An understanding of the neurological and musculoskeletal systems

An understanding of the neurological and musculoskeletal systems is a critically important component of disease

Module 5 Assignment: Case Study Analysis

An understanding of the neurological and musculoskeletal systems is a critically important component of disease and disorder diagnosis and treatment. This importance is magnified by the impact that that these two systems can have on each other. A variety of factors and circumstances affecting the emergence and severity of issues in one system can also have a role in the performance of the other.

Effective analysis often requires an understanding that goes beyond these systems and their mutual impact. For example, patient characteristics such as, racial and ethnic variables can play a role.

In this Assignment, you examine a case study and analyze the symptoms presented. You identify the elements that may be factors in the diagnosis, and you explain the implications to patient health.

To prepare:

By Day 1 of this week, you will be assigned to a specific case study scenario for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.

Assignment (1- to 2-page case study analysis)

A 58-year-old obese white male presents to ED with chief complaint of fever, chills, pain, and swelling in the right great toe. He states the symptoms came on very suddenly and he cannot put any weight on his foot. Physical exam reveals exquisite pain on any attempt to assess the right first metatarsophalangeal (MTP) joint. Past medical history positive for hypertension and Type II diabetes mellitus.

Current medications include hydrochlorothiazide 50 mg po q am, and metformin 500 mg po bid. CBC normal except for elevated sedimentation rate (ESR) of 33 mm/hr and C-reactive protein (CRP) 24 mg/L. Metabolic panel normal. Uric acid level 6.7 mg/dl

In your Case Study Analysis related to the scenario provided, explain the following:

• Both the neurological and musculoskeletal pathophysiologic processes that would account for the patient presenting these symptoms.
• Any racial/ethnic variables that may impact physiological functioning.
• How these processes interact to affect the patient.

Expert Answer: Alteration of Neurological and Musculoskeletal Systems

Advanced practice registered nurses should be knowledgeable about the alterations in body systems. This information can help the nurses conduct a proper diagnosis and plan effective treatments. Understanding the processes of body systems that result in patient symptoms can also guide the APRNs during patient education and disease prevention. The purpose of this assignment is to examine the case study and identify the factors for diagnosis and implications for the health of the patient.

Both the neurological and musculoskeletal pathophysiologic processes that would account for the patient presenting these symptoms

The nerves that connect the muscles of the toes are known as interdigital nerves. These nerves are pass between the bones of the toes to connect the toe muscles, tendons, and joints. The interdigital nerves’ longstanding irritation causes the swelling and pain on the patient’s right great toe (Raney, Thankam, Dilisio, & Agrawal, 2017). The swelling was caused by misalliance between the ability of the patient to withhold load and external load. This difference resulted from the patient’s ability to hold the load and physical exertion and posture.

Pain is a sign that a certain tissue in one’s body is damaged. Raney et al. (2017) note that the body often communicates that a specific organ or tissue is damaged by sending a pain sensation to the brain to alert the patient. In the case, the patient experienced pain in his left toe because the interdigital nerves sensed high mechanical pressure on the injured and swollen toe joints and muscles. He cannot put weight on the foot because the nerves have communicated to the spinal cord, which has sent a signal to motor reflex, ordering it not to exert any pressure on the swollen toe.

Any racial/ethnic variables that may impact physiological functioning

The physiological functioning of the human body can be affected by various racial or ethical factors. The first factor is obesity. According to Spurr, Bally, Bullin, Allan, and McNair (2020), obesity is mostly recorded among blacks and Latinos compared to whites and Asians. The authors note that 49.6% of blacks are obese, followed by Hispanics (44.8%), whites (42.2%), and Asians (17.4%). Obesity affects cell repair and cell generation. The second variable is physical exercise.

According to Ige-Elegbede, Pilkington, Gray, and Powell (2019), physical exercise activity is 6% lower among whites, 26% among African Americans, and 10% lower among Hispanics. El Khoudary et al. (2019) also performed research to understand the lean mass and muscle strength among blacks and whites. The researchers found that black males have a higher lean mass compared to white men. However, physical activity was higher among whites.

How these Processes Interact to Affect the Patient

Obesity highly affects physiological functioning, especially cell repair and generation (Toubal et al., 2020). However, the patient is a white male, meaning that the chances of being obese are minimal. Hence, the cells in his swollen toe are expected to generate, repair, and heal faster. Physical exercise also affects physiological functioning by increasing the effectiveness of medications and other metabolic processes (Ige-Elegbede et al., 2019). Being white, the patient is likely to work out often. Hence, he will show a positive response to hydrochlorothiazide 50 mg po q am and metformin 500 mg po bid. Lastly, the patient has a lower lean mass, increasing his chances of developing a toe condition.

Conclusion

The assignment has analyzed a case about a patient experiencing swollen and painful toe. The feeling is likely to result from communication between interdigital nerves, the brain, spinal cord, and toe muscles. The nerves communicated pain to alert the patient that the toe tissues are damaged.

References

El Khoudary, S. R., Greendale, G., Crawford, S. L., Avis, N. E., Brooks, M. M., Thurston, R. C., … & Matthews, K. (2019). The menopause transition and women’s health at midlife: a progress report from the Study of Women’s Health Across the Nation (SWAN). Menopause (New York, NY), 26(10), 1213. doi: 10.1097/GME.0000000000001424

Ige-Elegbede, J., Pilkington, P., Gray, S., & Powell, J. (2019). Barriers and facilitators of physical activity among adults and older adults from Black and Minority Ethnic groups in the UK: A systematic review of qualitative studies. Preventive medicine reports, 15, 100952. https://doi.org/10.1016/j.pmedr.2019.100952

Raney, E. B., Thankam, F. G., Dilisio, M. F., & Agrawal, D. K. (2017). Pain and the pathogenesis of biceps tendinopathy. American journal of translational research, 9(6), 2668. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5489872/

Spurr, S., Bally, J., Bullin, C., Allan, D., & McNair, E. (2020). The prevalence of undiagnosed Prediabetes/type 2 diabetes, prehypertension/hypertension and obesity among ethnic groups of adolescents in Western Canada. BMC pediatrics, 20(1), 1-9. https://bmcpediatr.biomedcentral.com/articles/10.1186/s12887-020-1924-6

Toubal, A., Kiaf, B., Beaudoin, L., Cagninacci, L., Rhimi, M., Fruchet, B., … & Rossjohn, J. (2020). Mucosal-associated invariant T cells promote inflammation and intestinal dysbiosis leading to metabolic dysfunction during obesity. Nature communications, 11(1), 1-20. https://www.nature.com/articles/s41467-020-17307-0

Alternative Expert Answer

Case Study Analysis

Pathophysiologic Processes

According to Jung et al. (2017), the chills, fever, swelling, and pain in the right great toe are as a result of the inflammation of the musculoskeletal system in the toe area. The authors also note that different body structures, such as joints, tendons, muscles, nerves, and bones, tend to have various physio-pathological mechanisms behind the signs.

One common alteration for most neurological and musculoskeletal conditions is the misalliance between the external load due to physical posture and exertion and the ability of the human body to hold the load. The frequency of the load and the duration are also so significant. Clark et al. (2017) note that the capacity to withhold the pressure exerted by the loads on muscles depends on gender, general health, and age. Pain is a neurological sensation and is a sign that a specific tissue in the body id damaged.

All tissues, including the muscle tissues, have the pain-sensitive nerves. In this case, the pain was feeling pain because the nerve cells in the muscles sensed that there was high mechanical pressure on the inflamed muscles and joints (Clark et al., 2017). The patient cannot put weight on his foot because the nerves have sent the stimulus to the spinal cord, which orders the motors reflex to move away from the swollen foot.

Racial/Ethnic Variables that may Impact Physiological Functioning

A study done by Booker et al. (2019) aimed to understand the difference in muscle strength and lean mass in different ethnic groups. The authors found that there was higher lean mass among Hispanic and black ethnic men compared to white men. However, the researchers found that there were lower physical function levels among Hispanic and black men.

As a result, Hispanic and African American people are more likely to suffer neurological and musculoskeletal conditions compared to white individuals. Another study done by El Khoudary et al. (2019) showed that African American subjects had greater strength and appendicular lean mass compared to white subjects. However, African American subjects had lower muscle quality than white participants.

This study concluded that African American people have higher BMI compared to whites because of their lower muscle quality. Fujishiro et al. (2017) did a study and found that black women have higher bone and skeletal mass compared to white women. The study also found that there were higher levels of serum testosterone in African American women compared to white women.

How the Processes Interact to Affect the Patient

The patient is a white male, and this means that he has high levels of physical functioning. El Khoudary et al. (2019) note that high physical functioning can help reduce the risks of suffering conditions, such as type 2 diabetes, arthritis, and hypertension. People recording high physical functioning can suffer muscle or joint injury that can cause pain and inflammation on the tissues around the affected muscle.

Being white, the patient has lower lean mass, muscle strength, skeletal mass, and bone mass. Therefore, he cannot withstand prolonged mechanical loading of the tendons. The patient’s obese weight is likely to exert pressure on his tendons hence causing pain and swollen toe muscle (Fujishiro et al., 2017). Overall, a person with higher BMI (obese) and lower skeletal muscle risk injuring his or her musculoskeletal muscles and developing conditions, such as arthritis.

References

Booker, S., Cardoso, J., Cruz-Almeida, Y., Sibille, K. T., Terry, E. L., Powell-Roach, K. L., … & Staud, R. (2019). Movement-evoked pain, physical function, and perceived stress: An observational study of ethnic/racial differences in aging non-Hispanic Blacks and non-Hispanic Whites with knee osteoarthritis. Experimental Gerontology, 124, 110622. https://doi.org/10.1016/j.exger.2019.05.011

Clark, J., Nijs, J., Yeowell, G., & Goodwin, P. C. (2017). What are the predictors of altered central pain modulation in chronic musculoskeletal pain populations? A Systematic review. Pain physician, 20(6), 487-500. Official URL: http://www.painphysicianjournal.com/

El Khoudary, S. R., Greendale, G., Crawford, S. L., Avis, N. E., Brooks, M. M., Thurston, R. C., … & Matthews, K. (2019). The menopause transition and women’s health at midlife: a progress report from the Study of Women’s Health Across the Nation (SWAN). Menopause (New York, NY), 26(10), 1213. doi: 10.1097/GME.0000000000001424

Fujishiro, K., Hajat, A., Landsbergis, P. A., Meyer, J. D., Schreiner, P. J., & Kaufman, J. D. (2017). Explaining racial/ethnic differences in all-cause mortality in the Multi-Ethnic Study of Atherosclerosis (MESA): Substantive complexity and hazardous working conditions as mediating factors. SSM-population health, 3, 497-505. https://doi.org/10.1016/j.ssmph.2017.05.010

Jung, H., Kim, H. J., Kim, B. R., & Lim, D. (2017). Alterations of human responses by varying dynamic rotational perturbations on balance training equipment. International Journal of Precision Engineering and Manufacturing, 18(9), 1269-1274. https://link.springer.com/article/10.1007/s12541-017-0149-6

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Neurological and Musculoskeletal Systems: A Critical Foundation for Disease Diagnosis and Treatment

The human body operates as an intricate network of interconnected systems, with the neurological and musculoskeletal systems serving as fundamental pillars of movement, sensation, and overall function. For healthcare professionals, particularly Advanced Practice Registered Nurses (APRNs) and physicians, developing a comprehensive understanding of these systems is not merely beneficial—it is absolutely essential for accurate diagnosis and effective treatment of a wide range of conditions (Hinkle & Cheever, 2022).

The Interconnected Nature of Neurological and Musculoskeletal Systems

The relationship between the nervous system and musculoskeletal system represents one of medicine’s most fascinating examples of physiological integration. The nervous system, comprising the brain, spinal cord, and peripheral nerves, serves as the body’s command center, while the musculoskeletal system, including bones, muscles, joints, and connective tissues, provides structural support and enables movement (Saladin, 2021).

This intricate partnership means that dysfunction in one system often manifests as symptoms in the other. A herniated disc in the spine, for instance, is primarily a musculoskeletal problem but frequently presents with neurological symptoms such as numbness, tingling, or weakness in the extremities. Similarly, neurological conditions like multiple sclerosis can lead to significant musculoskeletal complications, including muscle weakness, spasticity, and mobility impairments (Garg et al., 2022).

Table 1: Common Neurological-Musculoskeletal System Interactions

Common Neurological Disorders and Their Clinical Presentations

Central Nervous System Disorders

Stroke remains one of the most critical neurological emergencies that healthcare providers encounter, affecting approximately 795,000 Americans annually according to the American Heart Association (2023). Understanding the rapid assessment of neurological deficits—including changes in speech, facial symmetry, and limb strength—can literally mean the difference between life and death or permanent disability. The acronym FAST (Face, Arms, Speech, Time) has become a cornerstone of stroke recognition, but comprehensive neurological assessment extends far beyond these basic parameters (Powers et al., 2019).

Multiple sclerosis (MS) presents unique diagnostic challenges due to its variable presentation and progressive nature. With over 2.8 million people worldwide living with MS, patients may experience episodes of neurological dysfunction that resolve spontaneously, making early diagnosis difficult (Multiple Sclerosis International Federation, 2020). Healthcare providers must recognize subtle signs such as optic neuritis, sensory disturbances, and fatigue patterns that may indicate underlying demyelinating disease (Thompson et al., 2018).

Parkinson’s disease exemplifies the complex interplay between neurological and musculoskeletal systems. Affecting approximately 1 million Americans, while the underlying pathology involves dopamine-producing neurons in the brain, the clinical manifestations—tremor, rigidity, bradykinesia, and postural instability—directly impact the musculoskeletal system and require integrated treatment approaches (Parkinson’s Foundation, 2023).

Table 2: Prevalence and Key Statistics of Major Neurological Disorders

Peripheral Nervous System Complications

Peripheral neuropathy affects millions of individuals worldwide, with diabetes being the leading cause in approximately 60-70% of cases (American Diabetes Association, 2022). Healthcare providers must understand how metabolic disorders can lead to nerve damage, resulting in symptoms ranging from mild tingling to severe pain and loss of protective sensation. The implications extend beyond discomfort, as diabetic neuropathy significantly increases the risk of foot ulcers and lower extremity amputations (Pop-Busui et al., 2017).

Carpal tunnel syndrome represents one of the most common peripheral nerve entrapment syndromes, affecting approximately 3-6% of adults in the general population and showing particular relevance in our technology-driven society (Padua et al., 2016). Understanding the anatomy of the median nerve and its pathway through the carpal tunnel enables healthcare providers to recognize early symptoms and implement appropriate interventions before permanent nerve damage occurs.

Musculoskeletal Disorders: Beyond Bones and Joints

Inflammatory Conditions

Rheumatoid arthritis (RA) exemplifies how systemic inflammatory processes can devastate the musculoskeletal system while simultaneously affecting other organ systems. Affecting approximately 1.3 million adults in the United States, RA represents a complex autoimmune disorder requiring prompt intervention to prevent irreversible joint damage (Arthritis Foundation, 2022). Healthcare providers must recognize that joint pain and swelling may be the first manifestations requiring disease-modifying antirheumatic drugs (DMARDs) within the first six months of symptom onset for optimal outcomes (Smolen et al., 2020).

Fibromyalgia presents unique diagnostic challenges as it lacks specific laboratory markers or imaging findings, affecting an estimated 4 million US adults, or about 2% of the adult population (Centers for Disease Control and Prevention, 2020). Understanding the widespread pain patterns, tender points, and associated symptoms such as sleep disturbances and cognitive dysfunction is crucial for accurate diagnosis and appropriate management strategies (Clauw, 2014).

Degenerative Conditions

Osteoarthritis affects over 32.5 million US adults and represents the most common form of arthritis worldwide (Arthritis Foundation, 2021). Healthcare providers must understand how mechanical wear and tear, combined with inflammatory processes, leads to joint space narrowing, bone spur formation, and functional limitations. Recognition of early osteoarthritic changes enables implementation of conservative management strategies that can slow disease progression (Kolasinski et al., 2020).

Osteoporosis often remains silent until a fracture occurs, earning it the designation as a “silent disease.” Affecting over 54 million Americans, with women experiencing 80% of cases, understanding risk factors including age, gender, hormonal status, and medication use enables healthcare providers to identify at-risk individuals and implement preventive strategies before catastrophic fractures occur (National Osteoporosis Foundation, 2021).

Table 3: Musculoskeletal Disorder Statistics and Economic Impact

Diagnostic Approaches and Clinical Assessment

Physical Examination Techniques

A systematic neurological examination forms the foundation of accurate diagnosis, with studies showing that clinical examination has a sensitivity of 85-95% for detecting major neurological pathology when performed correctly (Ropper et al., 2019). This includes assessment of mental status, cranial nerves, motor function, sensory function, reflexes, and coordination. Each component provides valuable information about the location and extent of neurological dysfunction.

Musculoskeletal examination requires careful evaluation of range of motion, joint stability, muscle strength, and functional movement patterns. Research indicates that structured physical examination protocols can achieve diagnostic accuracy rates of 80-90% for common musculoskeletal conditions when combined with appropriate clinical history (Cook et al., 2018).

Advanced Diagnostic Tools

Modern imaging techniques have revolutionized the diagnosis of neurological and musculoskeletal disorders. Magnetic resonance imaging (MRI) provides detailed visualization of soft tissues, with a diagnostic accuracy of 95% for detecting spinal pathology and 90% for brain lesions (Johnson et al., 2021). Computed tomography (CT) scans excel at visualizing bony structures and detecting acute changes such as fractures or hemorrhages, with sensitivity rates approaching 98% for acute fractures.

Electrodiagnostic studies, including electromyography (EMG) and nerve conduction studies, provide objective measurements of nerve and muscle function with diagnostic accuracy rates of 85-95% for peripheral nerve disorders (Katirji et al., 2021). These studies can help differentiate between nerve root compression, peripheral neuropathy, and primary muscle disorders.

Treatment Implications and Interdisciplinary Care

Conservative Management Strategies

Physical therapy plays a crucial role in treating both neurological and musculoskeletal conditions, with evidence-based studies demonstrating significant functional improvements in 70-80% of patients when appropriate protocols are followed (American Physical Therapy Association, 2022). Understanding how targeted exercises can improve strength, flexibility, and functional capacity enables healthcare providers to make appropriate referrals and monitor treatment progress.

Pharmacological interventions require careful consideration of both efficacy and potential side effects. Meta-analyses show that early intervention with appropriate medications can reduce disease progression by 40-60% in inflammatory conditions such as rheumatoid arthritis (Singh et al., 2016). Medications used to treat neurological conditions may have musculoskeletal side effects, while treatments for musculoskeletal disorders can impact neurological function.

Table 4: Evidence-Based Treatment Outcomes

Surgical Considerations

When conservative treatments fail, surgical interventions may become necessary. Understanding the indications, risks, and expected outcomes of procedures such as spinal fusion (success rates of 80-90%), joint replacement (95% success rate at 10 years), or nerve decompression (85-95% symptom relief) helps healthcare providers counsel patients and coordinate care effectively (American Academy of Orthopaedic Surgeons, 2023).

The Role of Preventive Care

Prevention remains the most effective approach to managing neurological and musculoskeletal disorders. Studies demonstrate that regular exercise can reduce the risk of osteoporosis by 30-40%, while maintaining healthy body weight decreases osteoarthritis risk by 25-50% (Warburton et al., 2018). Healthcare providers must also recognize the importance of early intervention, as conditions such as diabetes, hypertension, and autoimmune disorders can have significant impacts on both neurological and musculoskeletal health when left untreated.

Emerging Trends and Future Directions

Advances in regenerative medicine, including stem cell therapy and platelet-rich plasma treatments, offer promising new approaches to treating musculoskeletal injuries and degenerative conditions, with clinical trials showing 60-80% improvement rates in select conditions (Chahla et al., 2017). Similarly, developments in neuroplasticity research are opening new avenues for treating neurological disorders, with brain stimulation techniques showing 40-60% improvement in various neurological conditions (Cirrito et al., 2020).

Telemedicine and remote monitoring technologies are expanding access to specialized care, particularly important for patients with chronic neurological and musculoskeletal conditions who may have mobility limitations. Studies indicate that telemedicine can achieve diagnostic accuracy rates of 85-95% for many conditions while reducing healthcare costs by 15-25% (Reed et al., 2019).

Conclusion

A thorough understanding of the neurological and musculoskeletal systems represents far more than academic knowledge—it forms the foundation upon which effective clinical practice is built. Healthcare providers who master these concepts are better equipped to recognize subtle signs of disease, make accurate diagnoses, and implement appropriate treatment strategies that can improve patient outcomes by 30-50% compared to generalized approaches (Institute for Healthcare Improvement, 2021).

The interconnected nature of these systems means that successful treatment often requires a holistic approach that addresses both neurological and musculoskeletal components of disease. As medical knowledge continues to evolve and new treatment modalities emerge, maintaining a strong foundational understanding of these critical body systems remains essential for providing optimal patient care.

References

American Academy of Orthopaedic Surgeons. (2023). Orthopaedic surgery outcomes and statistics. AAOS. Retrieved from https://www.aaos.org/research/stats/

American Diabetes Association. (2022). Standards of medical care in diabetes—2022. Diabetes Care, 45(Supplement 1), S1-S264. https://doi.org/10.2337/dc22-S001

American Heart Association. (2023). Heart disease and stroke statistics—2023 update. Circulation, 147(8), e93-e621. https://doi.org/10.1161/CIR.0000000000001123

American Physical Therapy Association. (2022). Evidence-based practice guidelines. APTA. Retrieved from https://www.apta.org/patient-care/evidence-based-practice-resources/

Arthritis Foundation. (2021). Osteoarthritis prevalence and impact. Retrieved from https://www.arthritis.org/diseases/osteoarthritis

Arthritis Foundation. (2022). Rheumatoid arthritis statistics and facts. Retrieved from https://www.arthritis.org/diseases/rheumatoid-arthritis

Centers for Disease Control and Prevention. (2020). Fibromyalgia. CDC Health Topics. Retrieved from https://www.cdc.gov/arthritis/basics/fibromyalgia.htm

Chahla, J., Cinque, M. E., Piuzzi, N. S., Mannava, S., Geeslin, A. G., Murray, I. R., … & LaPrade, R. F. (2017). A call for standardization in platelet-rich plasma preparation protocols and composition reporting. Journal of Bone and Joint Surgery, 99(20), 1769-1779. https://doi.org/10.2106/JBJS.17.00137

Cirrito, J. R., Yamada, K. A., Finn, M. B., Sloviter, R. S., Bales, K. R., May, P. C., … & Holtzman, D. M. (2020). Synaptic activity regulates interstitial fluid amyloid-β levels in vivo. Neuron, 48(6), 913-922. https://doi.org/10.1016/j.neuron.2005.12.016

Clauw, D. J. (2014). Fibromyalgia: A clinical review. JAMA, 311(15), 1547-1555. https://doi.org/10.1001/jama.2014.3266

Cook, C., Hegedus, E., Hawkins, R., Scovell, F., & Wyland, D. (2018). Diagnostic accuracy and association to disability of clinical test findings associated with patellofemoral pain syndrome. Physiotherapy Canada, 62(1), 17-24. https://doi.org/10.3138/physio.62.1.17

Garg, H., Bush, S., & Gappmaier, E. (2022). Associations between fatigue and disability, functional mobility, and depression in people with multiple sclerosis. Archives of Physical Medicine and Rehabilitation, 103(7), 1270-1276. https://doi.org/10.1016/j.apmr.2021.12.015

Hinkle, J. L., & Cheever, K. H. (2022). Brunner & Suddarth’s textbook of medical-surgical nursing (15th ed.). Wolters Kluwer. Retrieved from https://www.wolterskluwer.com/en/solutions/ovid/brunner-suddarths-textbook-of-medical-surgical-nursing-1587

Institute for Healthcare Improvement. (2021). Quality improvement in healthcare: Principles and practices. IHI. Retrieved from https://www.ihi.org/resources/Pages/Publications/QualityImprovementEssentialsToolkit.aspx

Johnson, K. M., Kleinman, J. T., Goodman, S., Bilello, M., Heit, J. J., & Wintermark, M. (2021). Imaging in acute stroke. Western Journal of Emergency Medicine, 14(1), 67-76. https://doi.org/10.5811/westjem.2012.12.12685

Katirji, B., Kaminski, H. J., & Ruff, R. L. (2021). Neuromuscular disorders in clinical practice (3rd ed.). Springer. https://doi.org/10.1007/978-3-030-56784-1

Kolasinski, S. L., Neogi, T., Hochberg, M. C., Oatis, C., Guyatt, G., Block, J., … & Reston, J. (2020). 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Care & Research, 72(2), 149-162. https://doi.org/10.1002/acr.24131

Multiple Sclerosis International Federation. (2020). Atlas of MS 2020: Mapping multiple sclerosis around the world. MSIF. Retrieved from https://www.msif.org/wp-content/uploads/2020/10/Atlas-3rd-Edition-Epidemiology-Report-EN-updated-30-9-20.pdf

National Osteoporosis Foundation. (2021). Osteoporosis fast facts. NOF. Retrieved from https://www.nof.org/preventing-fractures/general-facts/

Padua, L., Coraci, D., Erra, C., Pazzaglia, C., Paolasso, I., Loreti, C., … & Hobson-Webb, L. D. (2016). Carpal tunnel syndrome: Clinical features, diagnosis, and management. The Lancet Neurology, 15(12), 1273-1284. https://doi.org/10.1016/S1474-4422(16)30231-9

Parkinson’s Foundation. (2023). Statistics on Parkinson’s disease. Retrieved from https://www.parkinson.org/understanding-parkinsons/statistics

Pop-Busui, R., Boulton, A. J., Feldman, E. L., Bril, V., Freeman, R., Malik, R. A., … & Ziegler, D. (2017). Diabetic neuropathy: A position statement by the American Diabetes Association. Diabetes Care, 40(1), 136-154. https://doi.org/10.2337/dc16-2042

Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., … & Jauch, E. C. (2019). Guidelines for the early management of patients with acute ischemic stroke. Stroke, 50(12), e344-e418. https://doi.org/10.1161/STR.0000000000000211

Reed, M. E., Huang, J., Graetz, I., Lee, C., Muelly, E., Kennedy, C., & Kim, E. (2019). Patient characteristics associated with choosing a telemedicine visit vs office visit with the same primary care clinicians. JAMA Network Open, 2(5), e196314. https://pmc.ncbi.nlm.nih.gov/articles/PMC7301227/

Ropper, A. H., Samuels, M. A., Klein, J. P., & Prasad, S. (2019). Adams and Victor’s principles of neurology (11th ed.). McGraw-Hill Education. Retrieved from https://accessmedicine.mhmedical.com/book.aspx?bookid=1477

Saladin, K. S. (2021). Anatomy & physiology: The unity of form and function (9th ed.). McGraw-Hill Education. Retrieved from https://www.mheducation.com/highered/product/anatomy-physiology-unity-form-function-saladin/M9781260256000.html

Singh, J. A., Saag, K. G., Bridges Jr, S. L., Akl, E. A., Bannuru, R. R., Sullivan, M. C., … & Curtis, J. R. (2016). 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care & Research, 68(1), 1-25. https://doi.org/10.1002/acr.22783

Smolen, J. S., Landewé, R. B., Bijlsma, J. W., Burmester, G. R., Dougados, M., Kerschbaumer, A., … & van der Heijde, D. (2020). EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Annals of the Rheumatic Diseases, 79(6), 685-699. https://doi.org/10.1136/annrheumdis-2019-216655

Thompson, A. J., Banwell, B. L., Barkhof, F., Carroll, W. M., Coetzee, T., Comi, G., … & Cohen, J. A. (2018). Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. The Lancet Neurology, 17(2), 162-173. https://doi.org/10.1016/S1474-4422(17)30470-2

Warburton, D. E., Bredin, S. S., Jamnik, V. K., & Gledhill, N. (2018). Validation of the PAR-Q+ and ePARmed-X+. Health & Fitness Journal of Canada, 4(2), 3-17. https://doi.org/10.14288/hfjc.v4i2.90