Medicinal plants in homegardens of four ethnic groups in Thailand

Medicinal plants used for cutaneous wound healing in Uganda; ethnomedicinal reports and pharmacological evidences

Background

Wounds have become a major health challenge worldwide, presenting marked humanistic and economic burdens such as disabilities and death. Annually, approximately 14 million people suffer from wounds worldwide and 80 % of these occur in developing countries like Uganda. In Uganda, besides many cases of daily wound occurrences, approximately 10 % of surgical procedures become septic wounds and consequently lead to increased morbidity and mortality. Accordingly, several ethnomedicinal studies have identified plants used for wound treatment in different parts of Uganda and the wound healing activities of some plants have been reported. However, at present, these information remain largely separated without an all-inclusive repository containing ethnomedicinal and pharmacological information of the plants used for wound healing in Uganda, thus retarding appropriate evaluation. Therefore, this review focused on extensively exploring the plants used for treating cutaneous wounds in Uganda, along with associated ethnomedicinal information and their globally reported pharmacological potential.

Methods

Electronic data bases including Google Scholar, PubMed, and Science Direct were searched using key terms for required information contained in English peer reviewed articles, books, and dissertations. Additionally, correlations between selected parameters were determined with coefficient of determination (r2).

Results

The literature survey revealed that 165 species belonging to 62 families are traditionally used to treat wounds in Uganda. Most of the species belonged to families of Asteraceae (14 %), Fabaceae (10 %), and Euphorbiaceae (7 %). The commonest plant parts used for wound treatment include leaf (48 %), root (22 %), stembark (11 %), and stem (7 %), which are prepared majorly by poultice (34 %), decoction (13 %), as well as powdering (25 %). Fifty-four (33 %) of the plant species have been investigated for their wound healing activities whereas, one hundred eleven (67 %) have not been scientifically investigated for their wound healing effects. Pearson correlation coefficient between the number of wound healing plant families per part used and percent of each plant part used was 0.97, and between the number of wound healing plant families per method of preparation and percent of each method of preparation was 0.95, showing in both strong positively marked relationships.

Conclusion

The preliminarily investigated plants with positive wound healing properties require further evaluation to possible final phases, with comprehensive identification of constituent bioactive agents. Additionally, the wound healing potential of the scientifically uninvestigated plants with claimed healing effects needs examination. Subsequently, information regarding efficacy, safety, bioactive principles, and mechanism of action could prove valuable in future development of wound healing therapies.

Bioactive Compounds Formulated in Phytosomes Administered as Complementary Therapy for Metabolic Disorders

Metabolic disorders (MDs), including dyslipidemia, non-alcoholic fatty liver disease, diabetes mellitus, obesity and cardiovascular diseases are a significant threat to human health, despite the many therapies developed for their treatment. Different classes of bioactive compounds, such as polyphenols, flavonoids, alkaloids, and triterpenes have shown therapeutic potential in ameliorating various disorders. Most of these compounds present low bioavailability when administered orally, being rapidly metabolized in the digestive tract and liver which makes their metabolites less effective. Moreover, some of the bioactive compounds cannot fully exert their beneficial properties due to the low solubility and complex chemical structure which impede the passive diffusion through the intestinal cell membranes. To overcome these limitations, an innovative delivery system of phytosomes was developed. This review aims to highlight the scientific evidence proving the enhanced therapeutic benefits of the bioactive compounds formulated in phytosomes compared to the free compounds. The existing knowledge concerning the phytosomes' preparation, their characterization and bioavailability as well as the commercially available phytosomes with therapeutic potential to alleviate MDs are concisely depicted. This review brings arguments to encourage the use of phytosome formulation to diminish risk factors inducing MDs, or to treat the already installed diseases as complementary therapy to allopathic medication.

Local knowledge of homegarden plants in Miao ethnic communities in Laershan region, Xiangxi area, China

BACKGROUND

Homegardens are small-scale land use systems with significant implications for local livelihoods, biodiversity conservation, and sustainable development due to their diverse flora and fauna. Conducting homegarden surveys enables researchers to gain insights into the traditional ecological knowledge of indigenous communities, preserve homegarden biodiversity, and promote sustainable livelihoods. This study has two objectives: first, to collect, record, and organize data on homegarden plants and related traditional knowledge from three communities in the Laershan Plateau, and second, to analyze the species and functional diversity of homegarden plants in the region while exploring the factors that contribute to the heterogeneous distribution of these plants among the communities of three townships.

METHODS

This research employed field surveys in the Laershan Miao Autonomous Region in Xiangxi, China, from September 2021 to August 2023. Data were collected through observation and semi-structured interviews. The study utilized descriptive statistics and quantitative analysis, including the Relative Importance Value (RI), Use Value Index (UV), Jaccard Index (JI), and Comprehensive Index of Land Use Degree (La), to examine the diversity of local homegarden plants and related traditional knowledge, as well as community heterogeneity.

RESULTS

The study area exhibited rich biodiversity, with 152 plant species recorded belonging to 62 families and 124 genera. These findings highlight the importance of homegarden plants in maintaining ecological balance and enhancing system resilience against disturbances. Homegarden plants serve multiple functions such as food, ornamental, medicinal, and fodder purposes, with edible and trade plants having the most abundant knowledge. Furthermore, this research revealed that communities with similar forest resource compositions may have similar homegarden plant compositions, demonstrating the connection between cultural exchange among different communities and patterns of plant species distribution.

CONCLUSIONS

The Laershan region boasts diverse homegarden plant species crucial for ecological balance and resilience. Their multifunctionality reflects human impact. Plant diversity varies with residents' lifestyles, needs, and cultural exchanges. The close connection between plants and local life is clear. Factors like resource distribution, cultural exchange, and lifestyle influence plant distribution. Further research is needed for conservation and sustainable development. Future research should focus on culturally valuable plant species and traditional knowledge applications.

Phytosome Supplements for Delivering Gymnema inodorum Phytonutrients to Prevent Inflammation in Macrophages and Insulin Resistance in Adipocytes

Gymnema inodorum (GI) is a leafy green vegetable found in the northern region of Thailand. A GI leaf extract has been developed as a dietary supplement for metabolic diabetic control. However, the active compounds in the GI leaf extract are relatively nonpolar. This study aimed to develop phytosome formulations of the GI extract to improve the efficiencies of their phytonutrients in terms of anti-inflammatory and anti-insulin-resistant activities in macrophages and adipocytes, respectively. Our results showed that the phytosomes assisted the GI extract's dispersion in an aqueous solution. The GI phytocompounds were assembled into a phospholipid bilayer membrane as spherical nanoparticles about 160-180 nm in diameter. The structure of the phytosomes allowed phenolic acids, flavonoids and triterpene derivatives to be embedded in the phospholipid membrane. The existence of GI phytochemicals in phytosomes significantly changed the particle's surface charge from neutral to negative within the range of -35 mV to -45 mV. The phytosome delivery system significantly exhibited the anti-inflammatory activity of the GI extract, indicated by the lower production of nitric oxide from inflamed macrophages compared to the non-encapsulated extract. However, the phospholipid component of phytosomes slightly interfered with the anti-insulin-resistant effects of the GI extract by decreasing the glucose uptake activity and increasing the lipid degradation of adipocytes. Altogether, the nano-phytosome is a potent carrier for transporting GI phytochemicals to prevent an early stage of T2DM.

Very High Food Plant Diversity among Ethnic Groups in Northern Thailand

The combination of the high biodiversity and many ethnicities in Thailand results in extensive ethnobotanical studies, especially in the northern part of the country. Here we have assembled 7620 records from 60 references regarding how plants are used for food among 14 ethnicities in northern Thailand. The uses are based on 1182 different plant species. Vegetables are the most common food category, which contributed more than 60% of all use-reports and involved nearly 900 species. This was followed by the dessert fruit category, which included about 350 species and over 1800 use-reports. The similarity among the different ethnicities was low and the number of uses and species recorded among different ethnicities were significantly related to the number of studies that had been conducted for each group. This implies that additional ethnobotanical studies are still needed in order to conserve and compile the valuable traditional knowledge related to food plants. Many exotic species are now an important part of traditional knowledge, whereas rare endemic species are uncommon among wild food plants. This situation leads to a loss of traditional knowledge about food plants and reduced awareness of their importance. As a key to using this great reservoir of food for local people, traditional knowledge related to local wild food plants can contribute to the zero-hunger goal of the Sustainable Development Goal (SDG). More studies on the nutrient content and health properties of these plants could lead to the development of new crops to meet present consumer demands.

Healthcare service utilization of hill tribe children in underserved communities in thailand: Barriers to access

BACKGROUND

Hill tribe children, an ethnic minority group in Thailand, experience wide-ranging social and health inequalities. Previous reports indicate that hill tribe children, especially age under 5 years, face social health disadvantages but little is known about the underlying causes. Exploring healthcare utilization among hill tribe children is therefore essential and it may well provide some insight.

METHODS

A qualitative study was conducted using purposive sampling techniques to recruit participants based on our criteria. In-depth interviews and focus-group discussions were employed to explore the experiences of parents (n = 20), community leaders (n = 20), and healthcare providers (n = 20) when caring for children aged under 5 years. Interview transcripts were coded, and thematic analysis was then performed.

RESULTS

The participants shared their experiences with accessing healthcare services in underserved areas. Barriers to access was the central theme identified. Sub-themes included: (1) distance matters, (2) education and socioeconomic deprivation, (3) lack of cultural sensitivity, (4) communication problems, (5) tradition, beliefs, and differences in cultural practice, (6) lack of child health professionals, and (7) bureaucratic hurdles.

CONCLUSIONS

Healthcare services and environments must be transformed to provide healthcare services, education, and information appropriate to the cultures and beliefs prevalent in the hill tribe population.

Homegarden agroforestry systems in achievement of Sustainable Development Goals. A review

Homegarden, a type of agroforestry system, is one of the earliest thriving traditional food systems reported. Studying the contribution of homegardens in the context of Sustainable Development Goals (SDGs) is crucial when the COVID-19 pandemic has hindered the achievement of many of the crucial SDGs. In this review, we focused on 94 peer-reviewed papers on homegardens from 2010 to 2021 to interrelate them with the corresponding targets and indicators of each SDG. The SDGs were classified into five categories, each focusing on a specific aspect: Category 1 (SDGs 1-5, poverty dimension), Category 2 (SDGs 6-9, development infrastructures), Category 3 (SDGs 10-12, sustainable production and consumption), Category 4 (SDGs 13-15, green infrastructures), and Category 5 (SDGs 16-17, green institutions). The distribution of the 94 papers analyzed was 92%, 23%, 33%, 51%, and 50% in each of the SDG categories, respectively. Category 1 and SDG 2 were found to be most realized in the homegarden literature. Important observations were found that highlight homegardens' probable use in providing food security, nutritional needs, health and wellness, preservation of agrobiodiversity, and enduring sustainability. Homegardens appear to be an important strategy for attaining the SDGs and can be accomplished with proper planning, in addition to taking into consideration how the traditional societies have sustained it for long.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s13593-022-00781-9.

Temporal assessment of the medicinal plants trade in public markets of the state of Paraíba, northeastern Brazil

BACKGROUND

Open and public markets are the main providers of medicinal plants in urban environments. The present study evaluated the medicinal plants sold in public markets in different municipalities in the mesoregions of the state of Paraíba, northeast of Brazil, and the possible variations in the supply of these plants in the markets over the course of a year.

METHODS

Interviews with medicinal plant traders were conducted in four mesoregions of different climatic and phytophysiognomic characteristics (ranging from Caatinga to Atlantic Forest). The versatility of the species sold was elucidated using the relative importance (RI) index, and the set of species sold by each informant in each mesoregion was compared with each other by one-way Anosim  and by the analysis of main coordinates.

RESULTS

Thirty-five plant traders identified 163 medicinal plant species (151 genders and 76 families) and more 17 non identified species. The most frequent families were Fabaceae (19 species), Asteraceae (12), Lamiaceae (11), and Myrtaceae (6). Punica granatum, Zingiber officinale, and Myracrodruon urundeuva were the species with the highest RI. The analysis of similarity showed distinct differences between the Sertão and all other mesoregions. The Agreste, an ecotone area, was also the area where more species of other regions was found. The absence of 88 species in at least one of the trading locations at some stage of the fieldwork was recorded.

CONCLUSIONS

The presence and absence of the commercialized species do not seem to be related to the period of the year or the mesoregion. There were differences in the inventory of plants commercialized in markets in recent years. We identified an intermediate zone of knowledge and use of species commercialized between the studied localities.

Exploring the antifungal activity and mechanism of action of Zingiberaceae rhizome extracts against Malassezia furfur

ETHNOPHARMACOLOGICAL RELEVANCE

Rhizomes from members of Zingiberaceae have long been used in Thai traditional medicine to treat cutaneous fungal infections, including Malassezia-related skin disorders. Alpinia galanga, Curcuma longa, Zingiber cassumunar, and Zingiber officinale are particularly popular in folk remedies.

AIM OF THE STUDY

On account of the application background in traditional medicine, the present study aims to screen and determine the composition and possible mechanism of the rhizome extracts of selected Zingiberaceae and corresponding fractions against M. furfur.

MATERIALS AND METHODS

All solvent extracts (ethanol, methanol, and n-hexane) obtained from each plant were screened for anti-Malassezia activity by agar disc diffusion assay. The MIC and MFC values of the potent rhizome extract and its bioactive fraction isolated by TLC were determined using broth dilution assay followed by chemical characterization using GC-MS. The anti-Malassezia mechanism was investigated by macroscopic and microscopic observation of cells grown in the yeast phase and hyphal phase.

RESULTS

The primary screening results showed that the n-hexane extract from A. galanga possessed the most significant anti-Malassezia activity. The MIC and MFC values of this extract were in a range of 0.04-0.08 mg/mL and 0.04-0.16 mg/mL, respectively. The TLC purification of the n-hexane extract from A. galanga gave a total of nine fractions, of which only a single exhibited anti-Malassezia activity. The GC-MS analysis of the rhizome extract and the derivative fraction revealed that the major constituents were (2,6-dimethylphenyl)borate followed by a trace content of 1,8-cineol and hydrocarbons. For the antifungal mechanism of the fraction, treatments of the fraction led to morphological changes in cell size and shape, exerted massive vacuoles in yeast form, and inhibited the transition to hyphae but not likely affected chitin contents of the cell wall of M. furfur.

CONCLUSIONS

According to the results, the n-hexane extract of A. galanga rhizome exhibits promising anti-Malassezia potential. The inhibitory effect on virulent hyphal growth supports that A. galanga is a valuable source of natural antifungal agents for further pharmaceutical research.

Medicinal Plants Used for Treating Mild Covid-19 Symptoms Among Thai Karen and Hmong

Background: The COVID-19 pandemic is causing many severe problems globally, and it is not known for how long it will last. The only hope we have for dealing with the problem is to produce sufficient vaccines and administer them efficiently. However, the current demand for vaccines greatly exceeds the supply, and many people will suffer from the disease for still some time. Moreover, the period for immunity obtained by the vaccines remains unknown, and we cannot predict how long the world will suffer the COVID-19 infections. Therefore, there will be a continued demand for treatments of its symptoms. An alternative solution for providing such treatment is the use of traditional medicinal plants.

Aims: To document medicinal plants used by Hmong and Karen in Thailand to treat mild symptoms of COVID-19.

Methods: Traditional knowledge about ethnomedicinal plants used by Hmong and Karen in Thailand for treating mild symptoms listed by WHO as associated with COVID 19, was collected in field interviews and extracted from the literature.

Results: We identified 491 plant species used medicinally by both ethnic groups to treat fever, cough, diarrhea, muscle pain and ache, rash, headache, sore throat, and conjunctivitis. Of the 491 species 60 were mentioned at least five times in the literature or in our field data. Of these 60 species, we propose the most commonly used ones for treatments of mild COVID-19 symptoms. Ten of these most commonly mentioned species were used for treatments of fever, nine for treatment of cough, four for treatment of diarrhea, two for treatment of rash, and a single species was used to treat muscle pain and headache.

Conclusion: This study suggests alternative treatments for mild symptoms of COVID-19 with medicinal plants that are traditionally used by the ethnic minority groups of the Hmong and Karen in Thailand. Although COVID-19 is a new disease, its mild symptoms are shared with many other diseases. Traditional knowledge on medicinal plants used by the Thai Karen and Hmong could help in the treatments of these symptoms associated with COVID-19. Many of the proposed plants were used abundantly by both ethnic groups, and other studies on biological activities support their efficacy in such treatments.

Ethnochemometric of plants traditionally utilised as local detergents in the forest dependent culture

The purpose of this study is to access the existing awareness of nearly forgotten Thai detergent plants by the use of chemometrics tool. A Northern Thai forest dependent community was chosen as it played vital role on knowledge retaining of plant utilisations. For initial perception, ethnobotanical survey was conducted to determine usage of plants by the community. Then the utilised plant parts were screened for phytochemicals and their relationships with the defined cleansing terms (viz., shampoo, scrub, detergent, soap, scent and spiritual) were analysed by Principal Component Analysis (PCA). From the results, the most cited plants as known, used and found were Acacia concinna, Clitoria ternetea, Oryza sativa and Citrus hystrix. Biometric analyses advised that knowledge of detergent plant utilisation was well preserved at all age ranges and it was not variable with genders. Cluster analysis described that term 'spiritual' was not narrated with cleansing properties. For phytochemical analysis, plant extracts showed positive variable of bioactive ingredients and the main compounds in the extracts was saponins. These findings confirmed that the knowledge of indigenous plant utilisation was reserved by the forest dependent community and the information is beneficial toward local plant conservation movement.

Ethnobotanical study on herbal market at the Dragon Boat Festival of Chuanqing people in China

BACKGROUND

The Chuanqing people () are a linguistic group native to the Guizhou Province of China, with unique culture and rich knowledge of traditional medicinal plants. Herbal market at Dragon Boat Festival (DBF) plays an important role in the inheritance of traditional medicinal knowledge among the Chuanqing people. This study aims to record the profile of medicinal plants of the Chuanqing people, discuss the dilemmas faced by their inheritance, and propose some strategies for passing down information, which is critical for the inheritance and protection of the Chuanqing people's traditional medical knowledge.

METHODS

Data were collected through key informants and semi-structured interviews and free listing. Collected voucher specimens were identified using by botanical taxonomy method and deposited in the herbarium. Data were analyzed through use-value (UV) and cultural importance index (CI) values. Medicinal plants were compared with the Information System of Chinese Rare and Endangered Plants of the Chinese Academy of Sciences. Results were compared with the Pharmacopoeia of the People's Republic of China (ChP), the Quality Standard of Traditional Chinese Medicine and National Medicine in Guizhou Province (QSG), and traditional medicines of Southeast Asian countries.

RESULTS

A total of 102 species from 53 families and 92 genera were recorded, with Orchidaceae and Asparagaceae (six species each), and Berberidaceae and Asteraceae (five species each) as the predominant families. The whole plant (36%) was the most common medicinal part. Decoction (44%) was the most common preparation method. Seventy-one investigated human ailments were grouped into 12 categories. Diseases of the musculoskeletal system (34 mentions) were most frequently mentioned in this study. Moreover, the most frequently used taxon was Hedera sinensis (Tobler ) Hand.-Mazz. (UV and CI = 0.29). The Chuanqing people's medicine was highly similar to ChP and QSG. In comparison with Southeast Asian countries' traditional medicines, except for the same preparation methods, the similarities in terms of medicinal ingredients, plants, and disease treatment were very low.

CONCLUSIONS

The herbal market at the DBF is an important platform for exchanging knowledge about the Chuanqing people's traditional medicinal plants. The Chuanqing people's traditional medicine is facing many challenges to its inheritance and development. To solve these problems, this study highlights the traditional medicinal knowledge of the Chuanqing people, providing basic data for further research and protection of minority medicine.

Inhibitory effects of Gymnema inodorum (Lour.) Decne leaf extracts and its triterpene saponin on carbohydrate digestion and intestinal glucose absorption

ETHNOPHARMACOLOGICAL RELEVANCE

Chiang-Da, Gymnema inodorum (Lour.) Decne. (GI), is an ethnomedicinal plant that has been used for diabetic treatment since ancient times. One of the anti-diabetic mechanisms is possibly related to the actions of triterpene glycoside, (3β, 16β)-16,28-dihydroxyolean-12-en-3-yl-O-β-D-glucopyranosyl-β-D-glucopyranosiduronic acid (GIA1) in decreasing carbohydrate digestive enzymes and intestinal glucose absorption in the gut system.

AIMS OF THE STUDY

To observe the amount of GIA1 in GI leaf extracts obtained from different ethanol concentrations and to investigate the anti-hyperglycemic mechanisms of the extracts and GIA1.

MATERIALS AND METHODS

The crude extracts were prepared using 50%v/v to 95%v/v ethanol solutions and used for GIA1 isolation. The anti-hyperglycemic models included in our study examined the inhibitory activities of α-amylase/α-glucosidase and intestinal glucose absorption related to sodium glucose cotransporter type 1 (SGLT1) using Caco-2 cells.

RESULTS

GIA1 was found about 8%w/w to 18%w/w in the GI extract depending on ethanol concentrations. The GI extracts and GIA1 showed less inhibitory activities on α-amylase. The extracts from 75%v/v and 95%v/v ethanol and GIA1 significantly delayed the glycemic absorption by lowering α-glucosidase activity and glucose transportation of SGLT1. However, the 50%v/v ethanolic extract markedly decreased the α-glucosidase activity than the SGLT1 function.

CONCLUSION

Differences in the GIA1 contents and anti-glycemic properties of the GI leaf extract was dependent on ethanol concentrations. Furthermore, the inhibitory effects of the 75%v/v and 95%v/v ethanolic extracts on α-glucosidase and SGLT1 were relevant to GIA1 content.

The secret of health in daily cuisine: typical healthy vegetables in local markets in central Myanmar

BACKGROUND

Central Myanmar is located in the Indo-Burma biodiversity hotspot, and the Bamar people are the main ethnic group, which settled there over 1000 years ago. Despite being the core region of the country, central Myanmar has been ignored in previous ethnobotanical studies. Local healthy foods and knowledge are regarded as treasures for resource development and pharmaceutical drug discovery, and market surveys are a good strategy in ethnobotanical research. Thus, we collected and documented typical vegetables and local knowledge in local markets and then analysed the diversity and local knowledge of these vegetables.

MATERIALS AND METHODS

Observations and interviews were used in the field study, and 10 markets and fairs were selected in central Myanmar. A total of 277 vegetable stalls or shops were visited. We compared the local knowledge we collected with selected important and typical herbal books on traditional Myanmar medicine. Quantitative analysis, including frequency of citation (FC), relative frequency of citation (RFC) and use value (UV), was used to assess the diversity and local knowledge of these vegetables.

RESULTS

A total of 132 plant taxa from 47 botanical families and 116 genera were collected. Most (106 taxa, 80.3%) of these vegetables were cited by the informants as functional foods that had health benefits, while others were regarded as merely "good for health". The main health function of the vegetables was treating digestive problems. Sixty-four species were recorded in selected herbal books on traditional Myanmar medicine, and forty-seven taxa were not recorded in these books but were nonetheless used as healthy vegetables by local people. Twenty-eight species of vegetables were collected from wild places.

CONCLUSION

The diversity and local knowledge of healthy vegetables in central Myanmar were rich. Nevertheless, the diversity of wild vegetables was seemingly relatively low. The possible reason was that we counted only the vegetables that were from entirely wild sources as "wild vegetables". The most frequently cited vegetables were commonly cultivated species, which reflects the fact that plants cultivated on a large scale comprise the major source of vegetables. Some lesser known vegetables could reflect the unique food culture of local people, but most of these were cited only a few times by the interviewees, which caused low UV and RFC rankings for them in the league table. In addition, future research should pay more attention to the food safety of these vegetables.

Medicinal Plants for Treating Musculoskeletal Disorders among Karen in Thailand

Millions of people suffer from Musculoskeletal System Disorders (MSDs), including Karen people who work hard in the fields for their subsistence and have done so for generations. This has forced the Karen to use many medicinal plants to treat MSDs. We gathered data from 15 original references covering 27 Karen communities and we document 461 reports of the use of 175 species for treating MSDs among the Karen people in Thailand. The data were analyzed by calculating use values (UV), relative frequency of citation (RFC) and informant consensus factor (ICF). Many use reports and species were from Leguminosae and Zingiberaceae. Roots and leaves were the most used parts, while the preferred preparation methods were decoction and burning. Oral ingestion was the most common form of administration. The most common ailment was muscle pain. Sambucus javanica and Plantago major were the most important species because they had the highest and second-highest values for both UV and RFC, respectively. This study revealed that the Karen people in Thailand use various medicinal plants to treat MSDs. These are the main resources for the further development of inexpensive treatments of MSDs that would benefit not only the Karen, but all people who suffer from MSD.