International comparative study of low back pain care pathways and analysis of key interventions.

PURPOSE: Low back pain (LBP) is a major public health problem worldwide. Significant practice variation exists despite guidelines, including strong interventionist focus by some practitioners. Translation of guidelines into pathways as integrated treatment plans is a next step to improve implementation. The goal of the present study was to analyze international examples of LBP pathways in order to identify key interventions as building elements for care pathway for LBP and radicular pain. METHODS: International examples of LBP pathways were searched in literature and grey literature. Authors of pathways were invited to fill a questionnaire and to participate in an in-depth telephone interview. Pathways were quantitatively and qualitatively analyzed, to enable the identification of key interventions to serve as pathway building elements. RESULTS: Eleven international LBP care pathways were identified. Regional pathways were strongly organized and included significant training efforts for primary care providers and an intermediate level of caregivers in between general practitioners and hospital specialists. Hospital pathways had a focus on multidisciplinary collaboration and stepwise approach trajectories. Key elements common to all pathways included the consecutive screening for red flags, radicular pain and psychosocial risk factors, the emphasis on patient empowerment and self-management, the development of evidence-based consultable protocols, the focus on a multidisciplinary work mode and the monitoring of patient-reported outcome measures. CONCLUSION: Essential building elements for the construction of LBP care pathways were identified from a transversal analysis of key interventions in a study of 11 international examples of LBP pathways.

The Belgian national guideline on low back pain and radicular pain: key roles for rehabilitation, assessment of rehabilitation potential and the PRM specialist.

Low back pain (LBP) and radicular pain are very common health problems. They are rarely caused by serious underlying pathology and will usually recover spontaneously in time. In about one third of the cases however, the pain and functional impairment will persist one year after onset, being responsible for high health care costs and work absence. The management of LBP and radicular pain should focus therefore on excluding signs and symptoms of serious underlying pathology, on an active approach and on the prevention of chronicity. In 2017 the Belgian Health Care Knowledge Centre (KCE) published a guideline on LBP and radicular pain. This guideline formed the basis for a national pathway on LBP and radicular pain and is the first step to change and optimize our daily clinical practice. In this Belgian guideline the importance is stressed of a comprehensive clinical assessment and a tailored rehabilitation. Pharmacological and invasive treatments have a more doubtful effect or should only be considered under certain conditions. Implementing these recommendations in an interdisciplinary pathway necessitates a central role for Physical and Rehabilitation Medicine (PRM) especially in giving advice on and/or coordinating the tailored rehabilitation to prevent chronicity. To do this, the PRM specialist should perform a medical and functional assessment according to the ICF framework and taking into account the risk for chronicity or persistent impairment and the rehabilitation potential.

The pivotal role for the multidisciplinary approach at all phases and at all levels in the national pathway for the management of low back pain and radicular pain in Belgium.

INTRODUCTION: High level evidence on management of spinal disorders is scarce, which results in guidelines being of limited practical use for practitioners. Care pathways are complex interventions intended for the mutual decision making of organization of care processes for a well-defined group of patients. The goal of this project was to design a pathway for the management of low back pain and radicular pain for national implementation in Belgium. EVIDENCE ACQUISITION: An international and Belgian study on characteristics of low back pain care pathways was performed along with a literature study and focus group interrogation. Based on essential building elements identified and a consensus approach among all relevant stakeholders in primary, hospital and reintegration care, a national pathway was constructed. The process was endorsed by the Belgian Health Care Knowledge Center, Belgian National Institute of Health and Disability Insurance and the Spine Society of Belgium. EVIDENCE SYNTHESIS: Eleven international pathways were identified, varying in implementation width from hospital-based to region/province-based. Seven Belgian pathway initiatives were detected. Notwithstanding differences, consistent building elements were identified. Three groups of caregivers, divided in primary care, hospital care and reintegration and including all relevant medical/paramedical disciplines, worked on integrating the essential building elements into a single concrete patient pathway of direct use to any caregiver and patient and based on a consensus model including reference to the 2017 Belgian adaptation of the 2016 NICE guidelines. The resulting pathways on management of low back pain and radicular pain underpin the importance of multidisciplinary teamwork. CONCLUSIONS: Essential building elements were identified from literature and established pathways and were successfully integrated in a Belgian national low back pain and radicular pain pathway using an integrative consensus approach. The pathways are consultable at www.lowbackpain.kce.be.

CARDIOVASCULAR SCREENING OF YOUNG ATHLETES: A REVIEW OF ECONOMIC EVALUATIONS.

OBJECTIVES: Some experts have promoted preparticipative cardiovascular screening programs for young athletes and have claimed that such programs were cost-effective without performing a critical analysis of studies supporting this statement. In this systematic review, a critical assessment of economic evaluations on these programs is performed to determine if they really provide value for money. METHODS: A systematic review of economic evaluations was performed on December 24, 2014. Web sites of health technology assessment agencies, the Cochrane database of systematic review, the National Health Service Economic Evaluation Database of the Cochrane Library, EMBASE, Medline, Psychinfo, and EconLit were searched to retrieve (reviews of) economic evaluations. No language or time restrictions were imposed and predefined selection criteria were used. Selected studies were critically assessed applying a structured data extraction sheet. RESULTS: Five relevant economic evaluations were critically assessed. Results of these studies were mixed. However, those in favor of screening made (methodological) incorrect choices, of which the most important one was not taking into account a no-screening alternative as comparator. Compared with no screening, other strategies (history and physical examination or history and physical examination plus electrocardiogram) were not considered cost-effective. CONCLUSIONS: Results of primary economic evaluations should not be blindly copied without critical assessment. Economic evaluations in this field lack the support of robust evidence. Negative consequences of screening (false positive findings, overtreatment) should also be taken into account and may cause more harm than good. A mass screening of young athletes for cardiovascular diseases does not provide value for money and should be discouraged.

Systematic Review of the Efficacy and Safety of High-intensity Focussed Ultrasound for Localised Prostate Cancer.

CONTEXT: High-intensity focussed ultrasound (HIFU) has been used for 10 yr to treat localised prostate cancer (PCa). OBJECTIVE: To evaluate systematically the evidence on the efficacy and side effects of HIFU in the primary treatment of localised PCa. EVIDENCE ACQUISITION: We performed a critical review and appraisal of Medline (Ovid), PreMedline, Embase, and Cochrane Database of Systematic Reviews publications on HIFU up to May 2013. One systematic review and 18 primary studies, all case series, were eligible. EVIDENCE SYNTHESIS: Outcomes were summarised and evidence was evaluated using Grading of Recommendations, Assessment, Development and Evaluation methodology. Low-quality evidence suggests an overall survival rate after Ablatherm HIFU ranging from 80% to 89% for >5 yr. The PCa survival rate ranges from 97% to 99% for >5 yr. Effect of HIFU on quality of life remains undetermined. Erectile dysfunction was the most frequent adverse event reported from zero but up to 74% of patients. Adverse events affecting the urinary tract occurred in 0.7-31% of patients, bladder outlet obstruction in 4-51.5%, and they were more frequent in patients who had transurethral resection of the prostate the same day or within 2 d of HIFU. Outcomes vary for low- and high-risk categories. CONCLUSIONS: Good quality evidence on the efficacy of HIFU treatment for localised PCa is lacking. PATIENT SUMMARY: We reviewed all the data on treatment with high-intensity focussed ultrasound (HIFU) for localised prostate cancer (PCa). The quality of the evidence is very low because the information is based on a series of patients who received HIFU treatment with no comparison with active surveillance or radical treatment. Case series suggest an overall survival rate up to 89% and a PCa survival rate up to 99% after 5 yr, but these numbers vary according to the patient's risk category. Longer term and effects on quality of life are unknown.

The Belgian Health System Performance Report 2012: snapshot of results and recommendations to policy makers.

Following the commitments of the Tallinn Charter, Belgium publishes the second report on the performance of its health system. A set of 74 measurable indicators is analysed, and results are interpreted following the five dimensions of the conceptual framework: accessibility, quality of care, efficiency, sustainability and equity. All domains of care are covered (preventive, curative, long-term and end-of-life care), as well as health status and health promotion. For all indicators, national/regional values are presented with their evolution over time. Benchmarking to results of other EU-15 countries is also systematic. The policy recommendations represent the most important output of the report.

Development of a national position paper for chronic care: example of Belgium.

The management of chronic diseases is a prime challenge of most 21st century health care systems. Many Western countries have invested heavily in care plans oriented towards specific conditions and diseases, such as dementia and cancer. The major downside of this narrowly focused approach is that treatment of multimorbidity is ignored. This paper describes the development and main stance of a national position that proposes streamlined reforms of the Belgian health care system to improve care for patients with multiple chronic diseases. We used a combination of methods to develop this stance: literature review and stakeholders' consultation. The latter identified areas for improvement: efficiency of the health care system, coordination of care, investments in human care resources, informal caregivers' support, better accessibility, and changes in the financial payment system. The position paper list 20 recommendations that are translated into about 50 action points to reform the health care system. Chronic care tailored to the patient's needs, including implementation of multidisciplinary teamwork, new functions, task delegation in primary care, and empowerment of the patient and informal caregivers are some major areas discussed. In addition, improved support, revised payment mechanisms, and setting up a quality system, along with the tailoring of patient care, can all facilitate delivery of high quality care in patients with chronic comorbidities.

Successful preliminary walking experiments on a transtibial amputee fitted with a powered prosthesis.

This paper presents the results of preliminary walking experiments on a transtibial amputee wearing a powered prosthesis. The prosthesis prototype serves as a proof-of-concept implementation for investigating the potential of pleated pneumatic artificial muscles to power a transtibial prosthesis. The device is equipped with pleated pneumatic artificial muscles, and tethered to a laboratory pressure source. The prosthesis is capable of providing the amputee with 100% of the required push-off torque and it can adapt its joint stiffness to the walking speed. This study supports the hypothesis that a powered transtibial prosthesis with adaptable stiffness might be beneficial to the amputee.

Prosthetic feet: state-of-the-art review and the importance of mimicking human ankle-foot biomechanics.

Numerous prosthetic feet are currently on the market for individuals with a transtibial amputation, each device aimed at raising the 3C-level (control, comfort and cosmetics) with slightly different characteristics. In general, prosthetic feet can be classified into three categories. These are, following the time line: conventional feet (CF), energy-storing-and-returning (ESR) feet and the recent so-called 'bionic' feet. Researchers have shown enhanced performance properties of ESR feet compared with early CF. However, even with the advanced technology, none of the ESR feet is capable of significantly reducing energy cost of walking or enhancing prosthetic gait (Nielsen et al. J Prosthet Orthotics 1989;1:24-31; Waters et al. J Bone Joint Surg Am 1976;58:42-46; Torburn et al. J Rehabil Res Dev 1990;27:369-384). From the 1990s, gradually more attention has been paid to the incorporation of active elements in prosthetic feet as the passive devices are not capable of providing the individual with sufficient ankle power during gait. Most part of the 'bionic' devices are still on the research level nowadays but one can expect that they will become available on the market soon. In this article, the evolution of prosthetic feet over the last two decades is reflected. The importance of mimicking human ankle-foot biomechanics with prosthetic feet is briefly discussed. Prior work in both objective and subjective evaluation of prosthetic gait is reported.