Bregje L. Seves

Introduction: Chronic pain is a public health priority that affects 18% of Dutch and 16% of German adults, representing a major societal burden. The Ems Dollart Region (EDR), which forms the northern part of the Dutch–German border area, is particularly characterised by lower incomes, more physically demanding jobs and lower health literacy, which are associated with higher pain prevalence. Individuals with lower socioeconomic status face greater pain-related disability and reduced quality of life. Public health campaigns underpinned by pain science education provide a strategy to improve understanding of pain among the wider public by addressing common misconceptions about its causes and management. However, large-scale population-level interventions and evaluations of such campaigns remain limited. Methods and analysis: This protocol describes the design and implementation of a cross-border public health campaign in the EDR, aimed at improving public understanding of pain, changing attitudes and beliefs and promoting healthy behaviours. We will conduct a quasi-experimental before–after study in the EDR with a control group in Flanders (Belgium). The intervention is guided by behaviour change and biopsychosocial models. The campaign will deliver tailored content via social media, broadcast, print and online advertisements over a 24-month period. Two independent cross-sectional samples will be surveyed at baseline and at 2-year follow-up, comprising 3200 participants per measurement wave from three regions: the Netherlands and Germany as intervention regions, and Flanders, Belgium, as the control region. The primary outcome is the prespecified Pain Concepts Questionnaire ratio score, assessing pain-related knowledge, attitudes and beliefs. The primary analysis will use an adjusted difference-in-differences framework to estimate whether change in the primary outcome differs between the combined intervention regions and the control region. Secondary analyses will examine the Netherlands and Germany separately and will evaluate healthcare utilisation, medication use, health-related quality of life and work absenteeism. Ethics and dissemination: This study protocol was reviewed by the Medical Ethics Review Board of the University Medical Center Groningen and the University of Oldenburg. The study was considered not subject to the Medical Research Involving Human Subjects Act (non-WMO declaration; reference number M24.345555, issued on 31 December 2024) and was approved by the University of Oldenburg Ethics Committee (reference number 2025–056, issued on 07 March 2025). Informed consent was obtained electronically by the research agency at the time of participants’ registration with the research panel. Study findings, regardless of outcome, will be disseminated through peer-reviewed publications and presentations at national and international conferences.

Objectives This study aimed to (1) examine if activity fluctuations over 1 week differ between two groups: individuals who have received fatigue management advice versus those who have not, (2) examine the associations between activity fluctuations and fatigue, engagement in pacing, perceived risk of overactivity, quality of life, self-regulation and physical activity (PA) and if they differ for the two groups and (3) explore whether there are distinct pacing patterns across the week in adults with chronic conditions. Design Exploratory cross-sectional observational study. Setting Participants were recruited from a fatigue management clinic in the UK and through university networks. Participants 29 adults with chronic conditions who experience fatigue (18 received fatigue management advice; 11 did not). Primary and secondary outcome measures The primary outcome was activity fluctuations (SD of accelerometer-derived vector magnitude counts per minute), measured using the ActiGraph wGT3X-BT over 7 consecutive days. Secondary outcomes included fatigue (Fatigue Severity Scale), engagement in activity pacing, perceived risk of overactivity, quality of life (Functional Assessment of Cancer Therapy-General Instrument), self-regulation of PA (Physical Activity Self-Regulation scale) and self-reported PA (International Physical Activity Questionnaire-short form). Results No difference in activity fluctuations during the day was found between groups. Associations between self-regulation of PA and device-based PA with activity fluctuations significantly differed between groups (respectively, standardised regression (β)=1686.14; p=0.006 and β=288.83; p=0.042). Five distinct activity pacing patterns were identified through visual inspection of individual activity profiles: (1) high fluctuations in the morning, (2) high fluctuations in the afternoon, (3) high fluctuations at two time points, (4) consistent pacing pattern and (5) varied pacing patterns. Conclusions Individuals who received fatigue management advice demonstrated significant associations between activity fluctuations and self-regulation, suggesting a goal-directed approach, which could indicate that tailored support and goal setting could help in balancing rest and activity. This study also identified five distinct activity pacing patterns in individuals with chronic conditions, emphasising the need for tailored fatigue management instead of a ‘one-size-fits-all’ approach. Trial registration number NCT06001970.

Purpose: Chronic low back pain (CLBP) is a leading cause of disability worldwide, requiring coordinated referrals across different healthcare services. Despite clinical guidelines emphasising a biopsychosocial approach, referral decisions are often unstructured and poorly understood. Existing research has mainly focused on clinical management, with limited attention to the factors influencing referral decisions and their impact on referral pathways. The objective of this scoping review is to map the existing literature on factors influencing referral decisions for patients with non-specific CLBP and identify gaps for future research. Methods: Following PRISMA-ScR guidelines and Joanna Briggs Institute guidance for scoping reviews, a comprehensive literature search was conducted across the PubMed, EMBASE, and Web of Science databases. Studies focusing on referral decisions for patients with CLBP were included. Data extraction and descriptive synthesis were performed. Results: The search yielded 4,816 records, with 13 studies meeting inclusion criteria. Included studies, conducted between 1996 and 2025, spanned Europe, North America, and Israel, and comprised diverse designs including qualitative interviews, surveys, experimental vignettes, cross-sectional and cohort studies. Referral decisions in CLBP care were influenced by an interplay of clinical, psychosocial, patient-related, healthcare professional-related, systemic and contextual factors. Conclusion: This scoping review highlights the multifactorial nature of referral decisions in CLBP care and identifies critical gaps in current research. Future prospective studies are needed to better understand these factors and referral pathways, aiming to improve guideline adherence, patient outcomes, and equity in CLBP management.

Background: This systematic review aims to identify modifiable and non-modifiable predictors of exercise capacity (VO₂peak level or change) in stroke survivors. These insights may further optimize rehabilitation treatment and improve long-term health outcomes. Methods: PubMed (PubMed.gov), EMBASE (Elsevier), CINAHL (EBSCO), and Web of Science (Clarivate) were searched (last search on 7 October 2025). Inclusion criteria were: (1) adults (>18 years) who survived a stroke (ischemic and hemorrhagic), (2) outcome was a measurement of maximum exercise capacity (VO₂peak) measured with CPET (or equivalent), (3) predictors of exercise capacity were measured (e.g., personal factors, disease-related factors, components of rehabilitation), (4) predictors of exercise capacity were analyzed in multivariate regression models, (5) primary research, and (6) full-text available. During the data extraction phase, predictors were categorized into modifiable and non-modifiable predictors. Risk of bias was assessed with the McMaster Critical Review Form for Quantitative Studies. Results: Of 919 unique articles, seventeen were included. Modifiable factors such as BMI (4/8 articles) and fat mass (1/1), lower limb strength (3/3), cardiorespiratory fitness (e.g., baseline VO₂peak (2/4)), training intensity (2/2) and perceived fatigue (1/1) significantly predicted VO₂peak (level or change). Significant non-modifiable predictors were age (3/11), sex (1/8), diabetes (1/2), and stroke-specific (4/8) factors. Conclusions: This systematic review highlights the significant role of modifiable and non-modifiable predictors in optimizing exercise capacity (VO₂peak) for stroke survivors. In addition, considering modifiable and non-modifiable predictors allows for more personalized treatment planning. The findings can guide healthcare professionals in tailoring rehabilitation programs, though further research is needed to develop a comprehensive prediction model.

BACKGROUND: Use of a microprocessor-controlled knee (MPK) compared to a non-microprocessor-controlled knee (NMPK) can lead to improved walking ability, confidence and satisfaction. However, the MPK is more expensive than the NMPK and it is unknown whether the higher costs outweigh the potential benefits. OBJECTIVE: To evaluate the cost-utility and cost-effectiveness of MPKs and NMPKs from a societal perspective in the Netherlands. METHODOLOGY: Participants completed the Dutch version of the EuroQol - five dimensions - five levels (EQ-5D-5L) to assess health-related quality of life, three subscales (ambulation, utility and well-being) of the Prosthesis Evaluation Questionnaire (PEQ) to assess prosthesis-related quality of life and a cost-questionnaire from societal perspective. Incremental cost-utility ratio (ICUR) and incremental cost-effectiveness ratio (ICER) were calculated and the ICUR was compared with the Dutch willingness-to-pay threshold. Bootstrapping was used to estimate statistical uncertainty, and multiple imputation was applied to account for missing values. FINDINGS: In total, 111 participants were included (37 female, 73 male, 1 unknown; 71 transfemoral, 39 knee disarticulation, 1 unknown; age 64 ± 13 years; 49 NMPK users, 62 MPK users). The cost-utility analysis demonstrated that the MPK yielded an increase of 0.032 quality adjusted life years (QALY) but at considerably higher costs. The mean cost difference was € 14,626, resulting in a mean ICUR of € 457,063 per QALY gained. The cost difference was mainly driven by acquisition costs but was partially compensated by lower costs of work absence, health care consumption and household care. CONCLUSION: The cost-effectiveness analyses demonstrated that the MPK is likely to provide benefits in term of prosthesis-specific quality of life, but at higher costs. However, short-term improvement in health-related quality of life was too small to result in substantial QALY gain to offset the higher costs of the MPK and result in an incremental cost-utility ratio below the generally accepted willingness-to-pay thresholds. Layman's Abstract In this study, we compared two types of prosthetic knees that are used by people with a lower limb amputation. One is a high-tech version that uses a built-in computer sensor to help control movement (called a microprocessor controlled knee or MPK) and the other is a simpler, mechanical version (called a non-microprocessor controlled knee or NMPK). MPKs can help people walk more easily and feel more confident, but have a much higher acquisition cost. We compared the costs and benefits of both types of knees by studying 111 people who were either using an MPK or NMPK in their daily life. They completed surveys about their health, how they felt about their prosthesis, their healthcare use and work. Results showed that the people using an MPK reported better experiences in terms of mobility and satisfaction with their prosthesis. However, while the MPK did also improve quality of life a little bit, the improvement was small compared to how much more it costs. While the MPK helped reduce some other costs like time of work and healthcare use, the overall benefit wasn’t enough to make it cost-effective by current standards in the Netherlands. In conclusion, while the MPK offers some advantages, they may not be enough to justify the higher price, at least not in the short term. More research could help us understand whether the benefits grow over time. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/45823/34424 How To Cite: Bosman C.E, van der Sluis C.K, Vrieling A.H, Geertzen J.H.B, Seves B.L, Groen H. Health economic evaluation of microprocessor and non-microprocessor controlled prosthetic knees. Canadian Prosthetics & Orthotics Journal. 2025; Volume 8, Issue 2, No. 3. https://doi.org/10.33137/cpoj.v8i2.45823 Corresponding Author: Charlotte E. Bosman, PhDAffiliation: Department of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.E-Mail: c.e.bosman@umcg.nlORCID ID: https://orcid.org/0000-0001-7950-5893

Background: The use of lower limb prosthesis can impact all aspects of daily life, activities and participation. Various studies have compared the microprocessor-controlled knee (MPK) to the non-microprocessor-controlled knee (NMPK) using a variety of different outcome measures, but results are inconsistent and raise the question of which type of knee is most effective. Therefore, we aimed to assess the effect of MPKs compared to NMPKs across all classified ICF domains in adult prosthesis users. Methods: Participants performed baseline measurements with the NMPK (T0). One week later, they started a four-to-six-week trial period with the MPK. Afterward, measurements were repeated with the MPK (T1). Functional tests (6MWT, TUG-test and activity monitor) and questionnaires (ABC, SQUASH, USER-P and PEQ) were used. For statistical analyses, paired t-tests, Wilcoxon signed-rank tests and Chi² test were applied. The Benjamini–Hochberg procedure was applied to correct for multiple testing. Results: Twenty-five participants were included. Using an MPK compared to an NMPK significantly resulted in improvements in balance and walking confidence, safety, walking distance and self-reported walking ability, as well as a decrease in number of stumbles and falls. Additionally, participants using an MPK were significantly more satisfied with their participation, experienced fewer restrictions, reported greater satisfaction with the appearance and utility of the MPK, experienced less social burden and reported better well-being, compared to using an NMPK. Conclusions: Using an MPK instead of an NMPK can lead to significant improvements in all classified ICF domains, such as improved walking ability, confidence and satisfaction and reduced fall risk.

This study aimed to identify trajectories of physical activity behavior from discharge up to 6-8 years after rehabilitation among adults with physical disabilities and/or chronic diseases, and to determine modifiable determinants associated with trajectory membership. 390 Adults with physical disabilities and/or chronic diseases participated in the Rehabilitation, Sports and Active lifestyle (ReSpAct) 2.0 study with measurements at 3-6 weeks before discharge (T0), and 14 (T1), 33 (T2), and 52 weeks (T3), and 6-8 years (T4) after discharge from rehabilitation. Physical activity behavior and its determinants were assessed using questionnaires. Latent class growth modeling was used to identify trajectories of physical activity behavior. Associations between determinants at T0 and trajectory membership were analyzed using logistic regression analyses. Three trajectories of physical activity behavior were identified: a moderately active (n = 297; baseline total physical activity: 1370 (770:2070) min/week), highly active (n = 71; baseline total physical activity: 2950 (1945:3475) min/week), and increasingly active (n = 22; baseline total physical activity: 1755 (461:2415) min/week) trajectory. Barriers regarding physical activity (OR = 0.71, 95%CI 0.53-0.95) and perceived fatigue (OR = 0.75, 95%CI 0.57-0.98) were significantly associated with trajectory membership in univariable models, corrected for age and sex. Targeting barriers regarding physical activity and perceived fatigue early in rehabilitation seem crucial for membership of a trajectory resulting in a more favorable development of physical activity behavior after rehabilitation.

Adults with physical disabilities or chronic diseases face numerous barriers to participate in physical activity (PA). There is little knowledge about how these PA barriers evolve during and after rehabilitation, and how this relates to PA beh...