A clinical case of ochronosis with involvement of the cardiac valvular apparatus and the musculoskeletal system in an 80-year-old patient

Background Chiropractors are primary healthcare providers who provide a holistic form of healthcare for the treatment and management of neuromusculoskeletal disorders. The South African chiropractic scope of practice includes dietary advice or supplement recommendations in adjunct to other treatment options when managing a patient. Chiropractors treat a variety of runners of diverse levels, ages, genders and who participate in various domains of running. Runners are at a high risk of developing musculoskeletal (MSK) conditions, with numerous risk factors identified in literature. Musculoskeletal conditions may have a negative impact on a runner’s recovery, performance, quality of life, psychosocial wellbeing and cause financial burdens. Chiropractic treatment is often used to manage MSK conditions in runners but it is unknown what role the utilisation of vitamins and minerals may have in the management of conditions in runners. The utilisation of vitamins and minerals by chiropractors when managing runners has not been investigated; thus, it is unknown how chiropractors prescribe, dispense, or provide nutritional education to runners. The type of supplement recommended for certain conditions in runners remains unknown and the influence that supplementation may have in the management of runners is also unknown. The benefits of understanding supplement utilisation methods by chiropractors will assist the profession in the prevention, treatment and management of MSK conditions in runners. Improved treatment outcomes will assist runners’ recovery, performance and injury rates and promote beneficial outcomes in the chiropractic profession. Aim of the study The study aims to explore the utilisation of vitamins and minerals by chiropractors in the management of MSK conditions in runners. Methodology The study employed a qualitative, exploratory descriptive design to investigate how chiropractors utilise vitamins and minerals in the management of MSK conditions in runners. Interviews were conducted with 15 South African chiropractors, guided by predetermined open-ended questions in a semi-structured manner. The participants needed to be registered with the Allied Health Professions Council of South Africa (AHPCSA), practicing for a minimum of three years, regularly treat runners, and recommend nutritional supplements to runners. The research questions asked chiropractors how they utilise vitamins and minerals when they manage MSK conditions in runners; what type of supplements they advise; for what conditions do they advise supplements; and if supplementation had an influence in the management of runners. The data were analysed to identify themes and sub-themes, using Tesch’s method of data analysis. Results From the data, four main themes with their associated sub-themes emerged. The themes described the active utilisation of nutritional supplements by chiropractors for runners. Sub themes described the factors and reasoning for the recommendation of supplements to runners by the chiropractors. Furthermore, supplement recommendations were identified for both MSK and non-MSK conditions in runners. The data revealed the type of supplements which the chiropractors recommended for certain conditions in the runners. A positive influence of supplementation in runners was reported by the chiropractors. The sub-themes described improvements in the treatment outcomes after supplementation, improved recovery and performance of the runner, and decreased injury rates. A theme of holistic management of runners by chiropractors emerged, which included the use of dietary advice, monitoring of supplementation and interdisciplinary care of the runner when necessary. Conclusion This study determined how chiropractors selected, prescribed and dispensed nutritional supplements to runners. This study revealed which nutritional supplements the chiropractors recommended to runners and for certain MSK and non-MSK conditions, as well as the influence of supplementation in runners. As previous literature has not investigated the recommendation of supplements by chiropractors in runners, this study generated new information to fill a gap in the literature.

Musculoskeletal organoids: An emerging toolkit for establishing personalized models of musculoskeletal disorders and developing regenerative therapies.

Inherited Metabolic Disorders: Errors of Phenylalanine and Tyrosine Metabolism

Background/Aims Fatigue is an important symptom for people of all ages with musculoskeletal (MSK) conditions. This includes the 234,000 children and young people (CYP) in England and Scotland currently living with conditions such as juvenile inflammatory arthritis, myositis and lupus. This scoping review aimed to generate evidence to design or adapt non-pharmacological MSK-fatigue support across the lifespan, by creating an overview of current knowledge and highlighting gaps in the literature. Methods The protocol and search strategy were developed in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews, in collaboration with a Patient and Public Involvement and Engagement (PPIE) group consisting of CYP aged 13-22 years, with lived experience of MSK-related fatigue (N = 12). This group was hosted online and focused on discussion of non-pharmacological interventions either offered to or investigated by participants. Following initial data extraction, an in-person PPIE workshop (N = 7) was held to discuss the initial findings. The data extraction template was then revised and amended by the research team in response to PPIE input. A further online PPIE workshop (N = 10) was held to reflect on the scoping review findings, including CYPs’ views about its relevance to their health and how information regarding non-pharmacological interventions for fatigue should be shared. Results CYP contributed to and reviewed key search terms and inclusion criteria, ensuring relevance of the review to their lived experience of fatigue. By discussing the non-pharmacological treatments they had been offered or sought out, CYP broadened the researchers’ understanding of contextual factors relating to intervention success and acceptability. Limited evidence regarding non-pharmacological fatigue interventions for CYP with MSK conditions was found and most interventions were based on physical activity. Following initial data extraction, participants highlighted that information such as the level and mode of support, qualifications of the facilitator and the appropriateness of the setting were not captured, which they considered important factors in determining acceptability. They also noted the lack of research regarding nutritional approaches or complementary medicine. When reviewing the final data, participants emphasised significant difficulties in locating and researching treatments when actively experiencing fatigue, and therefore the need for information to be easily available from reliable sources. The trustworthiness of guidance was considered highly important in ensuring physical safety when engaging with interventions, whereas the accessibility and age-appropriate nature of the intervention was deemed key for ensuring psychological safety. Conclusion The lived experience of the CYP PPIE groups added valuable insight into the nature and challenges of MSK-fatigue. Their input had a significant impact on the search strategy and data extraction process and will be sought again to ensure that dissemination of the review findings is relevant and accessible for patients, demonstrating the benefit of this approach in the conduct of scoping reviews. Disclosure K. Fishpool: None. G. Young: None. C. Ciurtin: None. F. Cramp: None. B. Farisogullari: None. G.J. Macfarlane: None. P.M. Machado: Consultancies; Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche, UCB. J. Pearson: None. E. Santos: None. E. Dures: None.

Patient-reported outcomes and functional assessments of patients with Alkaptonuria in a 3-year Nitisinone treatment trial

Background: This study recorded the functional health literacy levels of people with musculoskeletal (MSK) conditions from harder to reach groups and explored their experiences in engaging with health care professionals to self-manage their MSK condition.Methods: We recruited participants, identified by key health and social care contacts as likely to have lower health literacy levels, and used semi-structured interviews to collect data. Thematic analysis was used to identify the main key themes arising from the transcribed interviews.Results: Eighteen participants were identified and recruited from harder to reach community populations, 10 were scored as having inadequate functional health literacy on the Short Form Rapid Estimate of Adult Literacy Measure. Three themes were identified in relation to participants’ experiences of MSK self-management approaches: engaging with health care services; interpreting the health care providers’ message; and facilitating participation in MSK self-management.Conclusions: Our findings indicate that people with a MSK condition, from harder to reach groups, experience multi-morbidity, find health care systems complicated and hear from health care professionals that their MSK condition cannot be cured. People interpreted that a lack of cure meant that nothing could be done to help their MSK pain. Engaging with self-management strategies was not seen as a priority for our participants. Strategies to simplify health communication, more time to process health information and supportive social networks helped our participants to understand and manage their MSK health on a day-to-day basis.Implications for RehabilitationMSK conditions are long term and prevalent in the UK with substantial impact on people’s daily life.Currently self-management strategies for MSK conditions are poorly communicated and many patients believe that nothing can be done to help their MSK pain.Good clinician communication that supports self-management is needed so that key messages can be effectively understood and used by patients with a range of literacy skills.Health services need to be even more accessible to help all individuals from a range of backgrounds better self-manage their MSK conditions.

Introduction: The current ethos within the United Kingdom (UK) health system is to encourage community management of health problems, increasing primary care workload. Yet General Practice (GP) is currently in ‘crisis’ with significant workload pressures. GP Federations have been developed to allow more collaborative working between GP practices and help develop new innovative models of care to better manage the GP workload pressures. Musculoskeletal(MSK) conditions constitute approximately 20% of General Practice(GP) consultations and therefore the Belfast GP Federation aimed to assess the demand for MSK conditions to allow development of new primary care-based treatment pathways for these conditions. The aim of this paper is therefore to assess the demand for orthopaedic, rheumatology and chronic MSK painful conditions by assessing the referrals from 2 GP practices and the referrals to one orthopaedic Integrated Clinical Assessment and Treatment services (ICATs) clinic for these conditions and then propose innovative models of care to manage this demand within the community. Methods: Secondary care referral rates for two urban GP surgeries in the Belfast area were assessed in April, 2016 to orthopaedics, rheumatology and chronic pain clinics. The referrals to an orthopaedic ICATs clinics, staffed by one GPwSI in MSK, in May 2016 were also reviewed. The orthopaedic ICATs team receive referrals from GPs regarding musculoskeletal conditions and this particular service is based in the Southern Trust area of Northern Ireland. Results: Overall from the 2 GP surgeries there was 59 orthopaedic referrals, 11 to rheumatology and 3 to the chronic pain clinic. The commonest joint referred to the orthopaedic clinic was knee (15 referrals, 25.4%) and the commonest reason to refer to rheumatology was to exclude an inflammatory arthritis (6 referrals, 54.5%). There was then 25 referrals to ICATs, with the commonest reason for referral being neck (6 referrals, 24%) and back (4 referrals, 16%). The commonest treatment options employed within the ICAT service included joint injections (8 patients, 32%) with referral to in-house physiotherapy (8 patients, 32%). Conclusions: UK GP is currently under significant workload pressures and musculoskeletal conditions, including orthopaedic, rheumatology and chronic painful conditions, make up a significant proportion of this workload. The main musculoskeletal areas which GPs are referring to secondary care include knee and spinal conditions. To help better manage this workload within primary care we propose developing a new community-based monthly musculoskeletal clinic based within local GP surgeries, supported by a MSK educational programme open to all GPs in the area. Outcomes which will be monitored from this quality improvement work will include secondary care referrals and maintaining high patient satisfaction as well as improving GP confidence in managing MSK conditions.

Unhoused individuals experience a high burden of musculoskeletal (MSK) conditions but often face barriers to traditional healthcare. Street Medicine Phoenix (SMP) is a mobile healthcare initiative composed of medical students and physicians providing free medical screenings to this population. This study aims to characterize the prevalence, demographic distribution, and treatment of orthopedic conditions among unhoused patients in an urban street medicine program. This retrospective observational study analyzed patient encounters from August 2023 to August 2024, collected by SMP in Phoenix, Arizona. Orthopedic conditions were identified through review of Subjective, Objective, Assessment, and Plan (SOAP) notes from 1,193 adult patient encounters. Diagnoses were categorized into clinical MSK types. Treatments included pharmacologic and non-pharmacologic interventions. Descriptive statistics, Mann-Whitney U tests, and chi-squared tests were used to assess differences by age and sex. Results are reported with 95% confidence intervals. Of 1,193 encounters, 228 (19.1%) involved orthopedic issues. The mean age of patients with MSK conditions was 50.2 years (95% CI: 48.9–51.5); 33.6% identified as female. The most common diagnoses were trauma-related injuries (35.1%; n = 80), joint pain (29.4%; n = 67), and chronic pain (21.9%; n = 50). A statistically significant age difference was observed between patients with trauma and arthritis (p < 0.05). Oral NSAIDs were the most common treatment ((19.3%; n = 59), followed by wound care kits (13.4%; n = 41), acetaminophen (11.5%; n = 35), and bracing (10.5%; n = 32). No significant differences in treatment rates by sex were identified. Orthopedic conditions are prevalent among unhoused individuals and represent a major source of morbidity. Mobile care models like SMP provide effective, immediate treatment using accessible modalities. Low-barrier treatments—particularly oral NSAIDs and durable medical equipment (DME: defined as boots, braces, walkers, crutches etc.)—represent feasible and effective interventions that improve pain and function in vulnerable populations with limited access to traditional care pathways. This study underscores the need for scalable MSK interventions and provides a data-driven framework for improving orthopedic care among unhoused populations. Not applicable.

The association between psoriatic arthritis (PsA) and psoriasis is well known, but some have suggested that other musculoskeletal (MSK) conditions might also be more common in patients with skin psoriasis compared with the general population. The aim of our study was to describe the prevalence of a large panel of MSK conditions, in consecutive patients with psoriasis according to skin phenotype. This was a cross-sectional study. We consecutively included 148 patients, consulting for their skin psoriasis, in the dermatology department of a tertiary hospital, Hospital Cochin in Paris, France. After the scheduled consultation with a dermatologist, a rheumatologist conducted a dedicated face-to-face interview to collected data, included demographics, comorbidities, information about the psoriasis, the MSK conditions and their treatments. Of the 148 patients, 122 (82%) had at least one MSK condition. The most common condition was mechanical back pain, present in 98 (66%) patients. Nineteen (13%) patients had spondyloarthritis (SpA), of which 95% had PsA. For all MSK conditions, the dominant psoriasis phenotype was psoriasis vulgaris. The prevalence of the other phenotypes of psoriasis differed by disease. In SpA patients, the three predominant psoriasis phenotypes were: psoriasis vulgaris (82%), scalp involvement (76%) and inverse psoriasis (65%). For all MSK diseases, the prevalence was higher than expected in the general population. Our data suggest that skin psoriasis is associated with different MSK diseases, and not only PsA.

To estimate the benefits and harms of interventions with and without surgery for musculoskeletal (MSK) conditions. Intervention systematic review with meta-analysis of randomized controlled trials (RCTs). MEDLINE, EMBASE, CINAHL, Web of Science, and CENTRAL, all up to January 7, 2021. RCTs (English, German, Danish, Swedish, and Norwegian) of interventions with and without surgery conducted in any setting for any non-fracture MSK condition in adults (mean age: 18+ years) evaluating the outcomes on a continuous (benefits) or count (harms) scale. Outcomes were pain, self-reported physical function, quality of life, serious adverse events (SAEs), and death at 1 year. Random-effects metaanalyses for MSK conditions where there were data from at least 2 trials. One hundred RCTs (n = 12 645 patients) across 28 different conditions at 9 body sites were included. For 9 out of 13 conditions with data on pain (exceptions include some spine conditions), 11 out of 11 for function, and 9 out of 9 for quality of life, there were no clinically relevant differences (standardized mean difference of 0.50 or above) between interventions with and without surgery. For 13 out of 16 conditions with data on SAEs and 16 out of 16 for death, there were no differences in harms. Only 6 trials were at low risk of bias. The low certainty of evidence does not support recommending surgery over nonsurgical alternatives for most MSK conditions with available RCTs. Further high-quality RCTs may change this conclusion. J Orthop Sports Phys Ther 2022;52(6):312-344. doi:10.2519/jospt.2022.11075.

Contextual effects (e.g. patient expectations) may play a role in treatment effectiveness. This study aimed to estimate the magnitude of contextual effects for conservative, non-pharmacological interventions for musculoskeletal pain conditions. A systematic review and meta-analysis of randomized controlled trials (RCTs) that compared placebo conservative non-pharmacological interventions to no treatment for musculoskeletal pain. The outcomes assessed included pain intensity, physical functioning, health-related quality of life, global rating of change, depression, anxiety and sleep at immediate, short-, medium- and/or long-term follow-up. MEDLINE, EMBASE, CINAHL, Web of Science Core Collection, CENTRAL and SPORTDiscus were searched from inception to September 2021. Trial registry searches, backward and forward citation tracking and searches for prior systematic reviews were completed. The Cochrane risk of bias 2 tool was implemented. The study included 64 RCTs (N = 4314) out of 8898 records. For pain intensity, a mean difference of (MD: -5.32, 95% confidence interval (CI): -7.20, -3.44, N = 57 studies with 74 outcomes, GRADE: very low) was estimated for placebo interventions. A small effect in favour of the placebo interventions for physical function was estimated (SMD: -0.22, 95% CI: -0.35, -0.09; N = 37 with 48 outcomes, GRADE: very low). Similar results were found for a broad range of patient-reported outcomes. Meta-regression analyses did not explain heterogeneity among analyses. The study found that the contextual effect of non-pharmacological conservative interventions for musculoskeletal conditions is likely to be small. However, given the known effect sizes of recommended evidence-based treatments for musculoskeletal conditions, it may still contribute an important component. Contextual effects of non-pharmacological conservative interventions for musculoskeletal conditions are likely to be small for a broad range of patient-reported outcomes (pain intensity, physical function, quality of life, global rating of change and depression). Contextual effects are unlikely, in isolation, to offer much clinical care. But these factors do have relevance in an overall treatment context as they provide almost 30% of the minimally clinically important difference.

Background: Physiotherapists commonly use hydrotherapy as a treatment approach for various types of conditions. As hydrotherapy utilizes the hydrodynamic properties of water to promote relaxation and decrease pain perception, previous research has suggested that hydrotherapy may help to decrease the health burden of musculoskeletal (MSK) conditions. The aim of this review was to critically examine literature investigating (a) the benefits of hydrotherapy on reducing pain and disability associated with chronic MSK conditions, and (b) report on literature findings regarding the perceived benefit of hydrotherapy on the well-being of adults with chronic MSK conditions.Methods: Select electronic databases were searched to identify relevant articles. Studies meeting the inclusion criteria were critically analyzed using the Downs and Black protocol with agreement between raters assessed via Kappa analysis.Results: Nine original articles addressing the benefits of hydrotherapy on adult populations with chronic MSK conditions were analyzed. The mean critical appraisal score was 73% (κ = 0.87) with the evidence suggesting that hydrotherapy had a positive effect on pain, quality of life, condition-related disability and functional exercise capacity. It was also noted that following hydrotherapy, the perceived benefit of well-being was superior to land-based exercise protocols in cases where water temperature was within a thermoneutral range (33.5–35.5 °C).Conclusion: Hydrotherapy helps to reduce the health burden of MSK conditions. Improvements in the perception of well-being are likely to occur following hydrotherapy that is conducted in water within the thermoneutral range.

IntroductionFatigue is an important and distressing symptom for many people living with chronic musculoskeletal (MSK) conditions. Many non-pharmacological interventions have been investigated in recent years and some have been demonstrated...

There are known risk factors that are associated with the onset and exacerbation of musculoskeletal (MSK) conditions and pain. Physiotherapists are uniquely placed to deliver brief interventions with their patients. Healthy Conversation Skills is the main training component of the Wessex approach to Making Every Contact Count. Despite its potential for promoting MSK health and wellbeing, there is no evidence to support its acceptability within MSK services. This is the first known study to explore the use and perceptions of the Wessex model of MECC HCS within MSK services. A mixed method design was used. Phase one employed an online questionnaire, open to all professionals trained in MECC HCS, consisting of items relating to implementation outcomes. Barriers and facilitators to delivery were explored and mapped to the Theoretical Domains Framework. Phase two invited physiotherapists for a follow-up interview and qualitatively explored their acceptability of delivering MECC HCS to patients with MSK conditions. MECC HCS was found to be highly acceptable, appropriate, and feasible. Physiotherapists reported using their skills at least daily but missed opportunities for delivering MECC HCS were evident. Barriers mapped mostly to ‘Environmental Context and Resources’ on the Theoretical Domains Framework. Qualitative themes developed during phase two were: ‘Recognising the patient as the expert supports change', ‘MECC HCS improves physiotherapy practice', ‘MECC HCS shared problem solving reduces workload', ‘time as a perceived barrier to MECC HCS’ and ‘system-level support needed to sustain MECC HCS'. MECC HCS is a promising brief intervention for supporting people with MSK conditions. Further rollout of this intervention may be beneficial for meeting the goals of the NHS and Public Health England in prevention of MSK conditions and promotion of MSK health. Barriers associated with sustainability must, however, be addressed.Key messages• Making Every Contact Count Healthy Conversation Skills is considered a highly acceptable brief intervention for supporting behaviour change in people with musculoskeletal conditions.• Organisational, system-level barriers to implementation must be addressed in order to increase sustainability and enhance future roll out of the brief intervention.

On the metabolism of 3H-tyrosine in the cerebrospinal fluid of the cat: Role of transamination