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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. ispartof: EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE vol:56 issue:2 pages:220-227 ispartof: location:Italy status: published

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. ispartof: EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE vol:56 issue:2 pages:228-236 ispartof: location:Italy status: published

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.

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.

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 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.

We read with interest the comments from Corrado and colleagues on our paper related to pre-participation screening in young athletes.1 2 The authors start their critique by suggesting that we are laypersons in the field of sports cardiology. The first author of our paper is a cardiologist with 30 years’ clinical experience. We are all active in critically appraising scientific literature and/or teaching evidence based medicine on a daily, professional basis. We may not be directly involved in sports cardiology, but the absence of conflicts of interest helps in being neutral when assessing scientific evidence. Furthermore, our manuscript has been peer reviewed through our submission to The BMJ by three renowned sports cardiologists from the UK, the US, and Australia. And the report from which our paper was extracted had been reviewed previously by independent Belgian and Dutch experts.3 More recently, two updated recommendations on pre-participation screening have been published, both from trusted sources. The UK National Screening Committee’s recommendation on screening to prevent sudden cardiac death (SCD) in 12-39 year olds, published in July 2015, is clear: “Systematic population screening programme is not recommended.”4 In December 2015 the …

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.

This paper reports on the development of a powered transtibial prosthesis. The initial prosthesis prototype is a pneumatically powered system, which serves as test bed for proof-of-concept and evaluating control algorithms in laboratory conditions. The characteristics and working principle of the actuators are described. The control approach is discussed. First experimental results with an amputee are presented that demonstrate the promising performance properties of the powered prosthesis.

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Due to its high power-to-weight ratio, a pleated pneumatic artificial muscle (PPAM) offers an interesting alternative actuation source for robotic devices. Its inherent compliant behaviour excites another broad field of interest: assistive clinical devices such as powered exoskeletons and prosthetics. In this paper, the design of a pneumatically powered transtibial prosthetic device is presented. A first prototype has been built and provides a preliminary test bed for control algorithm development and testing with able-bodied subjects in laboratory conditions. The characteristics and working principle of a PPAM are described. The design specifications and the mechanical model of the prosthesis are discussed. The mechanical design and the control structure are outlined. Furthermore, some initial walking trials with an able-bodied subject wearing the prosthesis prototype are presented and discussed.