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Background: Optimal management and surgical planning of severe bony deformities and muscle tendon unit contractures demands comprehensive evaluation of all structures including the dynamic muscle tendon length of all muscles around the joint during gait., Objectives: Present study aimed to explore dynamic muscle-tendon length for all muscles around the knee joint along with pelvis, hip, and ankle joint kinematics among adolescent children with varying crouch angle., Methods: Muscle-tendon length of 29 adolescent children with cerebral palsy with varying crouch angles was computed using a full-body musculo-skeletal model and expressed as a percentage of muscle-tendon length during walking compared to resting condition., Results: Children with knee flexion angle greater than 25° demonstrated lower anterior pelvic tilt and 11% greater muscle-tendon length of semimembranosus and biceps femoris during stance phase of gait compared to children with knee flexion angle less than 25° and typically developing children ( p  < 0.01)., Conclusions: The findings of present study reported that routine bedside clinical evaluation in adolescent children with knee flexion angle greater than 25° revealed moderate shortening of hamstring muscle in supine position. Whereas instrumented objective evaluation of gait demonstrated lengthened hamstring muscle and reduced hip extension and relatively lower anterior pelvic tilt. Therefore, it may be valuable to add objective assessment of dynamic muscle-tendon length to kinematics of all lower-extremity joint motion during gait, in order to understand the muscle-joint interactions; particularly in children with severe crouch and plan specific, tailor-made surgical and non-surgical interventions., Competing Interests: Conflict of InterestThe authors state that they have no conflict of interest, financial or otherwise, concerning the material or methods used in this study or the findings specified in this paper., (© Indian Orthopaedics Association 2024. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Daily living physical activities of rural pregnant women, across most continents in the world, involve adoption of high-flexion postures like deep-squat. Deep-squat elicits substantial activation of major trunk and lower extremity muscles. Adequate strength of trunk muscles is known to facilitate forward-downward propulsion of baby during labour. Therefore, current study aimed to explore influence of overall physical activity including squat exposure on trunk and lower-extremity muscle strength and labour outcomes in rural and urban primigravida women. Twenty-eight primi-gravida women were stratified into 2 groups: rural habitual-squatters (n=14) and urban non-squatters (n=14). Daily squat exposure was measured using MGM-Ground-Level-Activity-Questionnaire; lower-lumbar spine motion with modified-Schober-test; lower-extremity muscle strength using 30-sec-chair-raise-test, trunk muscle endurance with pressure biofeedback, calf muscle endurance was measured using calf raise test. Duration of second stage of labour and type of delivery was recorded. Habitual Squatters (average squat exposure=68.9±25.3 min) demonstrated lower waist: hip ratio (p=0.02); greater overall physical activity level (p=0.001), lumbo-pelvic mobility (p=0.02), lower-extremity muscle strength (p=0.001); and shorter duration of 2nd stage of labour (p=0.001) compared to non-squatters. Excellent positive correlation was observed between daily-squat exposure and back muscle endurance (Spearman's rho=0.98, p=0.001). Normal vaginal delivery was conducted in 83% squatters and in 71% non-squatters. Present findings indicate strong influence of habitual physical activity including squat exposure on improved trunk-lower-extremity strength, lumbo-pelvic mobility and shorter duration of second stage of labor.

Introduction: The purpose is to report on the fourth set of recommendations developed by SPINE20 to advocate for evidence-based spine care globally under the theme of "One Earth, One Family, One Future WITHOUT Spine DISABILITY"., Research Question: Not applicable., Material and Methods: Recommendations were developed and refined through two modified Delphi processes with international, multi-professional panels., Results: Seven recommendations were delivered to the G20 countries calling them to:-establish, prioritize and implement accessible National Spine Care Programs to improve spine care and health outcomes.-eliminate structural barriers to accessing timely rehabilitation for spinal disorders to reduce poverty.-implement cost-effective, evidence-based practice for digital transformation in spine care, to deliver self-management and prevention, evaluate practice and measure outcomes.-monitor and reduce safety lapses in primary care including missed diagnoses of serious spine pathologies and risk factors for spinal disability and chronicity.-develop, implement and evaluate standardization processes for spine care delivery systems tailored to individual and population health needs.-ensure accessible and affordable quality care to persons with spine disorders, injuries and related disabilities throughout the lifespan.-promote and facilitate healthy lifestyle choices (including physical activity, nutrition, smoking cessation) to improve spine wellness and health., Discussion and Conclusion: SPINE20 proposes that focusing on the recommendations would facilitate equitable access to health systems, affordable spine care delivered by a competent healthcare workforce, and education of persons with spine disorders, which will contribute to reducing spine disability, associated poverty, and increase productivity of the G20 nations., Competing Interests: Nothing to disclose., (© 2023 The Authors.)

The aim of this study is to investigate postural stability and function (functional tasks) in younger (<12 yr) and older (>12 yr) children with lesser (<25°) and greater crouch (>25°) during stance. Postural stability and functional tasks were assessed in 53 ambulatory children with spastic cerebral palsy (CP). Younger and older children with greater crouch angle demonstrated higher displacement of center of pressure compared to children with lesser crouch angle during gait ( p  < .01). All (younger and older) children with severe crouch angle demonstrated strong association of postural control with stair climb ( r  = 0.732; p  < .05) and timed-up-and-go test ( r  = 0.84; p  < .01). Greater crouch angle demonstrates a moderate association with postural stability ( r  = 0.528; p  < .01) in quiet stance and a strong association with functional tasks in children with CP ( r  = 0.7-0.84; p  < .05).

Background: Post-COVID residual dysfunction has been observed in a majority of people, with reduction in cardiopulmonary endurance emerging as a primary symptom. The Six-Minute Walk Test is a simple, reliable, and valid test that is used routinely on people with chronic respiratory dysfunction. In the current COVID-19 pandemic situation, reference values and a predictive equation developed from a large sample across a large age group, from 6 to 75 years, will enable one to establish goals of treatment for post-COVID rehabilitation., Methods: Following institutional ethical clearance, we recruited 1369 participants for the study (685 females and 684 males). Participants were classified according to biological age into group 1 (6-12 years), group 2 (13-17 years), group 3 (18-40 years), group 4 (41-65 years), and group 5 (>65 years). Informed consent was sought and participants were screened using a health history questionnaire. Demographic features, namely, age, height, weight, and body mass index (BMI) were noted. The Six-Minute Walk Test was administered as per ATS guidelines. Clinical parameters, namely, pulse rate, respiratory rate, systolic blood pressure, diastolic blood pressure, and rate of perceived exertion were recorded., Results: The Six-Minute Walk Test (6MWT) was significantly influenced by age and gender (r = 0.257, P = 0.00 and r = 0.501, P = 0.00, respectively). Walking distance was longest in 13-17-year-old males, whereas females demonstrated a linear decline after 12 years. In each age group, males walked a greater distance than females. Stepwise linear regression analysis was used to derive the following predictive equation: 6MWT = 491.93 - (2.148 × age) + (107.07 × gender) (females = 0, males = 1)., Conclusion: The study confirmed variability of the Six-Minute Walk Test, with age and gender being predominant predictors. Reference values, equations, and percentile charts generated from the study can be utilised to guide clinical decision-making while exercise prescription for patients with post COVID dysfunction.

Purpose: The current study aimed to explore Gross Motor Function Measure (GMFM) profiles among children with cerebral palsy (CP) at various Gross Motor Function Classification System (GMFCS) levels in a low-resource setting., Methods: Ambulatory capacity of children with CP was classified using GMFCS levels. Functional ability of all participants was measured using GMFM-88. Seventy-one ambulatory children with CP (61% males), were studied after signed informed consent was obtained from parents and assent from children older than 12 years., Results: Children with CP in a low-resource setting had 12-44% lower GMFM scores in dimensions of standing, walking, running, and jumping with reference to children from high-resource settings with similar ambulatory capacity reported previously. The most affected components across various GMFCS levels were 'sitting on a large and small bench from floor,' 'arm-free squatting,' 'half-kneeling,' 'kneel-walking,' and 'single-limb hop'., Conclusion: Knowledge of GMFM profiles can guide clinicians and policymakers in low-resource settings for strategic rehabilitation planning and extend the focus of rehabilitation from restoration of body structure and function to the wider domain of social participation in leisure, sport, work, and the community at large. Additionally, providing tailored rehabilitation based on a profile of motor function can ensure an economically, environmentally, and socially sustainable future.

Background: Dough kneading is a commonly performed activity in the kitchen, which influences hand grip strength., Objectives: To study the influence of dough kneading exposure on hand grip strength and to evaluate the effect of dough kneading intervention on hand grip strength with the purpose of recommending dough kneading as a therapeutic exercise for improving hand grip strength., Methods: One hundred and fifty healthy females with varying levels of exposure to dough kneading, stratified as occupational dough kneaders, habitual dough kneaders and non-kneaders, were studied. Hand grip strength of all participants was measured with a standard protocol using the Jamar dynamometer. Hand grip strength of occupational, habitual and non-kneaders was compared. Non-kneaders followed a 6-week intervention of dough kneading and grip strength was recorded post-intervention., Result: Comparison of hand grip strength between the three groups revealed significant difference (p value < 0.001). Linear contrast analysis, revealed the least hand grip strength in non-kneaders compared to habitual and occupational dough kneaders, with occupational dough kneaders presenting maximum hand grip strength (p value < 0.001). Significant improvement was demonstrated in hand grip strength post-intervention in non-kneaders (p value < 0.001)., Conclusion: Findings suggest that exposure to dough kneading has a positive influence on hand grip strength. Hand grip strength of non-kneaders was lowest compared to habitual and occupational kneaders. Kneading intervention improved hand grip strength and hence can be used therapeutically as a safe, low cost exercise in hand rehabilitation.

Objective: To implement rehabilitation services in a rural area of Raigad district, Maharashtra, India., Methods: We piloted a rehabilitation service delivery model through the Mahatma Gandhi Mission Institute of Health Sciences, in five villages. The institute performed participatory rural appraisal and focus group discussions with stakeholders to identify general issues in village life that could affect delivery. To integrate rehabilitation service delivery into the existing primary care system, a team from the institute developed a strategic plan through multidisciplinary clinical meetings. A rehabilitation team conducted a door-to-door survey and referred people needing rehabilitation services to the outreach visits the team was making to the primary health centre twice a week. If needed, patients could be referred to a university teaching hospital for tertiary-level care., Findings: The rural appraisal identified lack of awareness, inadequate workforce and infrastructure as key issues for rehabilitation services delivery. In response, we conducted awareness campaigns and formed a rehabilitation team consisting of personnel and students from the institute. Between 2018 and 2021, the team provided care to 1800 patients, of which half (900 patients) had musculoskeletal disorders. After rehabilitation, 360 (40%) of these 900 patients performed daily-living activities and continued to work with reduced pain within 2-3 days after rehabilitation. The team provided antenatal care to 1629 pregnant women with musculoskeletal pain or stress urinary incontinence., Conclusion: Provision of rehabilitation services built awareness about physiotherapy, developed a rehabilitation care pathway and established a need for regular services. Using existing resources of the institute and involving students rendered the model sustainable., ((c) 2022 The authors; licensee World Health Organization.)

Purpose: The focus of SPINE20 is to develop evidence-based policy recommendations for the G20 countries to work with governments to reduce the burden of spine disease, and disability., Methods: On September 17-18, 2021, SPINE20 held its annual meeting in Rome, Italy. Prior to the meeting, the SPINE20 created six proposed recommendations. These recommendations were uploaded to the SPINE20 website 10 days before the meeting and opened to the public for comments. The recommendations were discussed at the meeting allowing the participants to object and provide comments., Results: In total, 27 societies endorsed the following recommendations. SPINE20 calls upon the G20 countries: (1) to expand telehealth for the access to spine care, especially in light of the current situation with COVID-19. (2) To adopt value-based interprofessional spine care as an approach to improve patient outcomes and reduce disability. (3) To facilitate access and invest in the development of a competent rehabilitation workforce to reduce the burden of disability related to spine disorders. (4) To adopt a strategy to promote daily physical activity and exercises among the elderly population to maintain an active and independent life with a healthy spine, particularly after COVID-19 pandemic. (5) To engage in capacity building with emerging countries and underserved communities for the benefit of spine patients. (6) To promote strategies to transfer evidence-based advances into patient benefit through effective implementation processes., Conclusions: SPINE20's initiatives will make governments and decision makers aware of efforts to reduce needless suffering from disabling spine pain through education that can be instituted across the globe., (© 2022. The Author(s).)

Wearable inertial sensor-based motion analysis systems are promising alternatives to standard camera-based motion capture systems for the measurement of gait parameters and joint kinematics. These wearable sensors, unlike camera-based gold standard systems, find usefulness in outdoor natural environment along with confined indoor laboratory-based environment due to miniature size and wireless data transmission. This study reports validation of our developed (i-Sens) wearable motion analysis system against standard motion capture system. Gait analysis was performed at self-selected speed on non-disabled volunteers in indoor ( n  = 15) and outdoor ( n  = 8) environments. Two i-Sens units were placed at the level of knee and hip along with passive markers (for indoor study only) for simultaneous 3D motion capture using a motion capture system. Mean absolute percentage error (MAPE) was computed for spatiotemporal parameters from the i-Sens system versus the motion capture system as a true reference. Mean and standard deviation of kinematic data for a gait cycle were plotted for both systems against normative data. Joint kinematics data were analyzed to compute the root mean squared error (RMSE) and Pearson's correlation coefficient. Kinematic plots indicate a high degree of accuracy of the i-Sens system with the reference system. Excellent positive correlation was observed between the two systems in terms of hip and knee joint angles (Indoor: hip 3.98° ± 1.03°, knee 6.48° ± 1.91°, Outdoor: hip 3.94° ± 0.78°, knee 5.82° ± 0.99°) with low RMSE. Reliability characteristics (defined using standard statistical thresholds of MAPE) of stride length, cadence, walking speed in both outdoor and indoor environment were well within the "Good" category. The i-Sens system has emerged as a potentially cost-effective, valid, accurate, and reliable alternative to expensive, standard motion capture systems for gait analysis. Further clinical trials using the i-Sens system are warranted on participants across different age groups.

Background: Among non-communicable disorders, low back and neck pain are the most common causes of severe, long-term pain and disability affecting more than a billion people globally. Yet, the burden and impact of these conditions are not well understood, especially among rural and tribal people living in low- and middle-income countries., Objective: The aims of this study were to measure point prevalence of low back and neck pain among rural and tribal people in Raigad District of Maharashtra, India, and explore attitudes and beliefs of rural people towards spine pain and disability., Design: In a cross-sectional survey of six villages in the Raigad District of Maharashtra State of India from August to October 2016, low back and neck pain were measured using the Spine Pain Questionnaire., Results: We surveyed 2323 participants, which did not include children and adolescents. Among rural people (n = 2073), the point prevalence of low back and neck pain was 4.9% (95% CI 3.94-5.79) and 2.9% (95% CI 2.21-8.87), respectively. Among tribal people (n = 250), prevalence was 10.0% (95% CI 6.28-13.71) for low back pain and 3.6% (95% CI 1.29-5.90) for neck pain. Lifting heavy weights and bending trunk were the most limiting activities. During informal discussions, most villagers attributed spine pain to traditional lifestyle and age. Participants continued occupational work in the presence of pain. Lack of transport facilities and cost of treatment emerged as the two most common reasons for delay in seeking treatment at nearby healthcare centres. This information will inform the development of customized spine care programmes through community-engaged partnerships and self-empowerment of the local community.

Background: Bounce rope-skip holds immense scope as an aerobic exercise in space and time constrained urban setting with additional constraints placed by pandemic situations such as Covid 19, wherein adherence to commonly performed weight-bearing, aerobic activities like walking and running is a challenge. Limited knowledge informing biomechanical demands and misconceptions about knee joint loading, confines safe application of bounce rope-skip in health promotion. Thus, present study aimed to explore kinematics and lower-extremity joint loading during rope-skipping compared to walking and running., Methods: Following ethical approval, 3D motion analysis of bounce rope-skip, walk and run was captured from 22 healthy female participants aged 18-25yr using 12-camera Vicon system and 2AMTI force plates. Three trials for bounce rope-skip were recorded with five skip-jumps on force-plates at a cadence of 105 skips/min. Mid-skip, mid-gait and mid-run data were averaged to compute kinetic and kinematic variables for hip, knee and ankle during loading/initial contact, take-off/push-off and flight/mid-swing phases of rope-skip, walk and run., Result: Average time of one rope-skip cycle was 1.2sec; mean foot contact time was 0.55sec and flight time was 0.65sec. In one bounce rope-skip cycle, hip motion ranged between 13.4 o -35.3 o flexion; knee between 13.6 o -67.9° flexion and ankle between 34.5 o dorsiflexion to-13.4 0 plantarflexion. Vertical ground reaction force (vGRF) during rope-skip (landing-phase) was lower compared to run; however, it was higher than walk (p < 0.001). In coronal plane, peak hip and knee adductor moment during rope-skip were lower compared to run and higher than walk (p < 0.001)., Conclusion: Bounce rope-skip generated low lower extremity joint loading compared to run; supporting its prescription as a hip and knee joint-protective aerobic weight-bearing exercise for health promotion in young adults., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: The COVID-19 pandemic has greatly limited patients' access to care for spine-related symptoms and disorders. However, physical distancing between clinicians and patients with spine-related symptoms is not solely limited to restrictions imposed by pandemic-related lockdowns. In most low- and middle-income countries, as well as many underserved marginalized communities in high-income countries, there is little to no access to clinicians trained in evidence-based care for people experiencing spinal pain., Objective: The aim of this study is to describe the development and present the components of evidence-based patient and clinician guides for the management of spinal disorders where in-person care is not available., Methods: Ultimately, two sets of guides were developed (one for patients and one for clinicians) by extracting information from the published Global Spine Care Initiative (GSCI) papers. An international, interprofessional team of 29 participants from 10 countries on 4 continents participated. The team included practitioners in family medicine, neurology, physiatry, rheumatology, psychology, chiropractic, physical therapy, and yoga, as well as epidemiologists, research methodologists, and laypeople. The participants were invited to review, edit, and comment on the guides in an open iterative consensus process., Results: The Patient Guide is a simple 2-step process. The first step describes the nature of the symptoms or concerns. The second step provides information that a patient can use when considering self-care, determining whether to contact a clinician, or considering seeking emergency care. The Clinician Guide is a 5-step process: (1) Obtain and document patient demographics, location of primary clinical symptoms, and psychosocial information. (2) Review the symptoms noted in the patient guide. (3) Determine the GSCI classification of the patient's spine-related complaints. (4) Ask additional questions to determine the GSCI subclassification of the symptom pattern. (5) Consider appropriate treatment interventions., Conclusions: The Patient and Clinician Guides are designed to be sufficiently clear to be useful to all patients and clinicians, irrespective of their location, education, professional qualifications, and experience. However, they are comprehensive enough to provide guidance on the management of all spine-related symptoms or disorders, including triage for serious and specific diseases. They are consistent with widely accepted evidence-based clinical practice guidelines. They also allow for adequate documentation and medical record keeping. These guides should be of value during periods of government-mandated physical or social distancing due to infectious diseases, such as during the COVID-19 pandemic. They should also be of value in underserved communities in high-, middle-, and low-income countries where there is a dearth of accessible trained spine care clinicians. These guides have the potential to reduce the overutilization of unnecessary and expensive interventions while empowering patients to self-manage uncomplicated spinal pain with the assistance of their clinician, either through direct in-person consultation or via telehealth communication., (©Scott Haldeman, Margareta Nordin, Patricia Tavares, Rajani Mullerpatan, Deborah Kopansky-Giles, Vincent Setlhare, Roger Chou, Eric Hurwitz, Caroline Treanor, Jan Hartvigsen, Michael Schneider, Ralph Gay, Jean Moss, Joan Haldeman, David Gryfe, Adam Wilkey, Richard Brown, Geoff Outerbridge, Stefan Eberspaecher, Linda Carroll, Reginald Engelbrecht, Kait Graham, Nathan Cashion, Stefanie Ince, Erin Moon. Originally published in JMIR Public Health and Surveillance (http://publichealth.jmir.org), 17.02.2021.)

Cricket-bowling performance is known to be influenced by speed of ball release and accuracy. Currently, training sessions typically involve fielding-specific drills and conditioning exercises. Scientific evidence for inclusion of a comprehensive yoga intervention in daily training and exercise sessions remains unexplored. The present study explored the effect of yoga on bowling performance and physical fitness in cricket bowlers. Sports fitness testing and training were conducted among 60 non-elite recreational-club male cricket players aged 13-25 years. Cricket-bowling speed was e valuated using a speed radar gun, accuracy with a test developed by Portus et al., cardiorespiratory endurance using the yo-yo intermittent recovery test, lower-extremity and trunk strength using a back-leg dynamometer, upper-limb power using a medicine ball-throw test, power using a vertical-jump test, and flexibility using a sit-and-reach test. In addition to bowling practice, the yoga intervention group (n = 30) performed pranayama and standing and prone asana, whereas the control group (n = 30) practiced conventional conditioning exercises, for 45 minutes/day, three times a week, for 12 weeks. Improvement in bowling speed, accuracy, cardiorespiratory endurance, muscle strength, and flexibility were comparable between the two groups. Statistically significant improvements in baseline scores in bowling speed, accuracy, cardiorespiratory endurance, muscle flexibility, strength, and power were comparable between the two groups of non-elite male cricket players. Bowling speed improved by 6.52% in the yoga group and by 5.18% in the control group. Bowling accuracy improved by 35.40% in the yoga group and by 31.29% in the control group. Additional research on long-duration intervention in elite players may help to establish the role of yoga in conventional cricket-bowling training.

Purpose: The purpose of the study was to provide reference values for grip and pinch strength for healthy children and adolescents in India., Methods: Grip and pinch strength were recorded for 900 participants stratified into 5 chronological age groups (5-6, 7-9, 10-12, 13-15 and 16-18 years). Grip strength was measured using a Jamar Dynamometer and pinch strength using a Martin vigorimeter., Results: The difference in grip and pinch strength between age groups was significant (p< 0.001 respectively). A linear rise in grip strength was noted from age groups of 5-6 years to 16-18 years. Moderate to strong positive association was observed between grip and pinch strength and upper extremity anthropometric characteristics (i.e., palmar width, hand span, hand length, arm length, forearm length, and upper limb length) from age groups of 5-6 years to 16-18 years. Boys demonstrated greater grip and pinch strength compared to girls in all age groups (p< 0.001). No difference was observed between the dominant and non-dominant hand in all age groups., Conclusions: Findings from the present study provide reference values for grip strength, tip to tip, key and tripod pinch for healthy Indian children and adolescents from 5-18 years of age, which will be useful to guide rehabilitation outcomes in routine clinical practice.

Purpose: The purpose of this report is to describe the development of a classification system that would apply to anyone with a spine-related concern and that can be used in an evidence-based spine care pathway., Methods: Existing classification systems for spinal disorders were assembled. A seed document was developed through round-table discussions followed by a modified Delphi process. International and interprofessional clinicians and scientists with expertise in spine-related conditions were invited to participate., Results: Thirty-six experts from 15 countries participated. After the second round, there was 95% agreement of the proposed classification system. The six major classifications included: no or minimal symptoms (class 0); mild symptoms (i.e., neck or back pain) but no interference with activities (class I); moderate or severe symptoms with interference of activities (class II); spine-related neurological signs or symptoms (class III); severe bony spine deformity, trauma or pathology (class IV); and spine-related symptoms or destructive lesions associated with systemic pathology (class V). Subclasses for each major class included chronicity and severity when different interventions were anticipated or recommended., Conclusions: An international and interprofessional group developed a comprehensive classification system for all potential presentations of people who may seek care or advice at a spine care program. This classification can be used in the development of a spine care pathway, in clinical practice, and for research purposes. This classification needs to be tested for validity, reliability, and consistency among clinicians from different specialties and in different communities and cultures. These slides can be retrieved under Electronic Supplementary Material.

Purpose: Spine-related disorders are a leading cause of global disability and are a burden on society and to public health. Currently, there is no comprehensive, evidence-based model of care for spine-related disorders, which includes back and neck pain, deformity, spine injury, neurological conditions, spinal diseases, and pathology, that could be applied in global health care settings. The purposes of this paper are to propose: (1) principles to transform the delivery of spine care; (2) an evidence-based model that could be applied globally; and (3) implementation suggestions., Methods: The Global Spine Care Initiative (GSCI) meetings and literature reviews were synthesized into a seed document and distributed to spine care experts. After three rounds of a modified Delphi process, all participants reached consensus on the final model of care and implementation steps., Results: Sixty-six experts representing 24 countries participated. The GSCI model of care has eight core principles: person-centered, people-centered, biopsychosocial, proactive, evidence-based, integrative, collaborative, and self-sustaining. The model of care includes a classification system and care pathway, levels of care, and a focus on the patient's journey. The six steps for implementation are initiation and preparation; assessment of the current situation; planning and designing solutions; implementation; assessment and evaluation of program; and sustain program and scale up., Conclusion: The GSCI proposes an evidence-based, practical, sustainable, and scalable model of care representing eight core principles with a six-step implementation plan. The aim of this model is to help transform spine care globally, especially in low- and middle-income countries and underserved communities. These slides can be retrieved under Electronic Supplementary Material.

Purpose: The purpose of this systematic literature review was to develop recommendations for the assessment of spine-related complaints in medically underserved areas with limited resources., Methods: We conducted a systematic review and best evidence synthesis of guidelines on the assessment of spine-related complaints. Independent reviewers critically appraised eligible guidelines using the Appraisal of Guidelines for Research and Evaluation-II criteria. Low risk of bias clinical practice guidelines was used to develop recommendations. In accordance with the mandate of the Global Spinal Care Initiative (GSCI), recommendations were selected that could be applied to medically underserved areas and low- and middle-income countries by considering the limited access and costs of diagnostic technologies., Results: We screened 3069 citations; 20 guidelines were eligible for critical appraisal. We used 13 that had a low risk of bias that targeted neck and back pain., Conclusions: When assessing patients with spine-related complaints in medically underserved areas and low- and middle-income countries, we recommend that clinicians should: (1) take a clinical history to determine signs or symptoms suggesting serious pathology (red flags) and psychological factors (yellow flags); (2) perform a physical examination (musculoskeletal and neurological); (3) do not routinely obtain diagnostic imaging; (4) obtain diagnostic imaging and/or laboratory tests when serious pathologies are suspected, and/or presence of progressive neurologic deficits, and/or disabling persistent pain; (5) do not perform electromyography or nerve conduction studies for diagnosis of intervertebral disc disease with radiculopathy; and (6) do not perform discography for the assessment of spinal disorders. This information can be used to inform the GSCI care pathway and model of care. These slides can be retrieved under Electronic Supplementary Material.

Purpose: The purpose of this report is to describe the Global Spine Care Initiative (GSCI) contributors, disclosures, and methods for reporting transparency on the development of the recommendations., Methods: World Spine Care convened the GSCI to develop an evidence-based, practical, and sustainable healthcare model for spinal care. The initiative aims to improve the management, prevention, and public health for spine-related disorders worldwide; thus, global representation was essential. A series of meetings established the initiative's mission and goals. Electronic surveys collected contributorship and demographic information, and experiences with spinal conditions to better understand perceptions and potential biases that were contributing to the model of care., Results: Sixty-eight clinicians and scientists participated in the deliberations and are authors of one or more of the GSCI articles. Of these experts, 57 reported providing spine care in 34 countries, (i.e., low-, middle-, and high-income countries, as well as underserved communities in high-income countries.) The majority reported personally experiencing or having a close family member with one or more spinal concerns including: spine-related trauma or injury, spinal problems that required emergency or surgical intervention, spinal pain referred from non-spine sources, spinal deformity, spinal pathology or disease, neurological problems, and/or mild, moderate, or severe back or neck pain. There were no substantial reported conflicts of interest., Conclusion: The GSCI participants have broad professional experience and wide international distribution with no discipline dominating the deliberations. The GSCI believes this set of papers has the potential to inform and improve spine care globally. These slides can be retrieved under Electronic Supplementary Material.

Purpose: Spinal disorders, including back and neck pain, are major causes of disability, economic hardship, and morbidity, especially in underserved communities and low- and middle-income countries. Currently, there is no model of care to address this issue. This paper provides an overview of the papers from the Global Spine Care Initiative (GSCI), which was convened to develop an evidence-based, practical, and sustainable, spinal healthcare model for communities around the world with various levels of resources., Methods: Leading spine clinicians and scientists around the world were invited to participate. The interprofessional, international team consisted of 68 members from 24 countries, representing most disciplines that study or care for patients with spinal symptoms, including family physicians, spine surgeons, rheumatologists, chiropractors, physical therapists, epidemiologists, research methodologists, and other stakeholders., Results: Literature reviews on the burden of spinal disorders and six categories of evidence-based interventions for spinal disorders (assessment, public health, psychosocial, noninvasive, invasive, and the management of osteoporosis) were completed. In addition, participants developed a stratification system for surgical intervention, a classification system for spinal disorders, an evidence-based care pathway, and lists of resources and recommendations to implement the GSCI model of care., Conclusion: The GSCI proposes an evidence-based model that is consistent with recent calls for action to reduce the global burden of spinal disorders. The model requires testing to determine feasibility. If it proves to be implementable, this model holds great promise to reduce the tremendous global burden of spinal disorders. These slides can be retrieved under Electronic Supplementary Material.

Purpose: The purpose of this report is to describe the development of an evidence-based care pathway that can be implemented globally., Methods: The Global Spine Care Initiative (GSCI) care pathway development team extracted interventions recommended for the management of spinal disorders from six GSCI articles that synthesized the available evidence from guidelines and relevant literature. Sixty-eight international and interprofessional clinicians and scientists with expertise in spine-related conditions were invited to participate. An iterative consensus process was used., Results: After three rounds of review, 46 experts from 16 countries reached consensus for the care pathway that includes five decision steps: awareness, initial triage, provider assessment, interventions (e.g., non-invasive treatment; invasive treatment; psychological and social intervention; prevention and public health; specialty care and interprofessional management), and outcomes. The care pathway can be used to guide the management of patients with any spine-related concern (e.g., back and neck pain, deformity, spinal injury, neurological conditions, pathology, spinal diseases). The pathway is simple and can be incorporated into educational tools, decision-making trees, and electronic medical records., Conclusion: A care pathway for the management of individuals presenting with spine-related concerns includes evidence-based recommendations to guide health care providers in the management of common spinal disorders. The proposed pathway is person-centered and evidence-based. The acceptability and utility of this care pathway will need to be evaluated in various communities, especially in low- and middle-income countries, with different cultural background and resources. These slides can be retrieved under Electronic Supplementary Material.

Purpose: The purpose of this report is to describe the development of a list of resources necessary to implement a model of care for the management of spine-related concerns anywhere in the world, but especially in underserved communities and low- and middle-income countries., Methods: Contents from the Global Spine Care Initiative (GSCI) Classification System and GSCI care pathway papers provided a foundation for the resources list. A seed document was developed that included resources for spine care that could be delivered in primary, secondary and tertiary settings, as well as resources needed for self-care and community-based settings for a wide variety of spine concerns (e.g., back and neck pain, deformity, spine injury, neurological conditions, pathology and spinal diseases). An iterative expert consensus process was used using electronic surveys., Results: Thirty-five experts completed the process. An iterative consensus process was used through an electronic survey. A consensus was reached after two rounds. The checklist of resources included the following categories: healthcare provider knowledge and skills, materials and equipment, human resources, facilities and infrastructure. The list identifies resources needed to implement a spine care program in any community, which are based upon spine care needs., Conclusion: To our knowledge, this is the first international and interprofessional attempt to develop a list of resources needed to deliver care in an evidence-based care pathway for the management of people presenting with spine-related concerns. This resource list needs to be field tested in a variety of communities with different resource capacities to verify its utility. These slides can be retrieved under Electronic Supplementary Material.

Classical Indian dance has earned recognition across the globe; however, the health of dancers who are carrying forth this heritage has not received due attention. Therefore, this study aimed to explore musculoskeletal pain and injury prevailing among Indian dancers in Mumbai and Mangalore. A secondary aim was to compare pain tolerance levels between dancers and non-dancers. Fifty-one dancers trained in different traditional Indian and Western dance forms and 164 recreational dancers were recruited as participants. An indigenous questionnaire was designed and validated by physical therapists across various levels of experience and dancers across various training levels. The questionnaire recorded dance, pain, and injury profiles. Additionally, pain tolerance was evaluated using the Pain Sensitivity Questionnaire among dancers and healthy age- and gender-matched controls (N = 200). Descriptive statistical analysis was performed to present results of the site of current pain, site of past injury, perceived causes of injury, and exercise routine. The Student's t-test was used to compare Pain Sensitivity Questionnaire scores between dancers and non-dancers, and independent one-way ANOVA was used to compare scores among dancers practicing different dance forms. For both current pain and past injury, dancers reported the back (42.5%) followed by the knee (28.3%) and ankle (18.6%) as the most common sites. Stress was the most commonly perceived cause of injury (34.4%), followed by over work (24.7%), tiredness (17.2%), and falls (13.5%). Warm-up exercises were always performed by 43.30% of dancers, whereas only 20% performed stretching after dance. Almost 60% of dancers participated in forms of exercise other than dance, e.g., swimming, yoga, and aerobics. Pain sensitivity was not significantly different between dancers and non-dancers (p = 0.159). Level of training and gender did not influence pain.

Purpose: Physical inactivity in Indians is leading to an increase in noncommunicable disorders at an early age in life. Early identification and quantification of the lack of physical activity using simple and reliable exercise testing is the need of the hour. The incremental shuttle walk test (ISWT) is an externally paced walk test widely used for the evaluation of exercise capacity. Currently the normative values available for clinical reference are generated from Western populations. Hence, the study was conducted to find normative values for the ISWT in healthy Indian adults (17-75 years)., Materials and Methods: A convenience sample of 862 subjects was recruited after ethical approval was obtained. All subjects were divided into groups as per age and gender. For age, the grouping was as follows: Group 1: Young adulthood (17-40 years), group 2: Middle adulthood (40-65 years), and group 3: Old adulthood (>65 years). The ISWT was performed as per standard protocol by Sally Singh., Results: The average distance walked were 709.2m,556.4m and 441.3m in females and 807.9 m, 639.6 m and 478.2 m in males in the three respective age groups. Stepwise regression analysis revealed age and gender as key variables correlating with incremental shuttle walk distance (ISWD). The derived predictive equations for males and females may be given as follows: 740.351 - (5.676 × age) + (99.007 × gender)., Conclusion: Reference values were generated for healthy Indian adults. Physiological response to the ISWT was shown to be affected by gender and increasing age. Easily measurable variables explained 68% of the variance seen in the test, making the reference equation a relevant part of the evaluation of the ISWT.