sanchez, J.M., and Lin, C.-C. (2025). Editorial: Vestibular migraine. Front. Neurol., 16.","DOI":"10.3389\/fneur.2025.1587097"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1116","DOI":"10.1097\/MAO.0000000000002705","article-title":"The Relationship Between Vestibular Migraine and Motion Sickness Susceptibility","volume":"41","author":"Abouzari","year":"2020","journal-title":"Otol. Neurotol."},{"key":"ref_44","first-page":"887","article-title":"A Novel Virtual Reality Tool (CSQ-VR) for Neuropsychological Assessment: Development and Initial Validation","volume":"26","author":"Kourtesis","year":"2022","journal-title":"Virtual Real."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"108714","DOI":"10.1016\/j.cmpb.2025.108714","article-title":"A Comprehensive Exploration of Motion Sickness Process Analysis from EEG Signal and Virtual Reality","volume":"264","author":"Feng","year":"2025","journal-title":"Comput. Methods Programs Biomed."},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Kiryu, T., Iijima, A., and Bando, T. (2006, January 17\u201318). Relationships between Sensory Stimuli and Autonomic Regulation during Real and Virtual Exercises. Proceedings of the 2005 IEEE Engineering in Medicine and Biology 27th Annual Conference, Shanghai, China.","DOI":"10.1109\/IEMBS.2005.1615596"},{"key":"ref_47","first-page":"701","article-title":"Cybersickness: A Systematic Literature Review of Adverse Effects Related to Virtual Reality","volume":"39","year":"2024","journal-title":"Neurologia (Engl. Ed.)"},{"key":"ref_48","doi-asserted-by":"crossref","unstructured":"Wang, W., Wong, S.S.-l., and Lai, F.H.-y. (2021). The Effect of Virtual Reality Rehabilitation on Balance in Patients with Parkinson\u2019s Disease: A Systematic Review and Meta-Analysis. Electronics, 10.","DOI":"10.3390\/electronics10091003"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"967","DOI":"10.1097\/MAO.0000000000003155","article-title":"Virtual Reality for Vestibular Rehabilitation: A Systematic Review","volume":"42","author":"Xie","year":"2021","journal-title":"Otol. Neurotol."},{"key":"ref_50","first-page":"91","article-title":"Relationship Between Motion Sickness Susceptibility and Vestibular Test Results","volume":"39","author":"Kuru","year":"2024","journal-title":"Medeni. Med. J."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/1\/46\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,22]],"date-time":"2025-12-22T16:33:26Z","timestamp":1766421206000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/1\/46"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,12,21]]},"references-count":50,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,1]]}},"alternative-id":["jcm15010046"],"URL":"https:\/\/doi.org\/10.3390\/jcm15010046","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,12,21]]}}}