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Taylor S, Barker K, Stephensen D, Williamson E. Using evidence-based co-design to develop a hybrid delivered exercise intervention that aims to increase confidence to exercise in people with haemophilia. Haemophilia 2024; 30:817-826. [PMID: 38462814 DOI: 10.1111/hae.14972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/26/2024] [Accepted: 01/30/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION Due to advances in treatments, people with haemophilia (PWH) are living longer. They are not as active as the general population due to joint damage and lack confidence to be active due to concerns about further bleeds and pain. There is a need to facilitate healthy aging through promotion of physical activity (PA) and exercise. Changing patient beliefs and increasing physical literacy and confidence to move are thought to be key to helping PWH become more active. AIM This paper describes the development of an exercise and behaviour change intervention to improve confidence to exercise in PWH. METHODS The 4-stage Medical Research Council framework for complex intervention development was used. RESULTS Stakeholders included 17 PWH and 7 physiotherapists working in haemophilia. Seven online focus group meetings were held. The final intervention is a hybrid 12-week physiotherapist led progressive exercise programme. Classes are 45 min including Pilates, High intensity interval training and balance elements, together with discussion sessions focusing on PA recommendations, the types and benefits of different exercise styles and the effects of PA, together with the effects of aging for PWH. The COM-B model of behaviour change was used to develop the intervention. CONCLUSION Co-design helps to produce an intervention that understands the stakeholders needs. Through this process the intervention developed to incorporate not only increasing PA but also confidence to exercise. The use of behaviour change theory identified the behaviour techniques included in the intervention and aims to increase physical literacy in this population.
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Affiliation(s)
- Stephanie Taylor
- Oxford Haemophilia and Thrombosis Centre, Churchill Hospital, Oxford, UK
| | - Karen Barker
- Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford, UK
- NDORMS (Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences), University of Oxford, Oxford, UK
| | - David Stephensen
- Faculty of Medicine Health and Social Care, Canterbury Christ Church University, Canterbury, UK
| | - Esther Williamson
- NDORMS (Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences), University of Oxford, Oxford, UK
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Donoso-Úbeda E, Ucero-Lozano R, Meroño-Gallut J, Cuesta-Barriuso R, Pérez-Llanes R. Safety and efficacy of myofascial release therapy in the treatment of patients with hemophilic ankle arthropathy. Single-blind randomized clinical trial. Physiother Theory Pract 2024:1-10. [PMID: 38530214 DOI: 10.1080/09593985.2024.2334752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/19/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Hemophilia is characterized by degenerative joint damage. Patients with hemophilic arthropathy present joint damage, reduced range of motion, and decreased strength and functional capacity. Myofascial release therapy aims to decrease pain and improve tissue mobility and functionality. OBJECTIVES To evaluate the safety and efficacy of myofascial release therapy in patients with hemophilic ankle arthropathy. METHOD Single-blind randomized controlled trial. Fifty-eight adult patients with hemophilia were randomly allocated to the experimental group (myofascial release therapy with foam roller) or the control group (no intervention whatsoever). The daily home protocol of myofascial release therapy for the lower limbs using a foam roller lasted eight consecutive weeks. The primary variable was the safety of myofascial release therapy (weekly telephone follow-up). The secondary variables were pain intensity (visual analog scale), range of motion (goniometer), functional capacity (2-Minute Walk Test) and muscle strength (dynamometer), at baseline and at 8 and 10 weeks. RESULTS During the experimental phase, none of the patients in the experimental group developed ankle hemarthrosis. There were statistically significant changes in time*group interaction in ankle dorsal flexion (F[1.75] = 10.72; p < .001), functional capacity (F[1.16] = 5.24; p = .009) and gastrocnemius strength (F[2] = 26.01; p < .001). The effect size of the changes after the intervention was medium-large in pain intensity (d = -1.77), functional capacity (d = 1.34) and gastrocnemius strength (d = 0.76). CONCLUSION Myofascial release therapy is a safe form of physical therapy for patients with hemophilia. Myofascial release therapy can effectively complement prophylactic pharmacological treatment in patients with hemophilic arthropathy, improving range of motion in dorsal flexion, functional capacity and gastrocnemius strength.
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Affiliation(s)
- Elena Donoso-Úbeda
- Department of Physiotherapy, Catholic University San Antonio-UCAM, Murcia, Spain
- InHeFis Research Group, Instituto Asturiano de Investigación ,Sanitaria (ISPA), Oviedo, Spain
| | - Roberto Ucero-Lozano
- InHeFis Research Group, Instituto Asturiano de Investigación ,Sanitaria (ISPA), Oviedo, Spain
- Department of Physiotherapy, European University of Madrid, Madrid, Spain
| | - Javier Meroño-Gallut
- InHeFis Research Group, Instituto Asturiano de Investigación ,Sanitaria (ISPA), Oviedo, Spain
- Tú. Bienestar 360°, Physiotherapy and Medical Center, San Javier, Murcia, Spain
| | - Rubén Cuesta-Barriuso
- InHeFis Research Group, Instituto Asturiano de Investigación ,Sanitaria (ISPA), Oviedo, Spain
- Department of Surgery and Medical-Surgical Specialties, University of Oviedo, Oviedo, Spain
| | - Raúl Pérez-Llanes
- InHeFis Research Group, Instituto Asturiano de Investigación ,Sanitaria (ISPA), Oviedo, Spain
- Department of Physiotherapy, University of Murcia, Murcia, Spain
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McLaughlin P, Hurley M, Chowdary P, Khair K, Smith C, Stephensen D. Using theory of change to co-create a programme theory for a telerehabilitation intervention for pain management in people with haemophilia. Orphanet J Rare Dis 2023; 18:376. [PMID: 38041200 PMCID: PMC10693140 DOI: 10.1186/s13023-023-02988-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/18/2023] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND Improved approaches for chronic pain management are a clinical and research priority for people with haemophilia (PWH). Involving people with lived experience in the design of a complex rehabilitation intervention strengthens the credibility and plausibility of the intervention, particularly in relation to rare disorders. Here we describe using a 'Theory of Change' (ToC) dialogue-based stakeholder process to create a programme theory for a telerehabilitation intervention. METHODS An online workshop was convened and stakeholders received a briefing document in advance. Five stakeholders took part (3 PWH and 2 physiotherapists). At the workshop the group first agreed the overall aim of the intervention. Discussions then identified the resources, activities, barriers and enablers needed to achieve this outcome. All discussions were recorded and annotated by the workshop moderator. Behaviour change techniques were mapped for inclusion in the theory. RESULTS A programme theory and narrative report were produced. All stakeholders reviewed these for clarity and to ensure a true reflection of the workshop discussions. Agreement was based on how meaningful, well-defined, do-able, plausible, credible, and testable each component was. Stakeholders highlighted the importance of issues unique to PWH. Key components included the need for physiotherapists to be knowledgeable of the condition, a range of exercises that were inclusive of all abilities, and the need for people to feel safe and supported whilst taking part. CONCLUSIONS Co-developed theory based approaches to intervention design offer an inclusive and transparent way to develop novel and meaningful interventions for people with complex health conditions. The ToC is wholly transparent in its design and content. Together with the identified behaviour change techniques, the theory informs the protocol for a feasibility study evaluating a telerehabilitation intervention. Importantly, it allows the opportunity to revise, adapt and improve the programme theory for further implementation and evaluation.
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Affiliation(s)
- Paul McLaughlin
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK.
- Department of Academic Haematology, University College, London, UK.
| | | | - Pratima Chowdary
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
- Department of Academic Haematology, University College, London, UK
| | | | | | - David Stephensen
- School of Medicine, Health and Social Care, Canterbury Christchurch University, Canterbury, Kent, UK
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Khair K, McLaughlin P, Roussel N, Boyton M, Holland M. Prevalence and perceptions of pain in people with haemophilia: A UK study. Haemophilia 2023; 29:1509-1518. [PMID: 37694815 DOI: 10.1111/hae.14860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 08/11/2023] [Accepted: 08/30/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION Joint bleeds in haemophilia cause destruction of articular structures, impaired function and pain. Up to 70% of people with haemophilia (PWH) report chronic pain. Little is known about the pain experiences in PWH in the UK. AIM To identify prevalence and perceptions of pain among PWH living in the UK. METHODS A cross-sectional, non-interventional survey study conducted among PWH (all severities). The survey incorporated elements from validated tools (EQ-5D; EQ-VAS) and was distributed via participating treatment centres. RESULTS Five hundred and ninety-nine PWH responded, 91% aged > 18. 81% used factor prophylactically or on demand. More pain was reported by those treated on demand versus prophylaxis particularly in those who reported daily pain. 65% reported 'problem joints' based on individual impact rather than medically defined 'target joints', 2/3 reported multiple joint issues. The ankle was most commonly affected. 59% reported frequent pain, with 56% aware of pain constantly or most of the time and were more likely to report less favourable EQ-5D or EQ-VAS scores (p < .001). Pain frequency/awareness was consistent across all severities. Most discussed pain with care teams, 31% only when asked; 25% did not discuss it. Pain discussions resulted in physiotherapy referral (63%) analgesia prescription (48%), and a minority specialist pain referral (9%). Most felt well supported with regard to their pain, but 70% reported learning to live with it. CONCLUSION Pain affects PWH of all ages and severities even in a well-resourced country significantly impacting quality of life. Clinicians must be more aware of chronic pain in PWH. Biopsychosocial approaches to pain assessment and management are recommended.
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Affiliation(s)
| | - Paul McLaughlin
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free Hospital, London, UK
| | - Nathalie Roussel
- Department of Rehabilitation Sciences and Physiotherapy (MOVANT), Faculty of Medicine and Health Sciences, University of Antwerp, Campus Drie Eiken, Antwerp, Belgium
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Vanderstraeten R, Fourré A, Demeure I, Demoulin C, Michielsen J, Anthierens S, Bastiaens H, Roussel N. How Do Physiotherapists Explain Influencing Factors to Chronic Low Back Pain? A Qualitative Study Using a Fictive Case of Chronic Non-Specific Low Back Pain. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20105828. [PMID: 37239555 DOI: 10.3390/ijerph20105828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/07/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND While pain is influenced by multiple factors including psychosocial factors, previous research has shown that physiotherapists still favour a biomedical approach. PURPOSE To evaluate: (1) how physiotherapists explain the patient's chronic non-specific low back pain (LBP); (2) whether physiotherapists use one or multiple influencing factors, and (3) whether these factors are framed in a biopsychosocial or biomedical approach. MATERIALS AND METHODS This exploratory qualitative study uses a vignette depicting chronic non-specific LBP and employs a flexible framework analysis. Physiotherapists were asked to mention contributing factors to the pain based on this vignette. Five themes were predefined ("Beliefs", "Previous experiences", "Emotions", "Patients behaviour", "Contextual factors") and explored. RESULTS Physiotherapists use very brief explanations when reporting contributing factors to chronic pain (median 13 words). Out of 670 physiotherapists, only 40% mentioned more than two different themes and 2/3rds did not see any link between the patients' misbeliefs and pain. Only a quarter of the participants mentioned the patient's worries about pain and movement, which is considered to be an important influencing factor. CONCLUSION The lack of a multifactorial approach and the persistent biomedical beliefs suggest that it remains a challenge for physiotherapists to fully integrate the biopsychosocial framework into their management of chronic LBP.
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Affiliation(s)
- Rob Vanderstraeten
- Department of Rehabilitation Sciences and Physiotherapy (MOVANT), Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium
| | - Antoine Fourré
- Department of Rehabilitation Sciences and Physiotherapy (MOVANT), Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium
- Department of Neurosciences, Université de Mons, 7000 Mons, Belgium
| | - Isaline Demeure
- Department of Rehabilitation Sciences and Physiotherapy (MOVANT), Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium
| | - Christophe Demoulin
- Department of Sport and Rehabilitation Sciences, University of Liege, EVAREVA, 4000 Liege, Belgium
- Faculty of Motricity Sciences, UCLouvain, 1348 Louvain-la-Neuve, Belgium
| | - Jozef Michielsen
- Department of Rehabilitation Sciences and Physiotherapy (MOVANT), Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium
- Anatomy and Research Centre (ASTARC), University Hospital of Antwerp, Antwerp Surgical Training, 2650 Antwerp, Belgium
| | - Sibyl Anthierens
- Department of Family Medicine and Population Health (FAMPOP), Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium
| | - Hilde Bastiaens
- Department of Family Medicine and Population Health (FAMPOP), Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium
| | - Nathalie Roussel
- Department of Rehabilitation Sciences and Physiotherapy (MOVANT), Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium
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McLaughlin P, Hurley M, Chowdary P, Stephensen D, Khair K. How does a lifetime of painful experiences influence sensations and beliefs about pain in adults with severe haemophilia? A qualitative study. Disabil Rehabil 2022; 44:8412-8419. [PMID: 34951551 DOI: 10.1080/09638288.2021.2018053] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE To explore the life experiences of pain in people with severe haemophilia and understand how such experiences influence beliefs and sensation of pain in adulthood. METHODS A qualitative inquiry approach using focus groups and semi-structured individual interviews was used. Participants included people with severe haemophilia living with chronic pain. Data were analysed using reflexive thematic analysis. RESULTS Fourteen men with a median age of 47 (range 23-73) agreed to take part. Eleven participated in two focus groups and three were interviewed over telephone. Two themes were conceptualised from the data: (i) haemophilia and pain - an evolving life biography (the personal narrative, historical, social, and medical context, continuous adaptation of activity choices, surveillance of pain and its meaning); (ii) "My normal isn't normal" - identity and self-agency (pain as a feature of life and identify with severe haemophilia, loss of enjoyable activities balanced against staying active, barriers to participation). CONCLUSIONS Pain is a constantly evolving, lifetime feature for many adults with haemophilia and it is viewed as part of their identity with their condition. Healthcare professionals working in haemophilia should try to better understand the influence of an individuals lived experience with their haemophilia on beliefs and behaviours of pain.Implications for rehabilitationSevere haemophilia is a rare bleeding disorder that results in musculoskeletal joint disease.Adults with severe haemophilia have experienced multiple episodes of bleeding related musculoskeletal pain since childhood.Pain beliefs and behaviours in adulthood appear to be influenced by a lifetime of painful experiences associated with haemophilia.In order to better support people with haemophilia and chronic pain, healthcare professionals in haemophilia need to better understand how an individuals lived experience of pain helps inform their beliefs about it.
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Affiliation(s)
- P McLaughlin
- Faculty of Health, Social Care and Education, St George's University of London and Kingston University, London, UK.,Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - M Hurley
- Faculty of Health, Social Care and Education, St George's University of London and Kingston University, London, UK
| | - P Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - D Stephensen
- East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - K Khair
- Centre for Outcomes and Experience Research in Child Health, Illness and Disability (ORCHID) Research Unit, Great Ormond Street Hospital for Children NHS Trust, London, UK.,Haemnet, London, UK
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Matlary RED, Grinda N, Sayers F, Versloot O, McLaughlin P. Promoting physical activity for people with haemophilia in the age of new treatments. Haemophilia 2022; 28:885-890. [PMID: 35896000 PMCID: PMC9796679 DOI: 10.1111/hae.14641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 01/07/2023]
Abstract
Haemophilia treatment has seen great advances in recent years with an accompanied reduced risk of physical activity (PA) related bleeds. Based on its known health benefits, people with haemophilia (PWH) are currently encouraged to regularly engage in PA. However, this may not always translate to increased levels of PA. In this narrative review we aim to provide a brief overview of what is currently understood regarding PA levels and influences for the three broad age groups of children and adolescents, adults and older adults. We also provide recommendations for members of the haemophilia team on important aspects related to promotion of PA in their clinical practice. We highlight that PA behaviour is multifactorial and that many PWH still have limited access to adequate care. Whilst some still face unique challenges to being more physically active, overall, the barriers and facilitators to activity are very similar to that of the general population.
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Affiliation(s)
- Ruth Elise D. Matlary
- Department of HaematologyOslo University HospitalOsloNorway,Institute of Clinical MedicineUniversity of OsloOsloNorway
| | - Nathalie Grinda
- Haemophilia Reference CentreBicêtre Hospital AP‐HP University Paris XIParisFrance
| | - Fionnuala Sayers
- Haemophilia Comprehensive Care CentreBelfast Health and Social Care TrustBelfastUK
| | - Olav Versloot
- Centre for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands,Department of PhysiotherapyInstitute of Movement StudiesUniversity of Applied ScienceUtrechtthe Netherlands
| | - Paul McLaughlin
- Katharine Dormandy Haemophilia Centre and Thrombosis UnitRoyal Free London NHS Foundation TrustLondonUK
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Roussel NA, Chantrain VA, Foubert A, Lambert C, Hermans C, Meeus M, Guillaume S, Lecouvet F, Krüger S, Hilberg T, Lobet S. Gaining more insight into ankle pain in haemophilia: A study exploring pain, structural and functional evaluation of the ankle joint. Haemophilia 2022; 28:480-490. [PMID: 35294993 DOI: 10.1111/hae.14544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/25/2022] [Accepted: 02/25/2022] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Ankle arthropathy is highly prevalent among people with haemophilia (PwH), even with prophylaxis, and leads to pain and disability. Mechanisms and consequences of painful symptoms related to ankle arthropathy have not been extensively studied. METHODS A consecutive sample of 30 adult PwH was included (60 ankles). Ankle structure was assessed with magnetic resonance imaging (IPSG-MRI) and ultrasound (HEAD-US). The HJHS 2.1 assessed function of ankles and knees. Physical functioning was assessed with the Timed Up and Go test, the 2-Minute Walking Test and activity limitations with the HAL questionnaire. Health-related quality of life was evaluated using the EQ-5D-5L questionnaire. Overall pain severity was examined using the Brief Pain Inventory questionnaire and ankle pain intensity with a visual analogue scale. Pressure pain thresholds with an algometer assessed pain sensitivity. Spearman correlations were used to calculate interrelations between joint structure, function and pain. RESULTS Twenty-five PwH (83%) reported ≥1 painful joint, with 67% reporting the ankle as most painful joint. MRI-confirmed abnormalities were seen in 76% of talocrural and 55% of subtalar joints. HEAD-US abnormalities were seen in 93% of the ankles. A large variation was seen in pain sensitivity at the ankle. While moderate to high correlations were observed between ankle structure and HJHS, no meaningful correlations were found between MRI-scores and pain intensity or sensitivity. CONCLUSIONS Structural joint damage is present in many ankles but is not related to pain in PwH. Further studies should consider somatosensory nervous system dysfunction in PwH as contributing factor to painful ankle arthropathy.
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Affiliation(s)
- Nathalie Anne Roussel
- Faculty of Medicine and Health Sciences (MOVANT), University of Antwerp, Antwerp, Belgium
| | - Valérie-Anne Chantrain
- Faculty of Medicine and Health Sciences (MOVANT), University of Antwerp, Antwerp, Belgium.,Pain in Motion International Research Group, www.paininmotion.be
| | - Anthe Foubert
- Faculty of Medicine and Health Sciences (MOVANT), University of Antwerp, Antwerp, Belgium.,Pain in Motion International Research Group, www.paininmotion.be
| | - Catherine Lambert
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Cedric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Mira Meeus
- Faculty of Medicine and Health Sciences (MOVANT), University of Antwerp, Antwerp, Belgium.,Pain in Motion International Research Group, www.paininmotion.be.,Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium
| | - Sylvain Guillaume
- Department of Radiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Frédéric Lecouvet
- Department of Radiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Steffen Krüger
- Department of Sports Medicine, University of Wuppertal, Wuppertal, Germany
| | - Thomas Hilberg
- Department of Sports Medicine, University of Wuppertal, Wuppertal, Germany
| | - Sebastien Lobet
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques universitaires Saint-Luc, Brussels, Belgium.,Neuromusculoskeletal Lab (NMSK), Secteur des Sciences de la Santé, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Louvain, Belgium.,Secteur de kinésithérapie, Cliniques universitaires Saint-Luc, Brussels, Belgium
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