Dear Editor
Iam writing to highlight the need for consensus-based guidelines addressing mpox (formerly known as monkeypox) in the field of physiotherapy. The recent declaration of a public health emergency by the World Health Organization (WHO) due to the rapid spread of mpox [1] emphasizes the necessity for clear protocols to protect patients and healthcare providers.
Mpox, caused by the monkeypox virus, was declared a public health emergency of international concern on 14th August 2024 by the WHO because the virus strain rapidly spread following its emergence in the Democratic Republic of Congo in 2023, with more than 15000 cases and more than 530 deaths by August 2024 [1]. The virus is transmitted through direct contact with infected individuals or contaminated materials. Examples of person-to-person transmission include direct contact, such as touching and prolonged face-to-face contact. Occupational exposure has also been reported. Health workers are at risk of transmission through needlestick injuries or contact with contaminated gloves [2]. Pregnant persons passing the virus to their unborn babies constitute another example [3]. Indirect transmission can occur through fomites, such as clothing and linen contaminated with lesion crusts or bodily fluids [4, 5], posing significant risks to physiotherapists who engage in close physical contact during treatment. According to reports, several systems are affected, including the cardiopulmonary, neurological, and renal systems [6]. In rare cases, cardiovascular complications may lead to life-threatening arrhythmias, dilated cardiomyopathy, and cardiogenic shock. As in other viral cases, mpox-induced myocarditis or pericarditis may occur. Chest pain, dyspnoea, palpitations, and exercise intolerance are frequently observed [7]. Gastrointestinal symptoms often affect paediatric population, [7] with vomiting, nausea, diarrhoea, abdominal pain, and anorexia being the most commonly occurring symptoms [8]. Nonspecific neurological features present as muscle pain, headache, lethargy, and fatigue [9].
The hands-on nature of physiotherapy raises critical questions about how to maintain high-quality care while ensuring safety for both practitioners and patients. Despite the growing concerns surrounding mpox, there is a notable absence of specific guidelines for physiotherapy practice. This gap poses a risk to patient care quality and safety. The underlying question is whether it is necessary to establish specific evidence-based guidelines, such as telehealth integration, to support physiotherapists in delivering care, rather than relying solely on reasonable clinical thinking as long as positive results are observed. I propose that we develop comprehensive guidelines that encompass [1] infection control protocols, [2] telehealth integration, [3] ongoing education and [4] management strategies. It is also vital for physiotherapists working in sports settings to implement preventive measures. This includes educating athletes about hygiene practices and recognizing early signs of infection.
The stigma surrounding mpox can hinder effective patient-provider interactions. Physiotherapists must communicate sensitively about the condition while providing reassurance regarding confidentiality and support. 
The urgency of addressing mpox within physiotherapy is paramount. By establishing evidence-based guidelines that prioritize patient safety and quality of care, we can better equip physiotherapists to manage this public health challenge effectively. Collaboration between physiotherapy professionals and public health authorities is essential in shaping these interventions. Furthermore, integrating research findings into practice will enhance the ability of physiotherapists to respond to the evolving nature of mpox, ensuring that care is both informed and responsive to the needs of patients. This proactive approach will not only improve treatment outcomes but also foster greater confidence among patients in the safety and effectiveness of physiotherapy interventions during this public health challenge


References

1. CDC Newsroom. Fact sheet: United States response to the clade i mpox outbreak in several African countries [Internet]. 2024 [Updated 2024 August 25]. Available from: [Link]
2. Migaud P, Hosmann K, Drauz D, Mueller M, Haumann J, Stocker H. A case of occupational transmission of mpox. Infection. 2023; 51(4):1169-73. [DOI:10.1007/s15010-023-01989-x]
3. World Health Organization (WHO). Mpox [Internet]. 2023 [Updated 2024 August 25]. Available from: [Link]
4. Tesini BL. Mpox (Monkeypox) [Internet]. 2023 [Updated 2024 August 25]. Available from: [Link]
5. Jarrell L, Perryman K. Mpox (monkeypox): Diagnosis, prevention, and management in adults. The Nurse Practitioner. 2023; 48(4):13-20. [DOI:10.1097/01.NPR.0000000000000025]
6. Reda A, Dhama K. Mpox impact on different organ systems: Complications, mechanisms, and management. Reviews in Medical Virology. 2023; 33(4):e2443. [DOI:10.1002/rmv.2443]
7. Ajmera K, Shah H, Chourasia P, Chitturi S. Current evidence and practice guidelines of systemic complications of 2022 mpox outbreak: A scoping review. Cureus. 2023; 15(9):e45754. [DOI:10.7759/cureus.45754]
8. Simadibrata DM, Lesmana E, Pratama MA, Annisa NG, Thenedi K, Simadibrata M. Gastrointestinal symptoms of monkeypox infection: A systematic review and meta-analysis. Journal of Medical Virology. 2023; 95(4):e28709. [DOI:10.1002/jmv.28709]
9. Badenoch JB, Conti I, Rengasamy ER, Watson CJ, Butler M, Hussain Z, et al. Neurological and psychiatric presentations associated with human monkeypox virus infection: A systematic review and meta-analysis. EClinicalMedicine. 2022; 52:101644. [DOI:10.1016/j.eclinm.2022.101644]