Musculoskeletal Care Research Articles

Optimising Musculoskeletal Patient Flow Through Digital Triage and Supported Self-Management: A Service Evaluation Set Within Community Musculoskeletal Care.

Musculoskeletal (MSK) conditions are one of the leading causes of years of living with disability in the UK, resulting in pressure on the health system and the UK economy. In response to the increasing levels of patients accessing NHS care with MSK conditions across Sandwell and West Birmingham (SWB), a digital triage and self-management tool was implemented in 2023. To optimise safety, efficiency, and choice within the community MSK service from the first contact through to specialist MSK care through digital triage and supported self-management. SWB's community MSK service implemented two digital tools in January 2023. Objectives included 1. Increase safety, through providing 24/7 access to rapid digital MSK triage; 2. Optimise workforce by releasing clinicians back to face-to-face care, increasing clinical capacity, 3. Increase patient choice by offering digitally supported self-management to appropriate low risk patients. 4804 patients self-referred to the MSK service through the digital triage tool within the first 12 months. 378 of these patients were offered, accepted, and accessed self-management support using the digital self-management app. These innovations led to the release of 1240 clinical hours for face-to-face care, an average 8-week reduction in waiting times and high patient satisfaction (80% good/very good). Evaluation over the first 12 month showed that the digital innovations were safe, led to enhanced access to and choice of care pathways, optimised use of clinical staff, and received positive patient feedback. Research is needed in this newly emerging area of practice to support further adoption across the healthcare system.

Optimizing Rehabilitation Outcomes Through Rehabilitative Ultrasonography: Applications in Musculoskeletal Care

Rehabilitative ultrasonography (RUS) has significantly enhanced musculoskeletal care by providing real-time, detailed visualizations of muscle, tendon, and soft tissue structures. This symposium explores the diverse applications of RUS, highlighting its advantages over traditional imaging methods. In muscle rehabilitation, RUS is pivotal for assessing muscle morphology, activation patterns, and providing biofeedback, thereby optimizing personalized rehabilitation programs. For tendon injuries, RUS facilitates precise evaluation of tendon integrity, enabling accurate diagnosis, monitoring, and guiding therapeutic interventions. Beyond muscles and tendons, RUS is invaluable in diagnosing and managing soft tissue pathologies, such as ligament and fascia injuries, allowing for targeted treatment strategies. By offering superior precision, safety, and cost-effectiveness, RUS sets a new benchmark in rehabilitation practices, leading to improved patient outcomes and a deeper understanding of musculoskeletal conditions. The integration of RUS into rehabilitation medicine represents a transformative advancement in patient care and treatment efficacy.

Are Levels of Loneliness Associated With Levels of Comfort and Capability in Musculoskeletal Illness?

Variation in levels of pain intensity and incapability among patients with musculoskeletal conditions is associated with measures of mindset (unhelpful thoughts [such as hurt equals harm] and feelings of distress [overwhelm, rumination] regarding bodily sensations) and circumstances (social health as well as security in finances, roles, home, and support) as much or more so than pathophysiology severity. Loneliness is an important aspect of social health, it is associated with worse mental health, and it has been identified as worthy of attention and intervention by health authorities in several countries. It is estimated that up to one-third of adults older than 45 years of age experience loneliness. Given that a large percentage of people seeking musculoskeletal specialty care are older than 45 years, identification of notable levels of loneliness and an association with greater levels of pain intensity and incapability would support screening and treatment of feelings of loneliness as part of comprehensive, whole-person, musculoskeletal care strategies. In a cross-sectional study of people seeking musculoskeletal specialty care for upper and lower extremity conditions, we asked: (1) Are there factors associated with levels of capability including greater feelings of loneliness? (2) Are there factors associated with levels of pain intensity including greater feelings of loneliness? We recruited 146 new and returning, English-speaking, adult patients without cognitive deficiencies seeking care in metropolitan musculoskeletal specialty offices. Three patients were excluded because they did not complete the measures of pain intensity and incapability, and 143 were analyzed, including 57% (82) women with a mean age ± SD of 56 ± 17 years and 71% (102) with an upper extremity condition. Participants completed validated measures of feelings of loneliness (University of California, Los Angeles [UCLA] Loneliness Scale), thoughts and feelings regarding sensations (three items each validated in a factor analysis of commonly used measures), and levels of incapability (PROMIS Physical Function computer adaptive test), and pain intensity (pain intensity on an 11-point ordinal scale between 0 [no pain] and 10 [the most intense possible pain]). In the multivariable analysis, we measured the relationship between levels of incapability and pain intensity and feelings of loneliness, accounting for demographic factors and thoughts and feelings regarding sensations. Accounting for potential confounding variables such as income level and insurance status, we found that lower levels of capability were moderately associated with greater feelings of distress regarding symptoms (such as rumination or a sense of overwhelm; regression coefficient [RC] -0.99 [95% confidence interval (CI) CI -1.5 to - 0.51]; p < 0.001) and that higher levels of capability were more modestly associated with having an upper rather than lower extremity condition (RC 4.4 [95% CI 1.5 to 7.3]; p = 0.003) and an income between USD 46,000 and USD 75,000 (RC 6.7 [95% CI 1.4 to 12]; p = 0.01) compared with an income less than USD 24,000 a year. Levels of capability were not associated with levels of loneliness (RC = -0.15 [95% CI -0.38 to 0.086]; p = 0.22), even though the mean level of loneliness was 54, representing moderate to high levels of loneliness. Higher levels of pain intensity were moderately associated with greater feelings of distress regarding symptoms (RC 0.35 [95% CI 0.22 to 0.47]; p < 0.001) and also modestly associated with greater level of unhelpful thoughts about symptoms (such as pain equating to injury) (RC 0.19 [95% CI 0.036 to 0.34]; p = 0.002), having a 4-year college degree (RC -1.4 [95% CI -2.4 to -0.26]; p = 0.02), and having a postcollege graduate degree (RC -1.35 [95% CI -2.4 to -0.26]; p = 0.02) compared with high school or less education but not with higher levels of loneliness. The observation that levels of musculoskeletal incapability and pain intensity have limited association with loneliness reinforces the evidence that other cognitive and emotional factors are the key modifiable personal factors in musculoskeletal illness. Our findings do not discount the importance of addressing loneliness in musculoskeletal care, but efforts to tackle loneliness alone may be less effective than efforts to focus on loneliness in addition to thoughts and feelings regarding bodily sensations. Level II, prognostic study.

Predicting Pain Response to a Remote Musculoskeletal Care Program for Low Back Pain Management: Development of a Prediction Tool.

Low back pain (LBP) presents with diverse manifestations, necessitating personalized treatment approaches that recognize various phenotypes within the same diagnosis, which could be achieved through precision medicine. Although prediction strategies have been explored, including those employing artificial intelligence (AI), they still lack scalability and real-time capabilities. Digital care programs (DCPs) facilitate seamless data collection through the Internet of Things and cloud storage, creating an ideal environment for developing and implementing an AI predictive tool to assist clinicians in dynamically optimizing treatment. This study aims to develop an AI tool that continuously assists physical therapists in predicting an individual's potential for achieving clinically significant pain relief by the end of the program. A secondary aim was to identify predictors of pain nonresponse to guide treatment adjustments. Data collected actively (eg, demographic and clinical information) and passively in real-time (eg, range of motion, exercise performance, and socioeconomic data from public data sources) from 6125 patients enrolled in a remote digital musculoskeletal intervention program were stored in the cloud. Two machine learning techniques, recurrent neural networks (RNNs) and light gradient boosting machine (LightGBM), continuously analyzed session updates up to session 7 to predict the likelihood of achieving significant pain relief at the program end. Model performance was assessed using the area under the receiver operating characteristic curve (ROC-AUC), precision-recall curves, specificity, and sensitivity. Model explainability was assessed using SHapley Additive exPlanations values. At each session, the model provided a prediction about the potential of being a pain responder, with performance improving over time (P<.001). By session 7, the RNN achieved an ROC-AUC of 0.70 (95% CI 0.65-0.71), and the LightGBM achieved an ROC-AUC of 0.71 (95% CI 0.67-0.72). Both models demonstrated high specificity in scenarios prioritizing high precision. The key predictive features were pain-associated domains, exercise performance, motivation, and compliance, informing continuous treatment adjustments to maximize response rates. This study underscores the potential of an AI predictive tool within a DCP to enhance the management of LBP, supporting physical therapists in redirecting care pathways early and throughout the treatment course. This approach is particularly important for addressing the heterogeneous phenotypes observed in LBP. ClinicalTrials.gov NCT04092946; https://clinicaltrials.gov/ct2/show/NCT04092946 and NCT05417685; https://clinicaltrials.gov/ct2/show/NCT05417685.

A consensus-based agreement on a definition of a process variable: findings from a New Zealand nominal group technique study

BackgroundMusculoskeletal pain and disability are leading causes of reduced health and significant economic costs worldwide. Individualised, and evidence-based treatment approaches for specific musculoskeletal conditions aimed at improving patient outcomes and costs have not been successful. Recently authors have suggested that the ‘process’ of how care is implemented within a health system needs to be considered as an influencer on patient outcomes. With the rising prevalence of musculoskeletal conditions and the burgeoning costs associated with their treatment, it seems timely that new research focusing on process variables and their influence on patients with musculoskeletal conditions is explored. Before such studies can take place, a modern definition of a process variable within a musculoskeletal care pathway is needed to anchor future research endeavours. Therefore, the aim of this study was to establish a consensus-based definition of a process variable within a musculoskeletal care pathway, based on a New Zealand setting.MethodsThis study used a virtual nominal group technique and took place in July 2023 using a Microsoft Teams platform. A nominal group technique employs a structured approach to generate information and solutions to problems that can then be prioritised through group discussion and consensus. It is unique because it allows expert participants to explore using in-depth inquiry, areas previously unidentified or not yet investigated. There was an inclusion criterion and the participants completed pre-work before the two-hour five stage virtual meeting. The Auckland University of Technology Ethics Committee (AUTEC) approved this study (AUTEC 23/94).ResultsThe study included eight participants (five male, three female) who had extensive experience with the New Zealand ACC insurance scheme and the design, implementation, and administration of musculoskeletal care pathways. The consensus definition was ‘A health process variable is any modifiable factor in a health process or pathway that can be quantified and measured and that if varied may achieve a different operational or patient outcome’.ConclusionsThis study of New Zealand-based experts has formed a consensus-based agreement for a definition of a process variable in a musculoskeletal care pathway. This is an important first step in developing our understanding of process variables, and further research is needed to establish the link between process variables and their influence on the outcomes of patients with musculoskeletal conditions.

Recommended Elements of a Musculoskeletal Course for Fourth-Year Medical Students: A Modified Delphi Consensus

Background and Objectives: A recognized gap exists between primary care physicians’ training in musculoskeletal (MSK) medicine and the burden of MSK complaints in primary care. Family medicine interns often lack adequate baseline MSK physical exam skills, which prompted a proposal to introduce a fourth-year preceptorship to reinforce MSK education. The aim of this study was to prioritize the most important elements to include in this new clinical rotation. Methods: We employed a three-round, modified Delphi method to derive consensus. Eleven panelists with experience and expertise in MSK training, medical education, or both generated a list of 118 elements. Each panelist then ranked each element by level of importance, and we reviewed the results. The ranking process was repeated two more times with a goal of achieving consensus. Results: Seventy-seven curricular elements (topics, skills, experiences) achieved consensus recommendation by being ranked either “fairly important” or “very important” for inclusion in the curriculum. Twenty-eight items were unanimously ranked “very important,” 42 received a mix of “very important” and “fairly important” rankings, and seven received unanimous ranking of “fairly important.” Three items were unanimously ranked “neither important nor unimportant.” Conclusions: Longitudinal repetition of physical exam skills, reinforcement of relevant anatomy, and incorporation of specific frameworks for approaching MSK care are important components. Physical examination of the shoulder, knee, back, and hip are especially meaningful clinically.

Strengthening the pain care ecosystem to support equitable, person-centered, high-value musculoskeletal pain care

Abstract Improving health and wellbeing outcomes for people experiencing chronic musculoskeletal pain requires collective efforts across multiple levels of a healthcare ecosystem. System-wide barriers to care equity must however be addressed (eg, lack of co-designed services; overuse of low value care/underuse of high value care; inadequate health workforce; inappropriate funding models; inequitable access to medicines and technologies; inadequate research and innovation). In this narrative review, utilizing a systems’ thinking framework, we synthesize novel insights on chronic musculoskeletal pain research contextualized through the lens of this complex, interconnected system, the “pain care ecosystem.” We examine the application of systems strengthening research to build capacity across this ecosystem to support equitable person-centred care and healthy ageing across the lifespan. This dynamic ecosystem is characterized by three interconnected levels. At its centre is the person experiencing chronic musculoskeletal pain (micro-level). This level is connected with health services and health workforce operating to co-design and deliver person-centred care (meso-level), underpinned further upstream by contemporary health and social care systems (macro-level context). We provide emerging evidence for how we, and others, are working towards building ecosystem resilience to support quality musculoskeletal pain care: at the macro-level (eg, informing musculoskeletal policy and health strategy priorities); at the meso-level (eg, service co-design across care settings; health workforce capacity); and downstream, at the micro-level (eg, person-centred care). We outline the mechanisms and methodologies utilized and explain the outcomes, insights and impact of this research, supported by real world examples extending from Australian to global settings.

Negative health impacts of navigating the healthcare system for musculoskeletal conditions: A scoping review protocol.

Musculoskeletal (MSK) conditions, particularly shoulders, knees, and the low back issues, place a significant burden on individuals, society, and healthcare systems. There is a lack of attention to negative health effects impacting patients because of their interactions to access appropriate diagnostics, assessments, and treatments. This scoping review intends to search and synthesize peer-reviewed evidence on the negative health impacts associated with navigating the healthcare system for MSK care. A scoping review will be conducted following the PRISMA guidelines for Scoping Reviews and Arksey and O'Malley's 5-step process. Six databases will be searched with no time or geographic limits. Included articles must meet all the following criteria: 1) the patients must be adults, 2) patients must be seeking care for their knee, low-back, or shoulder condition, 3) interacted with the healthcare system, and 4) experienced health impacts due to navigating the healthcare system. Information from each article will be charted in a pre-determined extraction. This protocol aims to share our methods ahead of analysis to increase rigour and transparency. The scoping review results will better elucidate the health impacts of the inaccessibility of high-quality care for MSK conditions. The findings also aim to inform the development of patient-centered outcomes to evaluate alterations to the current MSK pathways.

Distribution Patterns of Tumors and Tumor-Like Lesions of the Forefoot and Midfoot A 12.5-Year Study at a University Hospital.

Masses in the forefoot and midfoot are common reasons for medical presentation and can be caused by various pathological conditions. The challenge in clinical practice is to distinguish the multitude of trivialities from the few malignant entities and to arrive at a reliable clinical diagnosis in a reasonable amount of time with a moderate use of diagnostic tools. In a retrospective analysis, tumors, tumor-like lesions, and pseudotumors distal to the Chopart joint presented to our multidisciplinary university tumor board between January 2010 und June 2023 were analyzed concerning entity, location, age, and sex. Of the 167 cases included, 18 were osseous and 149 were soft tissue lesions. Overall, the metatarsal region was most frequently affected, accounting for 42.5% of all cases. Osseous lesions showed a preference for the phalanges and soft-tissue lesions occurring more frequently in the metatarsal region. In total, 88.0% of all cases were benign. All 20 malignant cases derived from soft tissue, occurred in all sections of the forefoot and midfoot and comprised 13 entities. Most lesions affected middle-aged patients, but cases occurred in almost every age group. In the examined patient population of a German university hospital, most cases were benign soft tissue lesions with a substantial share of pseudotumors and tumor-like lesions. However, the malignancy rate of 12.0% highlights the importance of differential diagnostic considerations. In cases of uncertain results, it is crucial to refer individuals with unclear masses to a specialized center for musculoskeletal tumor care early on in their treatment process. III.

Orthopedic Injections: A Longitudinal Musculoskeletal Curriculum in a Family Medicine Residency.

Musculoskeletal (MSK) complaints comprise more than 20% of all visits to health care providers each year. Despite required experiences in MSK care, family physicians report low confidence in diagnosing and treating MSK conditions. The purpose of this study was to analyze the effects of early and longitudinal exposure to MSK education on residents' confidence in and likelihood of performing MSK physical exams and injections in future practice. From 2017 to 2019, residents completed an annual survey assessing confidence in, frequency of, and future intentions to perform exams and injections for MSK conditions. We compared responses between family medicine residents who completed a 176-hour longitudinal sports medicine (LSM) curriculum distributed over all 3 years of residency and a comparable cohort of family medicine residents who completed a 188-hour concentrated MSK curriculum primarily in the final year of residency. We made comparisons using the Fisher exact test for categorical variables and an independent samples t test for numeric variables. We analyzed the 98 total responses from 50 residents. The proportion of residents reporting high ratings of their residency MSK education (26% to 60%), performing &gt;5 injections (38% to 73%), reporting confidence in performing injections (12% to 40%), and indicating likelihood to perform MSK injections in the future (52% to 65%) were all greater in the LSM versus concentrated MSK curriculum cohorts (P&lt;.05 for all). Early and longitudinal exposure to MSK care and sports medicine in family medicine residency led to both an increase in MSK injections during residency training and a greater desire to perform these injections in postresidency practice.

Disparities in Musculoskeletal Oncology.

Disparities within the healthcare system serve as barriers to care that lead to poor outcomes for patients. These healthcare disparities are present in all facets of medicine and extend to musculoskeletal oncology care. There are various tenets to health disparities with some factors being modifiable and non-modifiable. The factors play a direct role in a patient's access to care, time of presentation, poor social determinants of health, outcomes and survival. In musculoskeletal oncologic care, factors such as race, socioeconomic factors and insurance status are correlated to advanced disease upon presentation and poor survival for patients with a sarcoma diagnosis. These factors complicate the proper delivery of coordinated care that is required for optimizing patient outcomes. Healthcare disparities lead to suboptimal outcomes for patients who require musculoskeletal oncologic care in the short and long term. More research is required to identify ways to address the known modifiable and non-modifiable factors to improve patient outcome.

MSK ultrasound imaging-assisted clinical examination.

Musculoskeletal disorders are a significant global health concern, affecting over 1.71 billion individuals worldwide, with a considerable impact on quality of life and economic burden due to healthcare costs and productivity losses. In the United Kingdom, approximately one-third of the population suffers from musculoskeletal disorders, underscoring the need for effective diagnostic and management strategies. Musculoskeletal ultrasound imaging emerges as a preferred diagnostic modality, offering a balance between technical capabilities and cost-effectiveness, owing to its non-invasive nature, portability and lack of radiation exposure. However, the operator-dependent nature of musculoskeletal ultrasound imaging necessitates specialised training for medical and healthcare professionals. The integration of musculoskeletal ultrasound imaging into traditional clinical examinations, known as ultrasound imaging-assisted clinical examination (UIACE), enhances traditional diagnostic processes by providing immediate visual feedback, facilitating a more accurate and comprehensive assessment of musculoskeletal conditions. This approach not only refines diagnosis in cases with ambiguous symptoms or overlapping signs but also significantly improves patient reassurance and management strategies. In addition, incorporating musculoskeletal ultrasound imaging into medical education through ultrasound imaging-assisted clinical examination offers students a dynamic, interactive learning experience, fostering a deeper understanding of clinical anatomy and examination skills. By advocating for its systematic inclusion in the undergraduate medical curriculum, the study highlights the potential to enhance the competence and confidence of future professionals in utilising ultrasound imaging, ultimately improving patient outcomes in musculoskeletal care.

Usage, Attitudes, Facilitators, and Barriers Toward Digital Health Technologies in Musculoskeletal Care: Survey Among Primary Care Physiotherapists in Norway.

Work burden increases for physiotherapists in the primary health care sector as the prevalence of musculoskeletal disorders (MSDs) increases. Digital health technologies (DHTs) are proposed as a viable solution to secure the sustainability of the health care system and have shown promising results in a range of conditions. However, little is known about use of DHTs among physiotherapists in the primary health care sector in Norway. This study aimed to investigate the use of and attitudes toward DHTs among physiotherapists treating patients with MSDs in primary care, and potential facilitators or barriers for adopting DHTs in clinical practice. An author-developed web-based questionnaire was distributed to physiotherapists in all Norwegian municipalities in March 2023. The questionnaire included items regarding use of technologies, attitudes, suitability, and factors influencing adoption of DHT. Suitability and agreement on statements were scored on an 11-point numeric rating scale (0=very unsuitable or strongly disagree, 10=very suitable or strongly agree). Differences across employment sites and users versus nonusers of DHT were analyzed using the χ2 test, Fisher exact test, Student t test, and Mann-Whitney U test. Approximately 5000 physiotherapists were invited to participate, of which 6.8% (338) completed the questionnaire. A total of 46.2% (156/338) offered DHTs in their practice, of which 53.2% (83/156) used it on a weekly basis, mostly telephone consultations (105/156, 67.3%). A higher proportion of physiotherapists in private practice offered DHT compared with those employed by municipalities (95/170, 55.9% vs 61/168, 36.3%; P<.001). A majority (272/335, 81.2%) were positive about recommending DHTs to their patients. Suitability of DHTs in physiotherapy was rated an average of 6 (SD 2.1). Apps for smartphones or tablets were rated most suitable (mean rating 6.8, SD 2.4). The most frequently reported advantages were flexibility in how physiotherapy is offered (278/338, 82.3%) and reduced travel time for the patient (235/338, 70%). The highest rated disadvantages were limited scope for physical examination (252/338, 74.6%) and difficulty in building rapport with the patient (227/338, 67.2%). The main facilitators and barriers included a functioning (median rating 10, IQR 8-10) or lack of functioning (median rating 9, IQR 8-10) internet connection, respectively. Lack of training in DHTs was prominent regarding evaluation, diagnosing, and treatment (median rating 0, IQR 0-2), with minor, but significant, differences between nonusers and users (median rating 0, IQR 0-1 vs median rating 1, IQR 0-4); P<.001). Physiotherapists in Norwegian primary care treating patients with MSDs are positive about using DHTs, and almost 50% (156/338) have adopted them in clinical practice. Concerns are related to lack of a physical examination and technical aspects. Training in the use of DHTs should be addressed in implementation processes.

Patient acceptance of care of a novel care pathway for those at risk of poor outcomes from musculoskeletal pain: A mixed methods study

ObjectiveInvestigate people's acceptance of specialist musculoskeletal care within a new care pathway for common musculoskeletal conditions (low back pain, neck pain/whiplash, knee osteoarthritis). DesignConvergent parallel mixed methods design referencing the Theoretical Framework of Acceptability. The study included a subset of participants (n = 29) at-risk of poor outcomes from the intervention arm of the PAthway of CarE for common musculoskeletal conditions (PACE-MSK) trial. In the PACE-MSK arm, participants received specialist physiotherapist care as an adjunct to the care provided by their primary healthcare professional(s). One-to-one semi-structured interviews were conducted around 3-months after commencing in the trial. Quantitative data were collected at baseline and 3-month follow-up (health-related quality of life, pain self-efficacy, global perceived change, satisfaction). ResultsFive themes were identified (Expectations and beliefs shaped patient experience; Clinical expertise and competence influence acceptance; Person-centred care; Mechanisms facilitating beneficial responses to care; Gaps in care pathway implementation). There were positive individual changes in physical quality of life for 17/29 (59%) participants, mental health quality of life for 12/29 (41%), pain self-efficacy for 8/29 (28%) and global perceived change for 19/29 (66%). Management met expectations with the majority reporting high levels of satisfaction. Integrating the qualitative and quantitative data with the Theoretical Framework of Acceptability, there were complementary meta-inferences in the constructs of ‘ethicality’, ‘intervention coherence’, ‘self-efficacy’ and ‘affective attitude’. Divergence was identified in ‘perceived effectiveness’. DiscussionIn general, there was positive acceptance of the care pathway by participants. Specialist physiotherapists’ care was perceived as a positive addition to usual care.

Description of Medical and Surgical Conditions Requiring Referral by Physical Therapy Providers in Primary Contact Musculoskeletal Practice

OBJECTIVE: The Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association's clinical practice guideline recommendations provide a foundation for clinicians' musculoskeletal care. Some patients’ presenting clinical findings suggest conditions that would benefit from medical or surgical evaluation and management. Guidelines are not available that direct this referral. DESIGN: This practice description directs the development of guidelines for clinicians working as first provider musculoskeletal practitioners on the diagnostic criteria for referring clients for medical or surgical management. METHODS: The foundational step in developing these guidelines is to identify the conditions that first provider musculoskeletal practitioners are likely to encounter during clinical practice. This study used standard practice analysis methodology to identify and describe these conditions. RESULTS/CONCLUSION: The ensuing clinical practice guideline, based on systematic methods to evaluate and classify evidence, will provide graded recommendations on the criteria to identify, level of confidence with identifying, and urgency for referring patients, with the conditions described in this practice analysis, for medical and surgical evaluation and management.

Achieving Health Equity: Combatting the Disparities in American Access to Musculoskeletal Care : Disparities Exist in Every Aspect of Orthopaedic Care in the United States - Access to Outpatient Visits, Discretionary and Unplanned Surgical Care, and Postoperative Outcomes. What Can We Do?

Healthcare disparities influence multiple dimensions of orthopaedic care including access, burden and incidence of disease, and outcome in varying populations. These disparities impact healthcare at both the micro and macro scale of the healthcare experience from individual patient-physician relationships to reimbursement rates across the United States. This article provides a review of how healthcare disparities contribute to the landscape of orthopaedic care and specifically highlights how disparities affect outpatient visits, discretionary and unplanned surgical care, and postoperative outcomes. Current research demonstrates the widespread presence of healthcare disparities in the field of orthopaedics and gives both objective and subjective evidence confirming disparities' measurable influence. The disparities most highlighted by our review include differences in orthopaedic care based on insurance type and race. Currently disparities in orthopaedic care are deeply connected to patient insurance status and race. In the outpatient setting insurance significantly impacts access to care, travel burden, and utilization of services. The emergent setting is similarly influenced with measurable differences in lack of access to acute care, rates of inappropriate triage, and timeliness of care based on insurance status and race. Additionally, the postoperative period is not immune to disparities with likelihood of follow up, experience of catastrophic medical expenses, and postoperative outcomes also being affected. Addressing these disparities is a pressing need and may include solutions like wider expansion and acceptance of publicly funded insurance and the development of readily available and easily measurable metrics for healthcare equity and quality in vulnerable populations.

Advocacy: a reflection on my 30 years of orthopedic practice

As orthopedic surgeons, we have the responsibility for advocating for our patients and our profession, on the local, state, and federal levels. The American Academy of Orthopaedic Surgeons (AAOS) created the American Association of Orthopaedic Surgeons to allow for political advocacy. The Association Political Action Committee, OrthoPAC, was created in 1999 and has become an effective tool in our advocacy committee. The American Shoulder and Elbow Surgeons (ASES), along with many orthopedic subspecialty societies, has established an advocacy effort and works with the AAOS through the OrthoPAC as a member of the Advisor’s Circle, which is designed to provide AAOS Members’ group practices and specialty societies with a leadership role within the Political Action Committee of the American Association of Orthopaedic Surgeons (Orthopaedic PAC). If we are to preserve individual patient access to specialized musculoskeletal care, we must support state and federal advocacy efforts. This can be in the form of financial support or personal involvement in relationship building. I encourage all members of ASES, especially the younger ones, to support your state orthopedic societies, the ASES, and the AAOS in their advocacy efforts. The well-being of our patients and the future of our profession depend on you.

Enhancing comprehensive primary care by integrating chiropractic led musculoskeletal care into interprofessional teams through supporting education, competency attainment, and optimizing integration.

Musculoskeletal (MSK) conditions are the leading cause of disability, resulting in up to 40% of visits to family physicians. Current primary care workforce shortages in Canada require other providers to maximize scopes of practice. Few MSK providers have been trained in team-based primary care settings. Study objectives included: (1) educating participating primary care teams through synchronous education, (2) educating Canadian primary care providers through asynchronous education, and (3) integrating chiropractors into primary care teams, whilst evaluating team MSK care knowledge/attitudes and integration experience. Results indicated improvements in collaborative competency, improved understanding and attitudes to chiropractic, and the importance of providing MSK care within funded primary care. Teams employed unique approaches to integrating chiropractors and indicated high demand for their services by patients and providers. Provision of MSK care without economic barrier is desirable and highly valued by teams. Chiropractors are well suited to participate in funded primary care teams in Canada.

Is the feeling of 'weakness' associated with unhelpful thoughts or distress regarding symptoms?

This cross-sectional study looked for factors associated with feelings of weakness, level of capability and pain intensity in people seeking musculoskeletal speciality care for non-traumatic upper extremity conditions. A survey was conducted in 139 English-speaking adults, with 135 participants completing it. We found that greater intensity of feelings of weakness correlated with higher distress regarding symptoms and with older age. Lower level of capability was associated with greater intensity of feelings of weakness, greater distress regarding symptoms and older age. Higher pain intensity was associated with greater distress regarding symptoms and greater intensity of feelings of weakness. These findings suggest that the symptom of weakness may be a cue to explore potential distress about symptoms in addition to examining for actual weakness. This understanding could be a guide to a more compassionate approach to alleviate distress rather than focusing on neuromuscular pathophysiology alone, with the potential to reduce unnecessary tests and treatments.Level of evidence: IV.

Exploring the role of therapeutic alliance and biobehavioural synchrony in musculoskeletal care: Insights from a qualitative study

BackgroundPerson-centred care underscores the therapeutic alliance (TA) as fundamental, fostering positive treatment outcomes through collaborative patient-clinician interactions. Biobehavioural synchrony within the TA, essential for effective care, reflects an adaptive process where organisms align responses during interactions. Enactivism and active inference provide profound insights into human perception, reshaping musculoskeletal care understanding. Touch and verbal communication, integral to the TA, foster synchrony and alignment of personal beliefs. AimThis study aimed to identify the tools used by manual therapists in musculoskeletal care to establish a TA with patients. Furthermore, it endeavours to evaluate the alignment of these strategies with current literature and their correlation with biobehavioural synchrony, enactivism, and the role of touch in active inference. MethodsThe methodology followed rigorous qualitative research principles, particularly Grounded Theory and interpretative-constructivist principles, conducting eleven semi-structured interviews with open-ended questions. ResultsThe core category identified in the study is elucidated as follows: "Interwoven Connection: The Fabric of Therapeutic Synchrony." The interviews unveiled three main categories, each comprising sub-categories: (1) Creating a meaningful dialogue; (2) Promoting active patient participation; (3) Synchronisation. ConclusionFostering meaningful dialogue, patient involvement, and therapeutic synchrony is crucial for a robust therapeutic alliance in musculoskeletal care. This underscores the importance of establishing a deep connection between clinicians and patients, central to effective person-centred care. Clinicians must prioritise two-way communication, empathy, and patient collaboration in defining personalised goals. Emphasizing touch and seeking patient feedback are also pivotal. Further research is needed to explore these elements and their impact.