Realization, Self-View, and Disclosure of Pedophilia: A Content Analysis of Online Posts.

In order to treat individuals with pedophilia1 who are at risk of committing offenses, disclosure of the attraction must first take place. The aim of this study was to understand processes of initial recognition of pedophilic attraction, disclosure, and help-seeking. We conducted a qualitative content analysis of online posts from self-identified individuals with pedophilia, finding four categories: (1) Awareness and Initial Self-View (with emotions including denial, shame, and fear), (2) Disclosure (typically made to family, friends, or therapists, but also done online in an anonymous way), (3) People's Reactions to Disclosure (ranging from rejection to support), and (4) Current Self-View (including minimization, distortions, despair, resignation, and non-offending/anti-contact commitment). Our findings highlight the internal process experienced by individuals with pedophilia when first recognizing their attraction to minors, what is involved in disclosure, the importance of others' reactions after disclosure, and the factors that can reinforce a non-offending commitment. Clinical and social implications are discussed.

Return to sport decisions after an acute lateral ankle sprain injury: introducing the PAASS framework-an international multidisciplinary consensus.

BACKGROUND: Despite being the most commonly incurred sports injury with a high recurrence rate, there are no guidelines to inform return to sport (RTS) decisions following acute lateral ankle sprain injuries. We aimed to develop a list of assessment items to address this gap. METHODS: We used a three-round Delphi survey approach to develop consensus of opinion among 155 globally diverse health professionals working in elite field or court sports. This involved surveys that were structured in question format with both closed-response and open-response options. We asked panellists to indicate their agreement about whether or not assessment items should support the RTS decision after an acute lateral ankle sprain injury. The second and third round surveys included quantitative and qualitative feedback from the previous round. We defined a priori consensus being reached at >70% agree or disagree responses. RESULTS: Sixteen assessment items reached consensus to be included in the RTS decision after an acute lateral ankle sprain injury. They were mapped to five domains with 98% panellist agreement-PAASS: Pain (during sport participation and over the last 24 hours), Ankle impairments (range of motion; muscle strength, endurance and power), Athlete perception (perceived ankle confidence/reassurance and stability; psychological readiness), Sensorimotor control (proprioception; dynamic postural control/balance), Sport/functional performance (hopping, jumping and agility; sport-specific drills; ability to complete a full training session). CONCLUSION: Expert opinion indicated that pain severity, ankle impairments, sensorimotor control, athlete perception/readiness and sport/functional performance should be assessed to inform the RTS decision following an acute lateral ankle sprain injury. TRIAL REGISTRATION NUMBER: ACTRN12619000522112.

Knowledge, attitudes, and behavior toward concussion in adult cyclists.

OBJECTIVE: To determine knowledge, attitudes, and behavior toward concussion in cyclists and to identify predictors of concussion knowledge. METHODS: Cycling organizations sent members a web link to online information about the study and a questionnaire. Anyone aged >16 years, living in New Zealand and engaged in a cycling activity was invited to participate. The 36-item questionnaire included sociodemographics, knowledge about concussion, helmet use, and personal concussion history. Data were collected between 15/05/19 and 30/06/19. A multiple linear regression model identified factors associated with levels of concussion knowledge. RESULTS: The questionnaire was completed by 672 participants aged between 16 and 82 years (x̄ = 48.6 years). Knowledge of concussion was high. However, knowledge that helmets are not able to prevent concussion was low and time to return to sport after injury was variable. Knowledge did not always translate to seeking of medical attention or replacement of helmet behavior. Younger age and having sustained at least one prior concussion were associated with higher levels of concussion knowledge F(df = 3) = 8.81, p < .001. CONCLUSIONS: Knowledge and attitudes toward concussion were positive. However, knowledge gaps and discrepancies between attitudes and behavior were identified. Consistent, clear messages are needed around return to sport timeframes.

Validation of an Inertial Sensor System for Physical Therapists to Quantify Movement Coordination During Functional Tasks.

Physical therapists evaluate patients' movement patterns during functional tasks; yet, their ability to interpret these observations consistently and accurately is unclear. Physical therapists would benefit from a clinic-friendly method for accurately quantifying movement patterns during functional tasks. Inertial sensors, which are inexpensive, portable sensors capable of monitoring multiple body segments simultaneously, are a relatively new rehabilitation technology. We sought to validate an inertial sensor system by comparing lower limb and lumbar spine kinematic data collected simultaneously with a commercial inertial sensor system and a motion camera system while 10 subjects performed functional tasks. Mean and peak segment angular displacement data were calculated and compared between systems. Mean angular displacement root mean square error between the systems across all tasks and segments was <5°. Mean differences in peak displacements were generally acceptable (<5°) for the femur, tibia, and pelvis segments for all tasks; however, the inertial system overestimated lumbar flexion compared to the motion camera system. These data suggest that the inertial system is capable of measuring angular displacements within 5° of a system widely accepted for its accuracy. Standardization of sensor placement, better attachment methods, and improvement of inertial sensor algorithms will further increase the accuracy of the system.

A 10-year Retrospective Review of Functional Outcomes of Adolescent Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Rupture of the anterior cruciate ligament (ACL) is an increasingly prevalent sporting injury in adolescents. Surgical reconstruction of the ACL in adolescents has been controversial and there has been little reported on functional outcomes after surgery.The aim of this study was to undertake a retrospective notes review and questionnaire survey of a group of adolescents who had their ACL surgically reconstructed over the previous 10 years, assessing delay to surgery, levels of meniscal damage, reoperation rates, and functional outcomes. METHODS: A retrospective chart review was performed on 100 adolescent patients who underwent arthroscopic ACL reconstruction using a transphyseal technique. These patients were also contacted and completed the Knee Osteoarthritis Outcome Score (KOOS). RESULTS: One hundred patients had their records reviewed. The average age at follow-up was 20.5 (SD, 2.4) years. There were 49 females and 51 males. Meniscal tears were present in 76% of patients at the time of surgery. The rate of medial meniscal tears increased with delay to surgical intervention beyond 3 months. Reoperation rate for these patients was 24%.Eighty patients completed the KOOS questionnaire. Patients were a mean of 4 (SD, 2.2) years postsurgery. The main findings indicate that in the 5 key KOOS domains patients scored a mean of 60 (SD, 13) for symptoms, 65 (SD, 10) for pain, 70 (SD, 6.4) for activities of daily living, 54 (SD, 17.6) for sport and recreation, and 47.2 (SD, 20.1) for quality of life. CONCLUSIONS: This study demonstrates that young people with ACL injuries have a very high associated incidence of meniscal pathology at the time of surgery. There is a high reoperation rate for meniscal surgery and graft failure. Four years post-ACL reconstruction many have not yet returned to a fully functional state.Further research to understand why functional outcomes are modest is required. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Factors affecting confidence and knowledge in spinal palpation among International Manual Physical Therapists.

OBJECTIVES: We sought to find if there was a relationship between the confidence in use of static palpation, passive physiological intervertebral motion (PPIVM) and passive accessory intervertebral motion (PAIVM) and the manual therapist's (MTs) knowledge of the literature on these topics. METHODS: We designed an international survey to achieve our objectives. Each skill was surveyed for the cervical, thoracic and lumbar spines. We also included several other factors that we believed might influence the use of these skills. RESULTS: We concluded that familiarity of the literature was significantly associated with a MTs' confidence in the use of static palpation, PPIVM and PAIVM techniques. We also found a relationship with the country of practice of the MT and their confidence using these techniques. DISCUSSION: Spinal palpation is an integral part of the MT's evaluation and treatment abilities. The vast majority of MTs use spinal palpation and nearly all entry-level education programmes include it in their training. Knowing what factors influence MTs' confidence assessing and treating the spine may allow for more effective teaching and training, as well as improved patient outcomes.

The prevalence, incidence and severity of low back pain among international-level rowers.

BACKGROUND/AIMS: There is a paucity of prospective cohort studies investigating the incidence of low back pain (LBP) in rowing. We investigated (1) the prevalence and incidence of LBP among international-level rowers in New Zealand, (2) the relationship between training volume and LBP and (3) the effect of LBP on rowers' ability to train and compete. METHODS: This was a prospective cohort study of 76 New Zealand representative rowers, including 46 men (mean age 22, SD=4) and 30 women (mean age 21, SD=4). Data were collected using an online questionnaire repeated monthly for 12 months. RESULTS: The prevalence of LBP ranged from 6% to 25% throughout the year. The incidence of episodes of LBP was 1.67 per 1000 exposure-hours. A total of 72 episodes of LBP were reported by 40 rowers (53%) during 12 months. Of these, 45% had an incidental effect on training. 29% minor, 18% moderate and 9% had a major effect as determined by the length of time the training was interrupted. There was a high correlation between new LBP and total training hours per month (r=0.83, p<0.01). A previous history of LBP was a risk factor in developing new LBP (OR 2.06, 95% CI 1.22 to 3.48, p=0.01). Age was also a risk factor, with the likelihood of developing LBP increasing for every year (OR 1.08, 95% CI 1.01 to 1.15, p=0.02). CONCLUSIONS: LBP is common among New Zealand representative rowers. There is a high correlation between training load and the development of LBP.

Cornual Ectopic Pregnancy Complicated by Infected Hematoma.

Cornual ectopic pregnancies are rarely encountered in clinical practice. A diagnostic and therapeutic challenge, complications include hemorrhage and the presence of persistently elevated serum beta-hCG requiring administration of methotrexate. In this case, we present a patient whose postoperative course was complicated by an infected hematoma that responded to conservative management.

Defining the role of sport and exercise physicians: the experience of different referrer types in New Zealand.

The aim of this study was to analyse the reasons health professionals refer to sport and exercise physicians (SEPs) and to define what service gap the specialty fills. This was a qualitative study design using thematic analysis. Online focus group interviews consisting of 4-6 participants in each group were conducted separately with physiotherapists, emergency clinicians, general practitioners and orthopaedic surgeons practising in New Zealand. Thematic analysis of the focus group interviews was then used for the identification of common themes around referral tendencies towards SEPs. Three primary themes were identified relating to referrals towards SEPs: (1) role utilisation of SEPs, (2) collaboration and (3) accessibility. SEPs are viewed as experts in the assessment, investigation and diagnosis of musculoskeletal (MSK) conditions, including some which might traditionally be viewed as surgical diagnoses. Some confusion or lack of understanding exists regarding the range of conditions that SEPs can treat and manage, with some referrers assuming that SEPs only treat sport-related injuries. SEPs are often used alongside other specialist practitioners in the management of patients with MSK conditions. This requires collaboration with other health professionals who also treat MSK conditions to ensure the best patient outcome. A common feeling towards SEPs is they are easily accessible compared with other potential health providers who may also treat MSK conditions such as orthopaedic surgeons and general practitioners, and that SEPs provide sound management plans and access to investigations such as MRI, in a timely fashion.

Current practice, guideline adherence, and barriers to implementation for Achilles tendinopathy rehabilitation: a survey of physical therapists and people with Achilles tendinopathy.

Objective: To explore clinical practice patterns of physical therapists (PTs) who treat people with Achilles tendinopathy (AT), and identify perceived barriers and facilitators for prescribing and engaging with therapeutic exercise among PTs and people with AT. Methods: Two cross-sectional surveys were electronically distributed between November 2021 and May 2022; one survey was designed for PTs while the second was for people with AT. Survey respondents answered questions regarding their physical therapy training and current practice (PTs), injury history and management (people with AT), and perceived barriers and facilitators (PTs and people with AT). Results: 341 PTs and 74 people with AT completed the surveys. In alignment with clinical practice guidelines, more than 94% of PTs surveyed (97% of whom had some form of advanced musculoskeletal training) prioritise patient education and therapeutic exercise. Patient compliance, patient knowledge, and the slow nature of recovery were barriers to prescribing therapeutic exercise reported by PTs, while time, physical resources, and a perceived lack of short-term treatment effectiveness were barriers for people with AT. Conclusions: Consistent with clinical practice guidelines, PTs with advanced training reported prioritising therapeutic exercise and education for managing AT. However, both PTs and people with AT identified many barriers to prescribing or engaging with therapeutic exercise. By addressing misconceptions about the time burden and ineffectiveness of exercise, and by overcoming access issues to exercise space and equipment, PTs may be able to improve intervention adherence and subsequently outcomes for people with AT.

Suggested improvements to the 11+ as identified by coaches, players, strength and conditioning staff and medical staff in New Zealand Football.

The aim of this study was to investigate the experience with the 11+, attitudes towards injury prevention, and potential improvements to the 11+ and the delivery of injury prevention strategies within football. A qualitative study design was used to investigate the views of four stakeholder groups (players, coaches, strength and conditioning staff and clinicians). Twenty-two adults participated (nine women; median age 35.5 years). Participants were purposively recruited and were based in New Zealand. They represented various levels of football, including different genders, ages and levels of play. Focus group interviews were conducted, which were recorded, transcribed and subject to thematic analysis. Four key themes were identified: understanding of the 11+ injury prevention warm-up, content of an ideal injury prevention programme, structure of the programme and education, adherence and dissemination. The study found that while participants appeared to have good awareness of the existing 11+ programme and an interest in injury prevention, adherence and enthusiasm towards the programme was limited. Participants highlighted a number of elements that may help shape the development of a new injury prevention strategy, including a desire to retain many of the elements of the 11+ and to have a proven programme. Participants wanted greater variety, more football-specific elements and to implement a new strategy throughout a session, rather than being seen as a stand-alone warm-up. Whether the intervention should also include strength-based exercises, or whether this should be promoted outside of a football training session, was less certain.

Lateral Wedging of the Foot: A Scoping Review.

Lateral wedges are a common intervention used to alter biomechanical function of the lower limb. Although there is evidence investigating the use and impact of lateral wedges in individuals with medial knee osteoarthritis, knowledge of how these wedges affect foot function in healthy adults is limited. Therefore, this study intends to investigate how lateral wedging affects foot function in healthy adults and, furthermore, how wedge design influences the outcome. The framework outlined by Arksey and O'Malley was used for this scoping review. To ensure methodologic quality and transparent reporting, the study adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews preferred reporting guidelines. A systematic search was conducted using MEDLINE by means of EBSCO; SPORT Discuss; CINAHL; AMED by means of OVID; and Scopus. The initial search yielded 252 articles in total; 21 studies were included in the final analysis. Significant incongruence exists in descriptions of wedge length among the 21 included studies. Thirteen studies (61%) reported using full-length wedges, five studies did not report wedge length, and only one study analyzed more than one wedge length. Ethylene vinyl acetate was the most common material, and reporting of hardness was inconsistent. A broad range of inclination angles were used, with limited explanation for why these values were selected. All but one study that analyzed ankle/subtalar joint frontal plane moments reported an increase in the external eversion moment. The review identified significant variation in the design of wedges used within this body of work and a lack of investigation into the influence of wedge design. Wedge design appears to be a secondary consideration, with very few studies examining multiple material types or wedge placements. All but one of the included studies reported a significant change in ankle/subtalar joint moments with lateral wedging. Unfortunately, further generalization was not possible because of the inconsistency and variation.

Current perspectives of New Zealand physiotherapists on rehabilitation and return to sport following anterior cruciate ligament reconstruction: A survey.

OBJECTIVE: To investigate the clinical beliefs and practices of New Zealand physiotherapists regarding pre- and post-surgical rehabilitation and return to sport (RTS) criteria following anterior cruciate ligament reconstruction (ACLR). DESIGN: Online cross-sectional survey. METHODS: A survey was adapted from a previously published survey and disseminated to New Zealand physiotherapists who were considered more likely to be involved in post-ACLR rehabilitation. RESULTS: The number of completed surveys was 318. Most physiotherapists (85%) preferred to first consult patients within 14 days of ACLR. In the first six weeks following ACLR, 89% of physiotherapists see patients at least once per week. Between 3- and 6-months post-ACLR, 76% of physiotherapists see patients at least once a fortnight. Pre-operative rehabilitation and post-operative rehabilitation exceeding six months are considered essential or important to patient outcomes by over 95% of physiotherapists. While 63% of physiotherapists support RTS 9-12 months after ACLR, 11% permit RTS within 6-9 months of surgery. Common RTS considerations include functional capacity, movement quality during functional tasks, time from ACLR, and knee strength. CONCLUSION: The survey revealed variability in the beliefs and practices of NZ physiotherapists regarding post-ACLR rehabilitation, and these beliefs and practices are at times inconsistent with best practice recommendations.

The effectiveness of preoperative exercise programmes on quadriceps strength prior to and following anterior cruciate ligament (ACL) reconstruction: A systematic review.

OBJECTIVES: to evaluate the effectiveness of preoperative exercise programmes on quadriceps strength prior to and following anterior cruciate ligament (ACL) reconstruction. DESIGN: Systematic review. METHODS: a systematic review was undertaken, included studies were evaluated using the Modified Downs and Black checklist which is appropriate for determining the quality of randomised and non-randomised studies. Scientific databases searched included PubMED, EBSCO Health, CINAHL, Medline, and Cochrane Library databases from inception to March 2021. RESULTS: Ten studies met the inclusion criteria. There were six randomised studies and four prospective studies. The level of evidence is categorised as 'limited' due to heterogenicity and only six studies reported quadriceps strength increases. Five studies demonstrated preoperative exercise of 4-16 weeks duration can significantly increase preoperative quadriceps strength. One study demonstrated preoperative OKC exercise produced significantly stronger preoperative quadriceps compared to CKC exercise. One study showed no between group (intervention vs control) quadriceps strength difference pre or 12 weeks postoperatively. CONCLUSIONS: 4-16 weeks of preoperative exercise could increase quadriceps strength preoperatively but any persistent postoperative strength benefit from undertaking a standardised preoperative intervention is unclear. There is considerable variation and methodological limitations across the included studies and the composition of optimal preoperative ACLR exercise is currently unknown.

Knowledge and management of sport-related concussion in primary care in New Zealand.

AIM: To assess the current state of knowledge around sport-related concussion (SRC) guidelines and management among primary care doctors in New Zealand. METHODS: An online, self-administered, 21-item multi-choice questionnaire targeted at general practitioners and urgent care doctors in New Zealand was used. Main outcome measures were knowledge and management of patients with SRC through to return-to-sport. RESULTS: There were 230 total valid responses. Over half had no knowledge of the Consensus Statement on Concussion in Sport, and only 43% used the Sport Concussion Assessment Tool (SCAT) routinely. Fifty-eight percent would prefer to have a screening tool integrated into their patient management software. Most reported using appropriate management strategies for patients with concussion and recognised the potential benefit of relative cognitive and physical rest. There was low utilisation of referral pathways to allied health practitioners and specialist concussion services. Half (53%) felt confident in managing a patient with SRC and 46% felt comfortable managing return-to-sport. CONCLUSION: Primary care doctors have good knowledge of SRC but are not as confident managing return-to-sport. Further education opportunities were identified. Development of concussion tools adapted for use in primary care, integrated with patient management software and that support pathways to optimise patient recovery are recommended.

Injury incidence within male elite New Zealand cricket from the early T20 era: 2009-2015.

OBJECTIVES: This study aimed to describe the injury epidemiology of domestic and international level male New Zealand cricketers from seasons 2009-2010 to 2014-2015 across all match formats given the increasing popularity of T20 cricket. METHODS: Match exposure and injury surveillance data collected prospectively by New Zealand Cricket was analysed using international consensus recommendations for injury surveillance and reporting in cricket. Relationships between playing level, role and injury were statistically analysed. RESULTS: A total of 268 elite male New Zealand cricketers from seasons 2009-2010 to 2014-2015 were analysed from the New Zealand Cricket injury surveillance system. Total new match injury incidence rates were 37.0 and 58.0 injuries per 10 000 player hours in domestic and international cricket, respectively. Total new and recurrent match injury incidence in international cricket was approximately 1.7 times higher than domestic cricket (277.6 vs 162.8 injuries per 1000 player days). Injury prevalence rates were 7.6% and 10.0% in domestic and international cricket. The hamstring (8.2%) in domestic cricket and the groin (13.5%) in international cricket were the most injured body sites. Most match days lost in domestic cricket were to the lumbar spine (417 days), and groin in international cricket (152 days). There were statistically significant differences in injury between domestic and international level cricketers (χ2=4.39, p=0.036), and playing role (χ2=42.29, p<0.0001). CONCLUSIONS: Total injury incidence rates in elite New Zealand cricket increased in 2009-2015 compared with previous data. International-level players and pace bowlers were the most injured individuals.

How manual therapy provided a gateway to a biopsychosocial management approach in an adult with chronic post-surgical low back pain: a case report.

BACKGROUND: The management of patients with chronic post-surgical low back pain can be very challenging to surgeons, physiotherapists, and patients alike. Subsequent surgery is often associated with post-operative complications and even lower levels of success than the initial spinal surgery. Physiotherapy is often recommended as the first-line management, however, debate exists amongst physiotherapists regarding the optimal treatment strategy. A key focus of this debate has been the use of manual therapy in chronic pain populations, leading clinicians to reevaluate its use. CASE DESCRIPTION: A 44-year-old female presented to physiotherapy with a 13-year history of persistent pain, having had a spinal fusion 12 years prior, following a skiing accident. Her primary complaints were pain and decreased self-efficacy. The patient was treated with a 12-week multimodal approach consisting of manual therapy, exercise rehabilitation, and pain neuroscience education. OUTCOMES: The patient had a significant reduction in the Numerical Pain Rating Scale (NPRS), the Oswestry Disability Index (ODI) and the Fear Avoidance Belief Questionnaire Physical Activity Subscale (FABQ-PA) scores following the intervention. She returned to running and cycling, reporting that pain was something she would 'work with instead of against'. DISCUSSION: This case study suggests that manual therapy can enhance an individualized biopsychosocial approach in the physiotherapy management of a patient with chronic post-surgical low back pain. Further research is needed to evaluate optimal intervention dosages and effective strategies in the management of patients with chronic low back pain following spinal surgery.

Does research help to inform a district health board's purpose? A qualitative thematic analysis of clinician researcher views.

AIM: The outcomes from research should guide the decisions of healthcare providers, policymakers and funders. This study sought the perspectives of senior hospital clinicians and researchers from a New Zealand district health board (DHB). METHOD: A series of interviews asked participants about the purpose and benefits of research to the DHB, and to reflect upon the enablers and barriers they had experienced in conducting and translating research in a DHB context. RESULTS: Three key themes were identified. The first theme suggested research should inform the DHB's purpose. The second theme identified how the general busyness, lack of research funding and the differing motivations of clinicians and business leaders doesn't make it easy to do research in a DHB. The third theme suggested that research barriers could be seen as opportunities. Participants placed importance on an environment that inspires enquiry; that permits staff to stop and question what they do; that overtly informs its community that research is done to improve the delivery of care; that communicates a purposeful research agenda; and that regularly discusses the intersection of research and the purpose of the DHB. CONCLUSION: This study found the absence of an organisation-wide research ethos affected staff engagement in and with research. As a consequence, the effective transfer and translation of knowledge from research was disrupted. Key recommendations were for the DHB to integrate research activity into practice, regularly discuss research evidence and celebrate research achievements.

Advanced practice physiotherapists are effective in the management of musculoskeletal disorders: a systematic review of systematic reviews.

BACKGROUND: There are increasing demands for orthopaedic specialist services due to the increasing burden of musculoskeletal (MSK) disorders. This situation creates a barrier for patients to access appropriate health care. Advanced practitioner physiotherapists (APP) may provide an alternative service for patients with MSK disorders. OBJECTIVE: To evaluate the evidence on whether APPs are accurate at diagnosis, can triage appropriately and improve patient treatment outcomes and access to care for patients with musculoskeletal disorders. DATA SOURCES: CINAHL, MEDline, Web of Science, SPORTdiscus, SCOPUS and AMED between January 2000 and March 2020. STUDY SELECTION: Systematic reviews evaluating the efficacy of APPs, in any healthcare setting, treating patients of any age range with MSK disorders, in comparison to orthopaedic surgeons or doctors. DATA EXTRACTION AND SYNTHESIS: Two researchers independently extracted and synthesised data according to the inclusion and exclusion criteria. Methodological quality was independently assessed by two reviewers using the AMSTAR tool. A third reviewer resolved discrepancies. RESULTS: Thirteen systematic reviews met the inclusion criteria. The evidence consistently found APPs are accurate at diagnosis, can triage appropriately, and improve patient treatment outcomes and access to care. There was a lack of high-quality primary studies in the included reviews, however, the highest quality studies had similar findings. LIMITATIONS: A meta-analysis was not possible due to heterogeneity of outcome measures. There was an overlap of primary studies which may cause bias. CONCLUSION: The evidence of varying quality consistently shows that APPs can accurately diagnose, appropriately triage and effectively manage patients with musculoskeletal disorders in various clinical settings.