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Meningioma mostly present with localised pain associated with signs of spinal cord compression. We present a case of a 72 year old woman with a thoracal meningioma with an atypical manifestation: radicular thoracal pain with signs of mechanical hyperalgesia and allodynia without any signs of spinal cord compression. Diagnosis was made by MRI-scan of the dorsal spine. After neurosurgical resection there was a complete recovery. We like to stress the importance of providing detailed information on clinical cases, especially with an atypical manifestation. We review the literature published on meningioma and discuss the most important symptoms and signs. [ABSTRACT FROM AUTHOR]

Worldwide, herbaria maintain collections of reference specimens representing global plant diversity. These collections are a valuable resource for fundamental botanical research and applied scientific research across various disciplines, and play a significant role in addressing major societal challenges such as biodiversity conservation. The digitisation of herbarium specimens and their online dissemination is one of the most important recent developments in the curation of these collections. Digitisation significantly enhances access to the collections for the research community and facilitates large-scale analysis of biodiversity data. Digitisation also provides a means for preserving the physical specimens, as it reduces the need for handling and transportation. Rapid technological developments have greatly accelerated the rate of databasing and digital imaging of collections. Meise Botanic Garden recently completed a six-year project to mass digitise its herbarium collections of about 3 million specimens mounted on sheets and through this process we have learned valuable lessons. We have captured our experience in 10 recommendations for other collection-holding institutions to take inspiration from as they start planning their own digitisation efforts. We also present case studies where we delve deeper into certain topics as examples., Competing Interests: The authors have declared that no competing interests exist., (Sofie De Smedt, Ann Bogaerts, Niko De Meeter, Mathias Dillen, Henry Engledow, Paul Van Wambeke, Frederik Leliaert, Quentin Groom.)

Objectives: To explore the views of patients and healthcare providers on current rehabilitation after lumbar fusion surgery (LFS) to fuel the development of a novel rehabilitation care pathway., Design: A cross-sectional, qualitative study with an interpretive descriptive design., Setting: Academic and non-academic hospital setting in Belgium., Participants: 31 caregivers from (non)-academic settings and 5 patients with LFS were purposefully sampled and in-depth interviewed., Results: Out of the data of all interviews, participants reported opinions on 23 thematic clusters that were expressed in a time-contingent manner from the preoperative, perioperative to postoperative phase. Afterwards, themes were mapped to the Consolidated Framework for Implementation Research, with a larger role for concepts related to the innovation, inner and individual domain. As an overarching theme, the importance of an 'individualised, patient-centred rehabilitation built on a strong therapeutic alliance with an accessible interprofessional team' was stressed for patients undergoing LFS. Specifically, participants stated that a biopsychosocial approach to rehabilitation should start in the preoperative phase and immediately be continued postoperatively. No consensus was observed for movement restrictions postoperatively. Uniform communication between the involved caregivers was considered essential for optimal therapeutic alliance and clinical outcome. The precise role and competence of each member of the interprofessional team needs, therefore, to be clearly defined, respected and discussed. An accessible case manager to guide the patient trajectory and tackle problems could further support this. Interestingly, only patients, psychologists and physiotherapists addressed return to work as an important outcome after LFS., Conclusions: This qualitative study identified key experiences and points to consider in the current and future rehabilitation pathway for LFS. Future research should incorporate these findings to build a novel rehabilitation pathway for LFS and evaluate its feasibility and cost-effectiveness., Trial Registration Number: This study was registered at clinicaltrials.gov (NCT03427294)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: There is limited evidence to guide the rehabilitation of patients following single or double-level lumbar fusion surgery (LFS). This is reflected in extensive variability in current rehabilitation regimes and subsequent low clinical success rates, which urges a call for a consensus rehabilitation pathway., Aim: To establish consensus on the optimal pre-, peri- and postoperative rehabilitation of LFS., Design: A modified Delphi Study., Setting: Belgium and the Netherlands., Population: A multidisciplinary panel of 31 experts in the field of LFS and rehabilitation participated. Nine patients validated the consensus pathway., Methods: A three-round online Delphi questionnaire was followed by an in-person consensus meeting. In each round, experts could suggest new statements, and received group summary statistics and feedback for reconsidered statements. Consensus threshold was set at ≥75% agreement. The resulting rehabilitation pathway was validated by patients through an online questionnaire and subsequent in-person focus group., Results: A total of 31 experts participated in the first online round, with 27 (87%) completing all online rounds, and 17 (55%) attending the in-person consensus meeting. Consensus was reached on 122 statements relating to pre-, peri- and postoperative rehabilitation of LFS, and validated by patients. Key components of the rehabilitation pathway included prehabilitation, education, physiotherapy in every phase, early postoperative mobilization, and little movement restrictions. Patients emphasized the need for support during the return-to-work process., Conclusions: This process resulted in 122 expert-consensus statements on best practice rehabilitation for managing LFS, validated by patients., Clinical Rehabilitation Impact: The proposed rehabilitation pathway can serve as guidance to support clinicians, reduce practice variability, and subsequently improve clinical outcomes after LFS.

Background: Diagnostic imaging for low back pain (LBP) without any indication of a serious underlying cause does not improve patient outcomes. However, there is still overuse of imaging, especially at emergency departments (EDs). Although evidence-based guidelines for LBP and radicular pain management exist, a protocol for use at the ED in the Belgian University Hospitals Leuven was not available, resulting in high practice variation. The present paper aims to describe the process from protocol development to the iterative implementation approach and explore how it has influenced practice., Methods: In accordance with a modified 'knowledge-to-action' framework, five steps took place within the iterative bottom-up implementation process: (1) identification of the situation that requires the implementation of evidence based recommendations, (2) context analysis, (3) development of an implementation plan, (4) evaluation and (5) sustainability of the implemented practice recommendations. Two potential barriers were identified: the high turnover of attending specialists at the ED and patients' and general practicioners' expectations that might overrule the protocol. These were tackled by educational sessions for staff, patient brochures, an information campaign and symposium for general practitioners., Results: The rate of imaging of the lumbar spine decreased from over 25% of patients to 15.0%-16.4% for CT scans and 19.0%-21.8% for X-rays after implementation, but started to fluctuate again after 3 years. After introducing a compulsory e-learning before rotation and catchy posters in the ED staff rooms, rates decreased to 14.0%-14.6% for CT scan use and 12.7-13.5% for X-ray use., Conclusions: Implementation of a new protocol in a tertiary hospital ED with high turn over of rotating trainees is a challenge and requires ongoing efforts to ensure sustainability. Rates of imaging represent an indirect though useful indicator. We have demonstrated that it is possible to implement a protocol that includes demedicalisation in an ED environment and to observe changes in indicator results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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.

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.

Digitisation of natural history collections has evolved from creating databases for the recording of specimens' catalogue and label data to include digital images of specimens. This has been driven by several important factors, such as a need to increase global accessibility to specimens and to preserve the original specimens by limiting their manual handling. The size of the collections pointed to the need of high throughput digitisation workflows. However, digital imaging of large numbers of fragile specimens is an expensive and time-consuming process that should be performed only once. To achieve this, the digital images produced need to be useful for the largest set of applications possible and have a potentially unlimited shelf life. The constraints on digitisation speed need to be balanced against the applicability and longevity of the images, which, in turn, depend directly on the quality of those images. As a result, the quality criteria that specimen images need to fulfil influence the design, implementation and execution of digitisation workflows. Different standards and guidelines for producing quality research images from specimens have been proposed; however, their actual adaptation to suit the needs of different types of specimens requires further analysis. This paper presents the digitisation workflow implemented by Meise Botanic Garden (MBG). This workflow is relevant because of its modular design, its strong focus on image quality assessment, its flexibility that allows combining in-house and outsourced digitisation, processing, preservation and publishing facilities and its capacity to evolve for integrating alternative components from different sources. The design and operation of the digitisation workflow is provided to showcase how it was derived, with particular attention to the built-in audit trail within the workflow, which ensures the scalable production of high-quality specimen images and how this audit trail ensures that new modules do not affect either the speed of imaging or the quality of the images produced., (Abraham Nieva de la Hidalga, Paul L Rosin, Xianfang Sun, Ann Bogaerts, Niko De Meeter, Sofie De Smedt, Maarten Strack van Schijndel, Paul Van Wambeke, Quentin Groom.)

Objective: The first aim of this review was to investigate the association between age, sex, height, weight, physical activity level, posture, lumbar level and body side, and structural characteristics (cross-sectional area [CSA], thickness, linear dimensions, and echo intensity) of the lumbar multifidus (LM) measured by ultrasound. Second, differences between healthy individuals and patients with chronic low back pain (CLBP) were investigated. TYPE: Systematic review., Literature Survey: PubMed, Embase and Web of Science were searched until September 2018., Methodology: Studies were included if (a) full text was available in English, Dutch, or French; (b) participants were older than 18 years of age and were asymptomatic or had nonspecific CLBP; and (c) the relation between structural characteristics of the LM, measured by ultrasound, and at least one of the above-mentioned factors was described, and/or a comparison between a CLBP and control group was made. Data were extracted independently by two reviewers. Quality of studies was assessed using an adapted version of the Downs and Black checklist., Synthesis: Twenty-seven studies were included. Thickness and CSA of the LM do not correlate with age. Males have a larger LM size than females. Thickness and CSA of left and right LM are highly correlated in healthy subjects. More significant side-to-side differences are present in subjects with CLBP than in those without. Muscle size increases from proximal to caudal lumbar levels. The presence of CLBP is associated with muscle size and function., Conclusions: The association between the factors age, sex, height, weight, physical activity level, posture, lumbar level, body side, and presence of CLBP, and the ultrasound characteristics of the LM is discussed. These factors should be taken into account in future research on structural muscle characteristics, or when correlating with functional behavior or investigating the effect of a targeted intervention., Level of Evidence: I., (© 2019 American Academy of Physical Medicine and Rehabilitation.)

Both frequent reason for consultation and cause of absence at work, low back pain is a notorious public health concern. The Belgian Health Care Knowledge Centre (KCE) has been surrounded by 31 clinicians from different disciplines to develop a guideline covering the entire management of low back and radicular pain. A recently published guideline of the British National Institute for Health and Care Excellence (NICE) was largely used as a starting point and adapted to the Belgian context.

Background: To identify distinct groups of patients with fibromyalgia (FM) with respect to multiple outcome measures., Methods: Data from 631 duloxetine-treated women in 4 randomized, placebo-controlled trials were included in a cluster analysis based on outcomes after up to 12 weeks of treatment. Corresponding classification rules were constructed using a classification tree method. Probabilities for transitioning from baseline to Week 12 category were estimated for placebo and duloxetine patients (Ntotal = 1188) using logistic regression., Results: Five clusters were identified, from "worst" (high pain levels and severe mental/physical impairment) to "best" (low pain levels and nearly normal mental/physical function). For patients with moderate overall severity, mental and physical symptoms were less correlated, resulting in 2 distinct clusters based on these 2 symptom domains. Three key variables with threshold values were identified for classification of patients: Brief Pain Inventory (BPI) pain interference overall scores of <3.29 and <7.14, respectively, a Fibromyalgia Impact Questionnaire (FIQ) interference with work score of <2, and an FIQ depression score of ≥5. Patient characteristics and frequencies per baseline category were similar between treatments; >80% of patients were in the 3 worst categories. Duloxetine patients were significantly more likely to improve after 12 weeks than placebo patients. A sustained effect was seen with continued duloxetine treatment., Conclusions: FM patients are heterogeneous and can be classified into distinct subgroups by simple descriptive rules derived from only 3 variables, which may guide individual patient management. Duloxetine showed higher improvement rates than placebo and had a sustained effect beyond 12 weeks.

Background: Self-critical perfectionistic personality features have been shown to influence the onset and perpetuation of pain symptoms. However, no study to date has investigated whether these personality features are associated with treatment response in chronic pain., Methods: Using a naturalistic pre-post design, the present study examined the effect of self-critical perfectionism on treatment outcome in terms of self-reported pain. The study was conducted in a sample of 53 chronic non-cancer pain patients who followed Multidisciplinary Pain Education Program (MPEP), a brief, 2-week cognitive-behaviorally based psycho-educational intervention for chronic pain that was recently found to be effective in reducing pain severity. Pre- and post-treatment pain intensity levels were assessed with the visual analog scale of the McGill Pain Questionnaire-Short Form., Results: Pretreatment self-critical perfectionism was significantly associated with negative treatment outcome, even after taking into account pretreatment levels of depression., Conclusion: Results suggest that self-critical perfectionistic personality features may negatively interfere with treatment response in patients with chronic pain. Thus, findings indicate that chronic pain patients with high levels of self-critical perfectionism may benefit less from brief interventions such as MPEP, and therefore may need more intensive and tailored treatment., (© 2013 World Institute of Pain.)

Background: Although some studies have found high rates of early childhood trauma in Chronic Fatigue Syndrome (CFS), the role of early trauma in this condition remains controversial., Methods: This study examined the prevalence of early childhood trauma and its impact on daily fatigue and pain levels over a 14-day period in a sample of 90 carefully screened CFS patients using a diary method approach. Data were analyzed using multilevel analysis., Results: More than half of the patients (54.4%) had experienced at least one type of early trauma, with the majority of these patients reporting multiple traumas. Prevalence rates were particularly high for emotional trauma (i.e., emotional abuse and/or emotional neglect) (46.7%). Moreover, total trauma scores and emotional abuse significantly predicted higher levels of daily fatigue and pain over the 14-day period, even when controlling for demographic features and depressed mood., Conclusions: This is the first study to demonstrate that early childhood trauma predicts increasing levels of core symptoms of CFS in the daily flow of life. Moreover, findings of this study suggest that emotional trauma may be particularly important in CFS., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: There is a need for effective brief interventions in chronic pain patients, and the identification of mechanisms of change., Method: In the present study, we tested the effectiveness of MPEP (Multidisciplinary Pain Education Program), a very brief, four-session cognitive-behaviorally based psycho-educational intervention for chronic pain using a pre-and post-test design. In addition, pre- to post-treatment change scores were calculated to investigate factors associated with change in pain. Participants of the study were 53 patients with chronic non-cancer pain. Primary outcome measures were (1) pain severity, (2) health perception, and (3) severity of depression. Secondary outcome measures included factors that have been implicated in the maintenance of chronic pain and that might be associated with worse treatment outcome: (1) catastrophizing, (2) kinesiophobia, and (3) action-proneness., Results: Findings provided preliminary evidence for the effectiveness of MPEP in that patients showed significant and clinically meaningful improvements in pain symptoms (F = 24.503, p < 0.001, d = 0.59) and action-proneness (F = 178.504, p < 0.001, d = 1.95), and small improvements in health perception (F = 7.116, p < 0.05, d = 0.30). Furthermore, results showed that changes in catastrophizing (β = -0.455, p = 0.001) and severity of depression (β = -0.300, p < 0.05) were independently and significantly associated with changes in pain. However, changes in health perception, kinesiophobia, and action-proneness were not significantly associated with changes in pain (β = 0.203, ns; β = 0.003, ns; and β = 0.154, ns, respectively). Importantly, duration of chronic pain was not related to treatment outcome (β = 0.070, ns)., Conclusions: Overall, this study provides preliminary evidence for the effectiveness of MPEP and possible mechanisms through which MPEP is effective. Yet, further research is needed to investigate the efficacy of MPEP.

In the current study, we investigated whether the distinction between adaptive (i.e. high personal standards) and maladaptive (i.e. concern over mistakes and doubt about actions) perfectionism that has been found in the literature, is also valid in patients with chronic fatigue syndrome (CFS). We hypothesized that maladaptive, but not adaptive, perfectionism would be significantly and positively related to severity of fatigue and depression in CFS. We examined this hypothesis in a sample of 192 CFS patients using structural equation modelling (SEM). Although the two perfectionism dimensions were related to each other, results supported a model in which only maladaptive perfectionism was positively related to severity of fatigue and depression. Further, we found that depression fully mediated the effect of maladaptive perfectionism on fatigue. The results suggest that adaptive and maladaptive perfectionism are two distinct, albeit related, dimensions in CFS. Findings of this study have important implications for theory and treatment of CFS, particularly for cognitive-behavioral treatment., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Chronic Fatigue Syndrome (CFS) is a highly disabling disorder that is part of a broader spectrum of chronic pain and fatigue disorders. Although the etiology and pathogenesis of CFS largely remain unclear, there is increasing evidence that CFS shares important pathophysiological disturbances with mood disorders in terms of disturbances in the stress response and the stress system. From a psycho-dynamic perspective, self-critical perfectionism and related personality factors are hypothesized to explain in part impairments of the stress response in both depression and CFS. Yet, although there is ample evidence that high levels of self-critical perfectionism are associated with stress generation and increased stress sensitivity in depression, evidence supporting this hypothesis in CFS is currently lacking. This study therefore set out to investigate the relationship between self-critical perfectionism, the active generation of stress, stress sensitivity, and levels of depression in a sample of 57 patients diagnosed with CFS using an ecological momentary assessment approach. Results showed, congruent with theoretical assumptions, that self-critical perfectionism was associated with the generation of daily hassles, which in turn predicted higher levels of depression. Moreover, multilevel analyses showed that self-critical perfectionism was related to increased stress sensitivity in CFS patients over a 14-day period, and that increased stress sensitivity in turn was related to increased levels of depression. The implications of these findings for future research and particularly for the development of psychodynamic treatment approaches of CFS and related conditions are discussed.

Background: Little is known about factors predicting treatment outcome in chronic fatigue syndrome (CFS)., Methods: Based on Vercoulen et al.'s (1998) cognitive-behavioral model of perpetuating factors in CFS, the predictive value of the following patient characteristics were examined in a sample of 178 CFS patients who followed a multi-component treatment program: (1) somatic attributions, (2) psychological attributions, (3) sense of control over symptoms, (4) physical activity, (5) functional impairment, (6) somatic focus, and (7) severity of depression., Results: Only pre-treatment severity of depression was associated with negative treatment outcome defined in terms of post-treatment fatigue and improvement in fatigue., Limitations: The study was conducted at a tertiary care centre and did not include a control group or a long-term follow-up., Conclusions: Level of depression may be the most important factor of the cognitive-behavioral model predicting post-treatment fatigue in CFS. Hence, findings suggest that treatment of CFS should include a focus on severity of depression., (Copyright 2010 Elsevier B.V. All rights reserved.)

Chronic fatigue syndrome (CFS) is a debilitating condition characterized by serious medically unexplained mental and physical fatigue. The high prevalence and both direct and indirect health costs of CFS patients represent a huge problem for contemporary health care. Moreover, the prognosis of CFS, even when treated, is often poor. In this paper, we first critically review current evidence based treatments of CFS. Second, we discuss the growing insights into the etiopathogenesis of CFS, and the need to translate and integrate these insights into future treatments. In particular, we formulate a pragmatic and empirically testable treatment approach, tailored to the individual needs of patients, which aims at restoring the mental and physical equilibrium of CFS patients by trying to bring about sustained life style changes.

Hyperventilation has been suggested as a concomitant and possible maintaining factor that may contribute to the symptom pattern of chronic fatigue syndrome (CFS). Because patients accepting the illness and trying to live with it seem to have a better prognosis than patients chronically fighting it, we investigated breathing behavior during different coping response sets towards the illness in patients with CFS (N=30, CDC criteria). Patients imagined a relaxation script (baseline), a script describing a coping response of hostile resistance, and a script depicting acceptance of the illness and its (future) consequences. During each imagery trial, end-tidal PCO2 (Handheld Capnograph, Oridion) was measured. After each trial, patients filled out a symptom checklist. Results showed low resting values of PetCO2 overall, while only imagery of hostile resistance triggered a decrease and deficient recovery of PetCO2. Also, more hyperventilation complaints and complaints of other origin were reported during hostile resistance imagery compared with acceptance and relaxation. In conclusion, hostile resistance seems to trigger both physiological and symptom perception processes contributing to the clinical picture of CFS.