Advanced practice physiotherapy is well established within musculoskeletal (MSK) services in the UK and Ireland, yet the meaning of "advanced" remains inconsistently defined. Although multiprofessional frameworks conceptualise advanced practice as capability across four pillars: clinical practice, leadership, education, and research, how this is represented within the musculoskeletal physiotherapy literature is unclear. A critical narrative review with systematic mapping and interpretive synthesis was undertaken. MEDLINE, CINAHL, and Embase were searched from inception to January 2026. Literature describing musculoskeletal advanced practice physiotherapy in the UK and Ireland was included. Data were analysed inductively to examine definitions, governance arrangements, and implicit assumptions underpinning advanced practice. Ethical approval was not required as this study synthesised published literature. Advanced practice was most commonly operationalised through clinical task expansion, role substitution, and service efficiency. Explicit definitions were uncommon, engagement with non-clinical pillars was inconsistent, and governance and credentialling arrangements were frequently absent or inferred. Implicit assumptions equating experience or task complexity with advancement were widespread. The findings highlight a persistent gap between policy intent and enacted practice, contributing to conceptual ambiguity and variability in how advanced practice is understood and implemented. Advanced practice physiotherapy in musculoskeletal care is variably defined and weakly governed within the literature. Greater conceptual clarity and alignment with multiprofessional frameworks are required to support role legitimacy and sustainability.
Dementia caregiving represents a major public health challenge, with spousal caregivers assuming the greatest burden. Spouses, themselves typically older adults, provide high intensity, long-term, and largely unpaid care across all stages of cognitive decline. Despite their central role in dementia care, the health consequences experienced by spousal caregivers remain insufficiently characterized in the literature and inadequately addressed in clinical and public health practice. This structured narrative review synthesizes current evidence on the multidimensional impact of dementia caregiving on the physical, psychological, cognitive, social, and financial health of spousal caregivers. It further contextualizes these consequences within the trajectory of dementia progression, and identifies interventions, support systems, and policy considerations necessary to mitigate caregiver burden. Spousal caregivers experience disproportionate burden due to continuous, escalating responsibilities that often mirror the progressive deterioration of their partners. Emotional burdens, including uncertainty during pre-diagnostic stages, role strain, conflict, loss of intimacy, and anticipatory grief. Physically, spouses endure musculoskeletal strain, sleep disruption, poor nutrition, and heightened frailty risk. Psychologically, spousal caregivers exhibit elevated rates of depression, anxiety, loneliness, and stress-related disorders. Socially, caregivers experience substantial isolation, stigma, and erosion of social networks. Financial hardship, including early retirement, reduced employment, and uncompensated care hours, further exacerbate stress. Evidence suggests that chronic caregiving stress contributes to biological changes such as immune dysregulation, inflammation, acceleration, aging, and potential cognitive decline in caregivers themselves. Caregiver burden influences patient outcomes as evidenced by increased emergency department use, falls, and earlier institutionalization in persons with dementia whose caregiver is subjected to a high burden. Current care models rarely include routine, caregiver assessment or structured guidance following diagnosis, resulting in substantial unmet needs. Effective mitigation requires integrated, stage-sensitive interventions, including psychosocial support, caregiver education, respite services, culturally tailored programs, and digital health tools, alongside broader policy reforms to reduce financial and structural barriers.
Musculoskeletal (MSK) disorders are a leading global cause of disability and healthcare utilization. In Saudi Arabia, the referral behaviors of primary care physicians (PCPs) for MSK management remain underexplored. This study aims to investigate referral patterns and awareness of prognostic stratification tools among primary-care physicians managing musculoskeletal conditions in Riyadh, Saudi Arabia. A web-based cross-sectional survey of 283 PCPs in Riyadh, Saudi Arabia, assessed demographic variables, MSK caseloads, referral frequencies to physiotherapy, specialist, and radiology services, satisfaction with existing pathways, and familiarity with stratified-care tools (eg, Keele STarT MSK). Associations between the healthcare sector and referral behaviors were examined using chi-square (χ2) tests with Cramér's V, and binary logistic regression was conducted to identify independent predictors of physiotherapy referral frequency. Open-ended responses were analyzed thematically. Most respondents (61.8%) were male and worked in government sectors. Physiotherapy referrals were infrequent (37.8% rarely referred), with significant sectoral differences (p < 0.001). Over half (53.4%) were unfamiliar with prognostic tools, while 18.4% reported occasional use. Barriers included lack of electronic integration (28%), unclear guidelines (27%), and time constraints (24%). Physicians recommended clearer referral criteria, electronic medical record (EMR) linked digital pathways, and interprofessional education. Multivariable binary logistic regression identified MSK caseload and senior registrar rank as significant independent predictors of more frequent physiotherapy referral. Physicians seeing 3-5 patients daily (OR = 11.597, 95% CI: 2.202-61.085, p =0.004) and senior registrars compared with consultants (OR = 2.857, 95% CI: 1.420-5.746, p =0.003) showed the highest odds of more frequent referral. Referral practices for MSK conditions among Saudi PCPs remain inconsistent and largely uninformed by evidence-based stratification tools. These findings suggest that enhancing multidisciplinary collaboration, training, and digital integration within EMRs may help align referral behavior with best practices and support Saudi Vision 2030 health system reforms. Future research should evaluate implementation strategies for these improvements within the Saudi primary care context.
Stem cell interventions (SCIs) are an exciting area of regenerative medicine (RM) that may offer improved outcomes for many patients, including those suffering from musculoskeletal conditions. They can also raise regulatory tensions and policy challenges, including how to manage direct-to-consumer markets where nonstandard SCIs - those falling outside the standard of care and lacking sufficient evidence of safety or efficacy - are sold. Ongoing regulatory reform efforts in several countries, including Canada, to address these and other related issues would benefit from insights regarding what is important to patients for trust in SCIs and their providers. Through interviews involving eight participants with musculoskeletal conditions, this qualitative, constructivist grounded theory study presents a preliminary model of factors that influence some patients' trust in nonstandard SCIs. Participants' anticipated approaches to nonstandard SCIs were rooted in their lived experiences of pain and frustration, shaped through interactions with healthcare providers, and framed by assumptions about regulatory protection. Healthcare providers play a pivotal role in helping navigate and interpret information. These results highlight the importance of evidence-based approaches to governance that integrate patient voices, practitioner education, and regulatory accountability to protect patients and help advance responsible RM innovation. Many people suffer from musculoskeletal conditions like osteoarthritis, a joint disease where cartilage wears down over time. Unfortunately, current treatments are not always effective in reducing pain and helping maintain quality of life. Regenerative medicine, which includes stem cell interventions, is a promising area of biomedicine. It may produce better treatments for different issues, including musculoskeletal conditions, but there are many unknowns that need further study. Nonetheless, there are stem cell-related treatments available on a direct-to-consumer basis that are still unproven, or “non-standard.” These practices raise concerns including regarding risks to patients. Policy and regulatory efforts are underway in countries, including Canada, to address these concerns and to encourage innovation in regenerative medicine and related fields, while protecting patients. This study offers evidence to inform this important work. Drawing on interviews with eight Canadians with musculoskeletal conditions, this research sheds light on what is important to them for developing trust in nonstandard stem cell treatments and in the healthcare professionals who provide them. Participants’ experiences of pain and frustration with their condition(s) were key in prompting interest in nonstandard stem cell treatments. They also looked to diverse healthcare providers to help navigate and interpret information about treatment options. While not overly familiar with oversight of health products or providers in Canada, our participants discussed their assumptions about the protection regulation offers. More research is needed, but these findings highlight the value of accounting for patients’ perspectives and of prioritizing provider education and oversight in efforts to strengthen regenerative medicine governance.
BackgroundRising demand for total hip arthroplasty (THA) and total knee arthroplasty (TKA) places significant pressure on healthcare systems. Routine in-person follow-up is resource-intensive and may limit access for new or higher priority patients. The Connected Care protocol integrates telehealth with patient-reported outcome measures (PROMs) to support a more efficient and patient-centred model of post-operative care.MethodsOver 2 years in a public health institution, all THA and TKA patients completed routine pre-operative and post-operative PROMs. Patients scoring ≤27 on the Oxford hip score or Oxford knee score, and/or requested further clinical review, were triaged to telehealth consultation. Following telehealth assessment, patients were either booked for face-to-face review, discharged from routine follow-up, or managed with ongoing remote monitoring.Results1272 patients returned PROMs. Of these, 451 patients (35.5%) scored ≤27 and/or requested further review. Following telehealth consultation, 47 (10.4%) were discharged from face-to-face care, while 71 (15.7%) previously discharged had appointments reinstated for timely in-person review. Among 821 patients (64.5%) who scored >27 and did not request further review, 169 (20.6%) had pre-existing face-to-face appointments cancelled. Overall, the Connected Care protocol generated 216 additional orthopaedic outpatient appointment slots over the 24-month period.DiscussionPROM-guided telehealth triage enabled risk-stratified, patient-centred follow-up post-THA/TKA, improving outpatient capacity within a publicly funded orthopaedic service. It reduced low-value outpatient encounters while preserving access to face-to-face care when clinically indicated. Future development should incorporate post-operative radiographic review, extend the model to other orthopaedic pathways, and enhance cultural and linguistic accessibility to support equitable digital post-operative care.
SYNOPSIS: The Moving Forward Together series is a collective effort developed to inform, guide, and inspire musculoskeletal physical therapists to bring Indigenous health to the forefront of their work in clinical practice, research, and education and to strengthen their roles in allyship and advocacy for Indigenous Communities. In the fourth article of the "Moving Forward Together" series, we highlight how physical therapy education can influence, and have responsibility for, improving students' knowledge and skills to care for Indigenous Peoples who are living with musculoskeletal conditions. Through a collaborative process, our group-comprising Indigenous educators from Aotearoa/New Zealand, Australia, and Canada-has reflected on current initiatives, explored future directions, and offered suggestions on how physical therapists can contribute to positive change in Indigenous musculoskeletal education. An interconnected approach positions students to graduate as physical therapists, capable of demonstrating cultural humility to provide reflective, strengths-based, and relational, culturally safe health care to all people with musculoskeletal conditions. J Orthop Sports Phys Ther 2026;56(5):272-276. Epub 3 December 2025. doi:10.2519/jospt.2025.13740.
Health-care workers face considerable physical demands that predispose them to musculoskeletal disorders (MSDs). This study examined and quantified the association between perceived physical workload and region-specific musculoskeletal pain among hospital staff in Tehran, Iran. In this cross-sectional study conducted in 2025 in university-affiliated hospitals in Tehran, 508 clinical personnel completed the Persian Physical Workload Questionnaire (PWQ) and the Extended Nordic Musculoskeletal Questionnaire (NMQ-E). Descriptive statistics summarized the burden and exposures. Generalized Estimating Equations (GEE) models were used to examine the association between physical workload scores and musculoskeletal pain across nine body regions. Robust standard errors were used. Mean total PWQ score was 59.52 (SD = 9.35). Lifetime prevalence was highest for neck (65.9%), low back (49.7%), and upper back (47.5%). Each one-unit increase in PWQ was associated with 1.7% higher odds of reporting regional pain (OR = 1.017; 95% CI 1.007-1.028; p = 0.001). While the per-unit effect is small, cumulative differences are meaningful: a 10-point increase corresponds to a 17% higher odds, and a one-standard-deviation increase (9.35 points) corresponds to a 15.9% higher odds. Among hospital staff in Tehran, higher perceived physical workload appears to be associated with increased likelihood of musculoskeletal pain, particularly in the cervical and lumbar regions. Although the per-unit odds ratios are modest, differences in exposure across the observed range of physical workload may translate into clinically relevant increases in risk. These findings should be interpreted cautiously due to the cross-sectional design, reliance on self-reported measures, and convenience sampling, which preclude causal inference. Interventions such as ergonomic redesign, patient-handling equipment, and targeted training warrant further evaluation in longitudinal or interventional studies.
The aim of this study was to investigate the impact of musculoskeletal (MSK) health literacy on clinical outcomes and patient satisfaction following total shoulder arthroplasty (TSA). We hypothesized that low MSK health literacy score would be associated with inferior clinical outcomes and lower patient satisfaction rates. A retrospective cohort study was conducted at a tertiary care center. Patients between 6 months and 9 years post-operative following shoulder arthroplasty, both anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty were included. All patients were treated by one of 2 sports fellowship-trained surgeons. Patients were emailed a questionnaire that included basic demographics, American Shoulder and Elbow Surgeons (ASES) shoulder score, TSA satisfaction, and the Literacy in Musculoskeletal Problems survey. Patients were categorized as having low health literacy (LHL) if they answered fewer than 6 out of 9 questions correctly on the Literacy in Musculoskeletal Problems survey and as having normal health literacy (NHL) if they answered 6 or more questions correctly. Statistical analysis was performed to determine associations between LHL, patient characteristics, and outcomes of interest. This included multivariate logistic and linear regression models that assessed the relationship between MSK health literacy and ASES. Of 734 patients emailed the survey, 310 responded, and 230 met inclusion criteria and were included in the final analysis. One hundred and seventy-seven patients (77%) had NHL and 53 individuals (23%) had LHL. The mean ASES score was 74.2 ± 19.8 in the NHL group and 62.9 ± 23.9 in the LHL group. Patients with LHL had significantly lower ASES scores than those with NHL (P = .0007). Patient satisfaction rate (90.3% vs. 82.7%, P = .2101) and willingness to undergo surgery again (89.8% vs. 84.9%, P = .334) were similar between the NHL and LHL groups, respectively. Multivariate analysis showed that NHL was independently predictive of a significantly higher ASES score (P = .009, odds ratio: 1.025). Approximately one-quarter of patients undergoing TSA at our institution had LHL. Patients with LHL were found to have significantly lower patient-reported outcome scores, although rates of patient satisfaction and willingness to undergo surgery again were comparable to those with NHL. These findings highlight an association between health literacy and post-operative recovery that likely reflects the influence of broader educational and socioeconomic determinants of health. These findings should be interpreted as associative and hypothesis-generating.
Public involvement is standard practice to enhance the quality, equity and impact of musculoskeletal pain research. In this review, we aimed to reflect on our own learning journey across multiple musculoskeletal projects and identify lessons learned from meaningful involvement. We then consider the changes needed at the researcher, funder and institutional levels to support involvement as a driver of relevance and impact. This is a narrative position paper drawing on experiential learning from three musculoskeletal pain studies and ongoing community engagement. We reflected on what we have learned from public contributors in our research, focusing on how involvement reshaped study priorities and tools. Lessons were synthesised to highlight recurring themes, supported by reference to reviews, guidance and empirical studies. Across all projects, several key themes emerged: (1) emphasis on purpose rather than process; (2) co-production and partnership rather than review; (3) flexibility and adaptation rather than predetermined steps; (4) relevant public contributors and partners; (5) focus on 'learning' rather than 'doing'; and (6) approaches to diversity and inclusion. Public partnerships should be a collaborative, transformative, relational and learning-based process that reshapes all aspects of research. Realising this potential might require flexible funding for early engagement, training in facilitation and reflexivity, sustained support beyond the research project to promote impact, and taking steps beyond building more infrastructure towards strengthening the systems that enable involvement to work effectively. Working together to improve muscle, joint, and bone pain research through shared learning This paper looks at how public partners (patients, service users, carers and members of the public with relevant lived experience) are involved in research on conditions affecting pain, muscles, bones, and joints. Involving the public in research is now widely expected. Not only does this approach ensures that research genuinely reflects the priorities of the public, but it also shapes the research question and methods to ensure relevance, thereby increasing the likelihood that the findings are meaningful and usable in the real-world. It ensures that research is conducted for the benefit of the public with public input. Involvement is not always meaningful. From our experience, we found that when involvement was genuine and followed the principles of good practice, it not only reshaped the research and tool design but also provided clearer pathways to end-user benefit, underpinned by continuous two-way learning. As we reflect on working with public partners as equals in co-creating our research, it has not only shaped the research to ensure it aligns with our public partners’ priorities, but it has also shaped us as researchers. As researchers, we also face challenges: we must learn to negotiate with public partners as equals and need appropriate support, such as flexible funding, to respond effectively to their knowledge and expertise.
In 2023, there was a sudden decline in the popularity of Accreditation Council for Graduate Medical Education (ACGME) Pain Medicine fellowship programs, as demonstrated by National Resident Matching Program (NRMP) application and match data. In comparison, little is known about the application rates and match performance of the North American Spine Society (NASS)-recognized Interventional Spine and Musculoskeletal Medicine (ISMM) fellowships established in 2020. We aimed to compare the characteristics of NASS-recognized ISMM applicants and their match results with those of NRMP-sponsored Pain Medicine applicants to determine whether both pathways faced similar challenges in recruiting and successfully matching trainees in recent years. This longitudinal observational study examines and describes the total number of applicants, match rate, and position fill percentage results of the ACGME NRMP and NASS ISMM from 2020 to 2025, stratified by gender and primary specialty. Over the study period, match rates did not markedly change for ISMM, but for ACGME they increased suddenly in 2023 and remained at this level. For ISMM and ACGME, the percentage of positions filled through the match trended downward. For both, the number of female applicants remained low and stable despite fluctuations in the total number of applicants. The distribution of applicants by primary specialties changed for the ACGME; notably, Anesthesiology applicants decreased by 65% from 2021 to 2025, while applications from all other specialties increased, including an increase in Emergency Medicine applicants by 221%. Since its inception, the NASS ISMM match has been primarily composed of Physical Medicine and Rehabilitation (PM&R) physicians, who accounted for 88% of applicants and 90% of successful matches. ACGME and NASS ISMM pain fellowships have been at the forefront of evolving trends in program fill rates from 2020 to 2025. Match rates for applicants remained high, reflecting a less competitive and more accessible process for those pursuing careers in pain and spine care.In 2025, male PM&R physicians were the largest group of applicants across both fellowship pathways, highlighting continued strong engagement from this specialty. Although overall applicant numbers have shifted, these trends present an opportunity to broaden outreach, strengthen early mentorship programs, and expand the pipeline of future pain and spine specialists.
This cross-sectional study aimed to quantify hope levels in adolescents with chronic musculoskeletal pain (CMP) and examine patient-reported outcomes associated with hope. This was an exploratory, cross-sectional, secondary analysis of baseline data from a prospective, single-center longitudinal study of 60 youth presenting for an initial evaluation at a pediatric subspecialty pain clinic. Subjects were English-speaking 12-17-year-olds with a diagnosis of CMP, primarily female and non-Hispanic White, with diffuse pain, median pain duration of 2 years, and moderate to severe physical dysfunction. Subjects completed surveys measuring hope (Children's Hope Scale [CHS]) and patient-reported mental, physical, and overall health. Associations between hope scores (total and each subscale) and patient-reported outcomes were evaluated using Spearman rank correlations. The median CHS score was 20.0 (IQR: 16.5-25.0), indicating slight hope. Patient hope was negatively correlated with depression (r = -0.61), anxiety (r = -0.49), psychological distress (r = -0.52), functional disability (r = -0.43), and pain interference (r = -0.37), but not pain intensity. Adolescents' hope was positively correlated with resilience (r = 0.74) and overall health (r = 0.55; all p < 0.01). Hope is correlated with various patient-reported health measures in youth with CMP. Although causal inferences are not possible due to the cross-sectional nature of this study, the results suggest that hope may be an important coping mechanism in pediatric chronic pain. Future efforts to incorporate existing resilience coaching programs into usual care may improve hope and health-related quality of life in youth with CMP.
Introduction Neck pain is a leading cause of musculoskeletal disability worldwide, significantly diminishing productivity and quality of life. Occupational risk factors such as prolonged static postures, repetitive upper-limb movements, and poor ergonomic practices are well documented. In hospital settings, laboratory technicians and clerical staff are particularly vulnerable due to sustained task-specific activities and extended periods of sitting. Despite this, these groups remain underrepresented in occupational health research. The primary objective of this study was to determine the prevalence of neck pain among laboratory technicians and clerical staff in a tertiary care hospital, while the secondary objective was to identify associated occupational and individual risk factors. Materials and methods A cross-sectional, questionnaire-based study was conducted at R.L. Jalappa Hospital and Research Centre, Kolar, from July to August 2025. The study population consisted of 100 participants, evenly divided between laboratory technicians (n = 50) and clerical staff (n = 50), each with a minimum employment duration of six months. Data were collected using a structured, pretested questionnaire designed to capture demographic information, occupational exposures, ergonomic practices, and history of neck pain. Pain intensity was measured using the Visual Analog Scale (VAS), while functional disability was assessed with the validated Neck Disability Index (NDI). Statistical analyses were performed using IBM SPSS Statistics Version 26 (IBM Corp., Armonk, NY, USA). Chi-square tests and multivariate logistic regression models were employed to identify independent predictors of neck pain, with statistical significance set at p < 0.05. Results The overall 12-month prevalence of neck pain was 71% (71/100; 95% CI: 61.9%-79.1%). When stratified by occupational group, the prevalence was significantly higher among laboratory technicians (42/50; 84%) compared to clerical staff (29/50; 58%) (p = 0.002). The mean Neck Disability Index (NDI) score was 18.5 ± 8.2, indicating moderate functional impairment. Multivariate analysis identified female gender (adjusted odds ratio (aOR) = 2.4; 95% confidence interval (CI): 1.3-4.5; p = 0.007), engagement in static postures exceeding four hours daily (aOR = 4.1; 95% CI: 2.1-8.0; p < 0.001), body mass index (BMI) greater than 25 kg/m² (aOR = 1.9; 95% CI: 1.0-3.6; p = 0.04), and low ergonomic awareness (aOR = 2.2; 95% CI: 1.2-4.1; p = 0.01) as significant independent predictors of neck pain. Conclusion The findings indicate a high prevalence of neck pain among laboratory technicians and clerical staff, with significant associations to prolonged static postures and poor ergonomic practices. Implementing targeted ergonomic interventions, encouraging regular breaks, and providing workplace health education programs may help reduce neck pain and improve occupational health outcomes.
Nurse fatigue is a prevalent and multifactorial occupational health risk that increases the likelihood of work-related injuries and safety incidents, with implications for both workforce well-being and patient care. In fatigue-prone nursing environments, injuries such as slips, sharps injuries, and musculoskeletal disorders related to patient handling represent critical yet often underrecognized consequences of sustained physical and cognitive overload. This review synthesizes findings from occupational health, human factors engineering, sleep medicine, and healthcare quality improvement to examine injury prevention strategies targeting nurse fatigue. Shifting beyond individual-level resilience, the review focuses on system-oriented interventions embedded within work design and care delivery processes. Three interrelated domains are examined: (1) organizational and scheduling strategies, including fatigue risk management systems, shift optimization, protected rest, and acuity-responsive staffing; (2) engineering and ergonomic solutions, such as safe patient handling programs, assistive technologies, environmental optimization, and alarm management; and (3) behavioral and team-based practices, including microbreaks, fatigue-aware communication, training for high-risk tasks, and non-punitive fatigue-related reporting. Across healthcare contexts, implementation is constrained by resource limitations, alarm burden, and deficiencies in safety culture. Evaluation commonly relies on injury incidence, near-miss reporting, sleep quality, and workforce retention, though data standardization remains challenging. Overall, preventing fatigue-related injuries in nursing requires integrated, multidisciplinary, and context-sensitive strategies that align organizational design, engineering controls, and behavioral practices. Embedding fatigue management within healthcare safety culture and policy frameworks is essential to protecting nurses' health, sustaining workforce stability, and improving patient safety.
Women experience musculoskeletal changes following pregnancy that may increase musculoskeletal injury risk. This trial explored 18-weeks combined rehabilitation and endurance and resistance training (Intervention, n = 17) compared with standard-of-care (Control, n = 14) on areal bone mineral density (aBMD), tibial bone, and patella tendon properties in postpartum UK Servicewomen. Intervention received standard care plus pelvic floor and core strength exercises from week 1 to 18 (week 6 to 24 postpartum), and combined high-intensity interval and resistance training from week 6 to 18 (week 12 to 24 postpartum). Control received standard care. Whole-body DXA and tibial HRpQCT scans (4% and 30% sites) were taken at week 1 and 18. Patella tendon properties at rest and during isometric contractions were measured by ultrasound at weeks 1, 6, and 18. There was no effect of training on aBMD (p ≥ 0.100) but trunk (-1.6%) and spine (-2.3%) aBMD decreased from week 1 to 18, irrespective of group (p ≤ 0.021). There was no effect of training on tibial bone (p ≥ 0.151) or patella tendon properties (p ≥ 0.185). An 18-week rehabilitation and endurance and resistance training programme had no effect on bone or tendon properties in postpartum Servicewomen.
Background: Care for knee osteoarthritis (KOA) is frequently fragmented, and pathway-level decisions within Physical Medicine and Rehabilitation (PM&R) are influenced by local organizations. The objective of this study was to identify areas of agreement and disagreement among PM&R experts and to translate these into a clinically interpretable, function-oriented care pathway for knee osteoarthritis (KOA) within rehabilitation services. Methods: A two-round Real-Time Delphi study was conducted using the SmartDelphi web platform. A steering committee of five PM&R physicians developed a 37-item questionnaire covering referral/access, functional and outcome assessment, conservative management, escalation/referral thresholds, and follow-up/discharge. Round 1 was online (SERMEF osteoarthritis working group; 46 invited, 40 completed; 87.0%) with responses collected until 30 April 2025. Round 2 was an in-person, facilitated validation round on 30 May 2025 at the SERMEF Congress (A Coruña; 85 invited, 70 completed; 82.4%). Items were rated on a 6-point Likert scale; consensus strength was defined by interquartile range (IQR): strong (0-1) vs. weak (≥2). No patient-level data were collected; participant characteristics were comparable across rounds, suggesting consensus refinement reflected deliberation rather than panel shifts over time. Results: Consensus supported a longitudinal, function-first pathway that was structured into five phases: entry/referral to PM&R; comprehensive functional assessment using a minimum outcomes dataset (pain VAS/NRS, WOMAC function, quality-of-life scale); multimodal conservative rehabilitation combining exercise/physiotherapy, education/self-management support, and indicated oral/topical therapies; reassessment-guided escalation in non-responders, reserving interventional PM&R techniques, multidisciplinary musculoskeletal pain-unit management, or orthopedic evaluation for persistent pain and/or functional limitation; and longitudinal monitoring with defined discharge criteria. Conclusions: SERMEF PM&R experts converged on an implementation-oriented, outcomes-driven KOA itinerary centred on functioning, conservative multimodal care, structured reassessment, and explicit discharge planning.
Prehabilitation is increasingly recognized as an important component of multimodal preoperative optimization, yet its structure, delivery, and degree of integration into routine practice vary widely across healthcare systems. This survey aimed to examine current implementation strategies, multidisciplinary team configurations, and prevailing barriers to inform standardized adoption. We conducted a multinational, cross-sectional survey of surgical departments performing major abdominal surgery. The survey, disseminated via the European Society for Clinical Nutrition and Metabolism (ESPEN) and national surgical societies, captured institutional characteristics, prehabilitation implementation practices, delivery settings, multidisciplinary team composition, and 21 predefined barriers. The primary outcome was a 5-point prehabilitation integration score, a novel measure of prehabilitation components integration (1-5 Likert scale; 1 = not integrated, 5 = fully integrated into routine care). Associations were assessed using nonparametric tests and multivariable ordinary least squares regression. A total of 200 departments from 45 countries participated. 31.5% reported a routine formal prehabilitation program; the mean (SD) integration score was 2.6 ± 1.1. Integration differed significantly by delivery setting, highest in departments with dedicated prehabilitation/ERAS units and rehabilitation services. Larger multidisciplinary teams were strongly associated with higher integration. In the final multivariable model, the presence of psychologists (β = +0.49, P = 0.002) and nurses (β = +0.35, P = 0.020) independently predicted greater integration, whereas lack of structured units (β = -0.51, P = 0.009), limited facility access (β = -0.39, P = 0.014), and absence of standardized protocols (β = -0.35, P = 0.031) were significant negative predictors. Hospital type and surgical volume showed no independent association. Prehabilitation is not widely implemented as clinical practice among responding units. Integration of prehabilitation into a multidisciplinary care package is driven primarily by modifiable organizational factors rather than institutional size or academic status. Dedicated perioperative units, standardized protocols, adequate facilities, and inclusion of nurses and psychologists appear critical for successful implementation. These findings support a pragmatic, ERAS-aligned pathway for expanding prehabilitation within existing perioperative care frameworks.
Orthopedic surgery is among the most physically demanding medical specialties, exposing surgeons to prolonged static postures, repetitive high-force movements, and heavy equipment that significantly increase the risk of musculoskeletal injury. Historical perspectives reveal that ergonomic principles have been recognized since antiquity, yet modern surgical practice continues to neglect them, resulting in high rates of pain, disability, and even premature retirement among orthopedic surgeons. Recent survey data demonstrate that musculoskeletal disorders affect surgeons across all subspecialties, with the lumbar spine, neck, and shoulders most frequently involved, and that these injuries directly influence surgical performance, career longevity, and workforce sustainability. Evidence-based strategies-including intraoperative postural awareness, optimized table and monitor positioning, ergonomic instrument design, microbreaks, targeted physical conditioning, and adoption of assistive technologies-have been shown to mitigate injury risk without compromising operative efficiency. Reframing ergonomics as a cornerstone of operative excellence is essential not only for surgeon well-being but also for ensuring high-quality, sustainable patient care in the future.
Falls are a leading cause of emergency department (ED) visits among older adults, often resulting in fractures. Point-of-care ultrasound (POCUS) has emerged as a valuable diagnostic tool for emergency nurse practitioners (ENPs), offering rapid, radiation-free evaluation of musculoskeletal injuries. This article examines the effectiveness of POCUS in detecting fractures, with evidence demonstrating high sensitivity and specificity, particularly for long-bone injuries. A case study of a patient with a humeral fracture highlights the utility of POCUS in diagnosis and expedited orthopedic referral. The article also discusses ultrasound physics, bone imaging techniques, and transducer selection for musculoskeletal assessments. Beyond clinical accuracy, POCUS use is associated with reduced ED length of stay and healthcare costs. While operator-dependent, structured training models are expanding ENP proficiency in POCUS. Integrating this modality into ED practice enhances timely triage and improves patient outcomes, particularly in resource-limited or high volume settings.
The menopausal transition represents a pivotal period in female aging, marked by profound endocrine, metabolic and cellular shifts. Increasing evidence indicates that menopausal symptoms - vasomotor instability, sleep disturbances, fatigue and cognitive complaints - are more than consequences of estrogen withdrawal, and may serve as a potential clinical indicator of biological aging. Experimental and clinical data suggest that declining estrogen signaling contributes to mitochondrial dysfunction, inflammation and telomere attrition, processes that are closely linked to cellular senescence and tissue deterioration. In addition to estrogen decline, the menopausal transition involves broader endocrine changes. Rising follicle stimulating hormone (FSH) levels, alteration in androgen balance and cortisol dysregulation of the hypothalamic-pituitary-adrenal axis may influence metabolic regulation, musculoskeletal health, stress physiology and body composition. Through these mechanisms, menopausal hormonal changes may contribute to increased cardiometabolic, musculoskeletal and neurocognitive vulnerability in midlife women. Clinical observations increasingly show that severe menopausal symptoms are associated with adverse cardiometabolic profiles, vascular dysfunction and markers of accelerated biological aging. Sleep disturbances and fatigue may further exacerbate metabolic dysregulation and systemic vulnerability, while cognitive complaints may reflect neuroinflammatory and vascular processes associated with aging. By restoring estrogen signaling, menopausal hormone therapy alleviates menopausal symptoms and may influence biological pathways involved in aging. Whether these effects translate into a modification of the aging trajectory remains unclear. Menopausal symptoms – such as hot flashes, sleep disturbances and mood changes – may indicate early biological aging. This commentary discusses connections between these symptoms, hormone changes and mitochondrial function, and how they can act as early clinical markers of accelerated aging. Recognizing these signals can help healthcare providers understand the wider health implications of menopause, offer personalized care, and guide strategies to support long-term physical and mental well-being, healthy aging and quality of life in midlife women.
Background: Acute radiation-induced skin injury (aRISI) is one of the most frequent adverse effects of radiotherapy (RT) in patients with head and neck cancer (HNC) and may compromise treatment delivery and quality of life. Topical glucocorticosteroids (GCS) are commonly used in clinical practice for aRISI management; however, evidence supporting their proactive use remains inconsistent. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of proactive topical GCS therapy during RT for HNC. Methods: A systematic search of PubMed, Embase, and the Cochrane Library was conducted from database inception to July 2025 in accordance with PRISMA 2020 guidelines. Randomized controlled trials comparing topical GCS with placebo or standard skin care in adult patients undergoing curative RT or RChT for HNC were included. The primary outcomes were incidence of clinically significant aRISI (grade ≥ 2) and severe aRISI (grade ≥ 3), assessed using validated grading systems (RTOG or CTCAE). Random-effects meta-analyses were performed to calculate pooled risk ratios (RRs) with 95% confidence intervals (CIs). Risk of bias was assessed using the Cochrane RoB 2 tool. Results: Three randomized controlled trials comprising 459 patients were included. Proactive topical GCS did not significantly reduce the pooled incidence of grade ≥ 2 aRISI compared with placebo or standard skin care (RR 0.87, 95% CI 0.60-1.27). Similarly, no statistically significant reduction in grade ≥ 3 aRISI was observed in pooled analysis (RR 0.81, 95% CI 0.22-3.06). Qualitative synthesis of secondary outcomes reported in individual trials suggested potential benefits of topical GCS, including delayed onset or slower progression of aRISI, and, in one large double-blind study, a reduced risk of severe reactions. No increase in treatment-related adverse events was observed in any included trial. Conclusions: Proactive topical GCS do not significantly reduce the overall incidence of aRISI in pooled analysis. Individual studies showed trend towards delayed onset, slower progression, and reduced severe aRISI without compromising safety. These findings support the judicious use of topical GCS as part of proactive supportive care in HNC RT, while highlighting the need for larger, standardized trials to define optimal regimens and patient selection.