Cliffton Chan

Although nasal breathing is the preferred pathway for quiet respiration, up to 30% of the population are habitual mouth breathers. This systematic review investigates the association between mouth breathing and musculoskeletal outcomes. A literature search was conducted on Medline, Embase, CINAHL, Web of Science, and Scopus from inception to August 8, 2025. Eligible studies included adults and investigated the association between chronic or induced mouth breathing (or relevant proxies such as nasal obstruction or induced nasal obstruction) and outcomes of musculoskeletal pain, temporomandibular joint dysfunction (TMD), changes in posture or muscle activity/electromyography (EMG). Outcome data were summarized using a narrative synthesis due to heterogeneity in included studies. GRADE was used to assess evidence certainty. Studies evaluated the impact of chronic mouth breathing (n = 4) or induced mouth breathing (n = 8) on posture, TMD, masticatory muscle activity, and efficiency. No study evaluated the direct relationship between chronic or induced mouth breathing and pain. Compared to nasal breathers, mouth breathers had a higher prevalence of TMD, adopted a head forward posture and increased lumbar lordosis, demonstrated reduced chewing efficiency, and had reduced masseter and temporalis, and increased suprahyoid EMG activity. Certainty of evidence was very low. This review found very low certainty evidence that chronic or induced mouth breathing may negatively impact posture, temporomandibular joint function, masticatory muscle activity, and efficiency. However, there is no data on whether there is an impact on pain. Due to the very low certainty of evidence, caution is recommended when interpreting the current literature. N/A.

Background: Feasibility and effectiveness of online pain management programs for chronic widespread pain conditions have been shown; yet, there are no empirically evaluated programs for hypermobile Ehlers–Danlos syndrome (hEDS) or hypermobility spectrum disorder (HSD). Bridging this gap, the Hypermobile Online Pain managemEnt (HOPE) program was developed with stakeholder input to be pilot tested. Methods: We conducted a randomised controlled trial of the HOPE program to assess Feasibility of Intervention Measure (FIM), Acceptability of Intervention Measure (AIM) and Intervention Appropriateness Measure (IAM) and eight clinical effectiveness outcomes. Intervention participants were given 8 weeks to complete 12 self‐paced modules, while control participants continued treatment as usual. Participants were assessed at baseline, post‐treatment and 3 months post‐treatment using online surveys. Results: Seventy‐two participants were recruited and randomised. Two control participants withdrew before starting, leaving 34 controls and 36 intervention participants for analysis. In all, 81%–91% agreed/completely agreed that the HOPE program was feasible with mean FIM score of 4.3/5 (SD 0.7), 62%–76% agreed/completely agreed that it was acceptable with mean AIM score of 3.9/5 (SD 0.96) and 67%–76% agreed/completely agreed that it was appropriate with mean IAM score of 4.0/5 (SD 0.9). Only two clinical effectiveness outcomes were significantly improved in the intervention group, with moderate and small effect sizes in worst pain intensity (Cohen's d = 0.63) and impact of hypermobility (Cohen's d = 0.32) at 3 months post‐intervention, respectively. Conclusion: The HOPE program seemed feasible, acceptable and appropriate, with preliminary improvements in worst pain intensity and impact of hypermobility. Our findings warrant a fully powered trial to further explore the clinical effectiveness of this online pain intervention. Significance Statement: Pain is of high concern among people with hypermobile Ehlers–Danlos syndrome (hEDS) or hypermobility spectrum disorder (HSD), yet there are limited online pain management resources for them. This pilot trial of the novel Hypermobile Online Pain managemEnt (HOPE) program is important in guiding the creation of evidence‐based and stakeholder‐relevant online resources. Promising results suggest the importance of further refinement and retesting its effectiveness before wider implementation among the hEDS/HSD population so as to empower them in pain self‐management.

Introduction: The Hypermobile Online Pain managemEnt (HOPE) programme is a stakeholder informed intervention adopting the biopsychosocial pain approach, specifically for people with hypermobile Ehlers–Danlos Syndrome (hEDS) and hypermobility spectrum disorder (HSD) experiencing pain. The programme topics included were based on a modified Delphi of a large sample of stakeholders: people with hEDS/HSD and healthcare practitioners who are experienced with managing these conditions. Programme feasibility, acceptability and appropriateness were previously evaluated quantitatively in a pilot randomised controlled trial, but the in‐depth experiences and perceptions of participants who engaged with the programme is unknown.Methods: Qualitative study. 1:1, semi‐structured online interviews of participants who took part in the HOPE programme. Data was analysed using an inductive thematic analysis approach as described by Braun and Clark.Results: Twelve participants were interviewed; 91% were female, mean age 38.1 (SD 9.1). Four themes emerged: (1) The biopsychosocial approach to understanding pain used in the HOPE programme was acceptable and appropriate, (2) benefits of the programme were stronger for those who were newer on their hEDS/HSD journey, (3) self‐guided reflections included in the programme required headspace and personal meaning and (4) participants desired more adaptable content and programme functionality. Additionally, participants gave suggestions on how to improve the content, adherence and engagement to the programme.Conclusion: The HOPE programme was considered feasible, acceptable and appropriate for people with hEDS/HSD. The four themes and suggestions from our study findings will be used to refine subsequent versions and large‐scale trials of the HOPE programme, as well as provide translatable insights for other online interventions for hEDS/HSD or similar complex, chronic multisystemic conditions.Patient or Public Contribution: A large community of hEDS/HSD patients' and healthcare providers' input were obtained from a two‐staged online Delphi from a prior study. This approach was preferred to capture the greatest amount of feedback from a diverse international voice. Via the Delphi study, they provided suggestions for content topics and consensus on what they felt were important to include in a hEDS/HSD specific online pain management programme, as well as programme parameters (e.g., duration and frequency of programme; healthcare provider telehealth component; types of learning activities).

Objective: Endoscopic sinus and skull base surgery has led to significant improvements in patient outcomes, yet may have come at a cost to surgeons' musculoskeletal (MSK) health. We aimed to determine the prevalence and characteristics of work‐related MSK disorders (WRMDs) in endoscopic sinus and skull base surgeons; to investigate contributing factors for WRMD in this population; and to evaluate the effectiveness of ergonomic interventions on the severity or prevalence of WRMD in this population.Data Sources: Medline, Embase, CINAHL, Web of Science, and Scopus from inception to April 2, 2024. A bibliographic examination was performed for further papers.Review Methods: Inclusion criteria included original peer‐reviewed papers with work‐related MSK outcomes (prevalence, contributing factors, and interventions) relating to endoscopic sinus and/or skull base surgeons in any language.Results: Of 25,772 unique citations, 37 studies met the inclusion criteria. The pooled lifetime, point, and 12‐month prevalences of WRMD were 75.9% (95% confidence interval; I², 67.2%‐83.6%, I² 95.6%), 80.8% (77.0%‐84.3%, I² 98.0%), and 82.0% (71.8%‐90.3%, I² 60.96%) respectively. The neck, lumbar spine, and thoracic spine were the most commonly involved areas. One of 9 studies on contributing factors investigated discomfort as an outcome. The remainder focussed on surrogate outcomes (eg, posture, hand dysfunction). Two of the 13 intervention studies investigated pain or fatigue as an outcome. The remainder targeted posture, muscle activity, or workload.Conclusion: WRMDs are highly prevalent in endoscopic sinus and skull base surgeons. Further studies focusing on the direct outcomes of WRMD such as pain are needed.

Hypermobile Ehlers-Danlos Syndrome (hEDS) and hypermobility spectrum disorder (HSD) are painful, chronic and multi-systemic conditions. No online pain management programs for hEDS/HSD currently exist. We aimed to develop one by exploring what people with hEDS/HSD want in such programs. A Delphi was conducted via online surveys of stakeholders: participants with hEDS/HSD and healthcare professionals (HCP). In survey 1, participants were asked if a hEDS/HSD-specific online pain management program was important, listing up to 20 topics important to know about pain. In survey 2, participants rated the importance of those topics. Consensus was set as ≥75% rating of at least "important". Using topics that reached consensus, the online program was developed. Usability testing was performed using the Systems Usability Scale (SUS). 396 hEDS/HSD and 29 HCP completed survey 1; 151 hEDS/HSD and 12 HCP completed survey 2. 81% of hEDS/HSD and 69% of HCP rated a hEDS/HSD-specific program as at least "important". Thirty-five topics reached consensus to guide content for the HOPE program (Hypermobile Online Pain managemEnt). SUS score was 82.5, corresponding to "high acceptability". A hEDS/HSD-specific online pain management program is important to stakeholders. Utilising a Delphi approach to incorporate stakeholder input, an evidence-informed and user appropriate program was developed.

While Chinese dance is a popular dance genre among Chinese teenagers and adults, little is known regarding the prevalence of dance-related injuries or factors associated with such injuries among Chinese dance practitioners. The current cross-sectional study aimed to determine the prevalence of dance-related injuries and their associated risk factors among young Chinese dance practitioners in Hong Kong. Online surveys were distributed to dancers through local dance associations, while paper-based surveys were distributed to young Chinese dance performers during the 54^th School Dance Festival in Hong Kong. Self-reported hours of dancing, injuries in the last 12 months, injury sites, and related factors were collected. The injury rate, 12-month prevalence of dance-related injuries were determined. Risk factors for common dance injuries were analyzed using separate multivariate regression models. A total of 175 children (aged 10–14 years) and 118 young (aged 15–24 years) Chinese dance practitioners provided their dance injury information. Young dancers had a significantly higher injury rate (6.5 injuries vs 4.6 injuries/1000 dance hours) and 12-month prevalence (52.5% vs 19.4%) than their child counterparts. The most commonly injured sites were the knee (children:7.4%; young:15.3%), lower back (children: 4.6%; young: 9.5%), and ankles (children: 5.1%; young: 16.9%). Age was a significant independent risk factor for dance-related injuries to the upper back, lower back, and pelvis/buttock (odds ratios ranging from 1.2 to 1.3/additional years). Additionally, height was a significant independent risk factor for lower limb injury (odds ratios ranging from 1.0–1.1/additional centimeter). Collectively, young Chinese dance practitioners are more vulnerable to dance-related injuries than are child dancers. Older age increases the risk of trunk injuries, whereas taller dancers are more likely to sustain lower-limb injuries. Future research should determine the mechanisms underlying dance-related injuries among these dancers.

Purpose: To establish reference ranges for four most commonly used diagnostic measures of craniocervical instability (CCI) in three cervical sagittal positions. This necessitated development of a reliable measurement protocol using upright, dynamic MRI (udMRI), to determine differences in the extent of motion between positions, and whether age and sex correlate with these measures. Materials and Methods: Deidentified udMRIs of 50 adults, referred for reasons other than CCI, were captured at three positions (maximal flexion, maximal extension and neutral). Images were analyzed, providing measures of basion-axial interval, basion-axial angle, basion-dens interval (BDI) and the Grabb–Oakes line (GOL) for all three positions (12 measures per participant). All measures were independently recorded by a radiologist and neurosurgeon to determine their reliability. Descriptive statistics, correlations, paired and independent t-tests were used. Mean (± 2 SD) identified the reference range for all four measures at each craniocervical position. Results: The revised measurement protocol produced inter-rater reliability indices of 0.69–0.97 (moderate–excellent). Fifty adults’ (50% male; mean age 41.2 years (± 9.7)) reference ranges for all twelve measures were reported. Except for the BDI and GOL when moving between neutral and full flexion, significant extents of movement were identified between the three craniocervical positions for all four measures (p ≤ 0.005). Only a minor effect of age was found. Conclusions: This is the first study to provide a rigorous standardized protocol for four diagnostic measures of CCI. Reference ranges are established at mid and ends of sagittal cervical range corresponding to where exacerbations of signs and symptoms are commonly reported.

There is exponential clinical and research interest in joint hypermobility due to recognition of the complexity of identification, assessment, and its appropriate referral pathways, ultimately impacting management. This state-of-the-science review provides an international, multidisciplinary perspective on the presentation, etiology, and assessment of joint hypermobility, as it presents in those with and without a systemic condition. We synthesize the literature, propose standardizing the use of terminology and outcome measures, and suggest potential management directions. The major topics covered are (i) historical perspectives; (ii) current definitions of hypermobility, laxity, and instability; (iii) inheritance and acquisition of hypermobility; (iv) traditional and novel assessments; (v) strengths and limitations of current assessment tools; (vi) age, sex, and racial considerations; (vii) phenotypic presentations; (viii) generalized hypermobility spectrum disorder and hypermobility Ehlers-Danlos syndrome; and (ix) clinical implications and research directions. A thorough understanding of these topics will equip the reader seeking to manage individuals presenting with joint hypermobility, while mindful of its etiology. Management of generalized joint hypermobility in the context of a complex, multisystem condition will differ from that of acquired hypermobility commonly seen in performing artists, specific athletic populations, posttrauma, and so on. In addition, people with symptomatic hypermobility present predominantly with musculoskeletal symptoms and sometimes systemic symptoms including fatigue, orthostatic intolerance, and gastrointestinal or genitourinary issues. Some also display skeletal deformities, tissue and skin fragility, and structural vascular or cardiac differences, and these warrant further medical follow-up. This comprehensive review on the full spectrum of joint hypermobility will assist clinicians, coaches/sports trainers, educators, and/or researchers in this area.