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1.  Constraint-induced movement therapy: trial sequential analysis applied to Cochrane collaboration systematic review results 
Trials  2014;15(1):512.
Trial sequential analysis (TSA) may establish when firm evidence about the efficacy of interventions is reached in a cumulative meta-analysis, combining a required information size with adjusted thresholds for conservative statistical significance. Our aim was to demonstrate TSA results on randomized controlled trials (RCTs) included in a Cochrane systematic review on the effectiveness of constraint-induced movement therapy (CIMT) for stroke patients.
We extracted data on the functional independence measure (FIM) and the action research arm test (ARAT) from RCTs that compared CIMT versus other rehabilitative techniques. Mean differences (MD) were analyzed using a random-effects model. We calculated the information size and the cumulative Z-statistic, applying the O’Brien-Fleming monitoring boundaries.
We included data from 14 RCTs. In the conventional meta-analysis (seven trials, 233 patients), the effect of CIMT on FIM was reported as significant (MD 2.88, 95% CI 0.08 to 5.68; P = 0.04). The diversity-adjusted required information size was 142 patients, and the cumulative Z-score did not cross the trial sequential monitoring boundary for benefit (adjusted 95% CI -0.02 to 5.78). The effect of CIMT on ARAT (nine trials, 199 patients) was reported as significant (MD 7.78, 95% CI 1.19 to 14.37; P = 0.02). However, the diversity-adjusted required information size was 252 patients, and the Z-score did not cross the trial sequential monitoring boundary for benefit (adjusted 95% CI -0.06 to 15.62).
Although conventional meta-analyses of CIMT reached statistical significance, their overall results remain inconclusive and might be spurious. Researchers should not be overconfident on CIMT efficacy based on the results of meta-analyses and derived recommendations.
PMCID: PMC4307139  PMID: 25542215
Stroke; Constraint-induced movement therapy; Meta-analysis; Random error; Trial sequential analysis
2.  Intra-rater reliability of an experienced physiotherapist in locating myofascial trigger points in upper trapezius muscle 
Myofascial trigger points (MTrPs) are considered the principal clinical feature of myofascial pain syndrome (MPS). An MTrP consists of spot tenderness within a taut band of muscle fibers and its stimulation can produce both local and referred pain. The clinical diagnosis of MPS depends on correct history taking and a physical examination aimed at identifying the presence of MTrP. The purpose of this study was to investigate the intra-rater reliability of a palpation protocol used for locating an MTrP in the upper trapezius muscle.
Twenty-four subjects with MTrP in the upper trapezius muscle were examined by an experienced physiotherapist. During each of eight experimental sessions, subjects were examined twice in randomized order using a palpation protocol. An anatomical landmark system was defined and the MTrP location established using X and Y values.
The intraclass correlation coefficient ICC(1,1) values were 0.62 (95% CI: 0.30–0.81) for X and 0.81 (95% CI: 0.61–0.91) for Y. The Bland–Altman plots for X and Y showed a mean of difference of 0.04 and −0.2 mm, respectively. Limits of agreement for X ranged from −26.3 to 26.2 mm and for Y from −27 to 26.4 mm.
The ICC(1,1) for the observed values revealed a moderate to high correlation and the Bland–Altman analysis showed means of difference very close to zero with narrow limits of agreement. An experienced physiotherapist can reliably identify MTrP locations in upper trapezius muscle using a palpation protocol.
PMCID: PMC3500129  PMID: 24179324
Myofascial pain syndromes; Myofascial trigger points; Intra-rater reliability; Palpation; Upper trapezius muscle
3.  Efficacy of Muscle Exercise in Patients with Muscular Dystrophy: A Systematic Review Showing a Missed Opportunity to Improve Outcomes 
PLoS ONE  2013;8(6):e65414.
Although muscular dystrophy causes muscle weakness and muscle loss, the role of exercise in the management of this disease remains controversial.
The purpose of this systematic review is to evaluate the role of exercise interventions on muscle strength in patients with muscular dystrophy.
We performed systematic electronic searches in Medline, Embase, Web of Science, Scopus and Pedro as well as a list of reference literature. We included trials assessing muscle exercise in patients with muscular dystrophy. Two reviewers independently abstracted data and appraised risk of bias.
We identified five small (two controlled and three randomized clinical) trials comprising 242 patients and two ongoing randomized controlled trials. We were able to perform two meta-analyses. We found an absence of evidence for a difference in muscle strength (MD 4.18, 95% CIs - 2.03 to 10.39; p = 0.91) and in endurance (MD −0.53, 95% CIs –1.11 to 0.05; p = 0.26). In both, the direction of effects favored muscle exercise.
The first included trial about the efficacy of muscular exercise was published in 1978. Even though some benefits of muscle exercise were consistently reported across studies, the benefits might be due to the small size of studies and other biases. Detrimental effects are still possible. After several decades of research, doctors cannot give advice and patients are, thus, denied basic information. A multi-center randomized trial investigating the strength of muscles, fatigue, and functional limitations is needed.
PMCID: PMC3680476  PMID: 23894268
4.  Myofascial trigger points and innervation zone locations in upper trapezius muscles 
Myofascial trigger points (MTrPs) are hyperirritable spots located in taut bands of muscle fibres. Electrophysiological studies indicate that abnormal electrical activity is detectable near MTrPs. This phenomenon has been described as endplate noise and it has been purported to be associated MTrP pathophysiology. Thus, it is suggested that MTrPs will be overlap the innervation zone (IZ). The purpose of this work was to describe the location of MTrPs and the IZ in the right upper trapezius.
We screened 71 individuals and eventually enrolled 24 subjects with neck pain and active MTrPs and 24 neck pain-free subjects with latent MTrPs. Surface electromyography (sEMG) signals were detected using an electrode matrix during isometric contraction of the upper trapezius. A physiotherapist subsequently examined the subject’s trapezius to confirm the presence of MTrPs and establish their location. IZ locations were identified by visual analysis of sEMG signals. IZ and MTrPs locations were described using an anatomical coordinate system (ACS), with the skin area covered by the matrix divided into four quadrants.
No significant difference was observed between active and latent MTrPs locations (P = 0.6). Forty-five MTrPs were in the third quadrant of the ACS, and 3 were included in second quadrant. IZs were located approximately midway between the seventh cervical vertebrae and the acromial angle in a limited area in the second and third quadrants. The mean distance between MTrP and IZ was 10.4 ± 5.8 mm.
According to the acquired results, we conclude that IZ and MTrPs are located in well-defined areas in upper trapezius muscle. Moreover, MTrPs in upper trapezius are proximally located to the IZ but not overlapped.
PMCID: PMC3683329  PMID: 23758854
Myofascial trigger point; Myofascial pain; Innervation zone; Endplate; Surface EMG
5.  Training of Manual Actions Improves Language Understanding of Semantically Related Action Sentences 
Conceptual knowledge accessed by language may involve the reactivation of the associated primary sensory-motor processes. Whether these embodied representations are indeed constitutive to conceptual knowledge is hotly debated, particularly since direct evidence that sensory-motor expertise can improve conceptual processing is scarce. In this study, we sought for this crucial piece of evidence, by training naive healthy subjects to perform complex manual actions and by measuring, before and after training, their performance in a semantic language task. Nineteen participants engaged in 3 weeks of motor training. Each participant was trained in three complex manual actions (e.g., origami). Before and after the training period, each subject underwent a series of manual dexterity tests and a semantic language task. The latter consisted of a sentence-picture semantic congruency judgment task, with 6 target congruent sentence-picture pairs (semantically related to the trained manual actions), 6 non-target congruent pairs (semantically unrelated), and 12 filler incongruent pairs. Manual action training induced a significant improvement in all manual dexterity tests, demonstrating the successful acquisition of sensory-motor expertise. In the semantic language task, the reaction times (RTs) to both target and non-target congruent sentence-picture pairs decreased after action training, indicating a more efficient conceptual-semantic processing. Noteworthy, the RTs for target pairs decreased more than those for non-target pairs, as indicated by the 2 × 2 interaction. These results were confirmed when controlling for the potential bias of increased frequency of use of target lexical items during manual training. The results of the present study suggest that sensory-motor expertise gained by training of specific manual actions can lead to an improvement of cognitive-linguistic skills related to the specific conceptual-semantic domain associated to the trained actions.
PMCID: PMC3517990  PMID: 23233846
embodied cognition; conceptual-semantics; language understanding; sensory-motor system; action training
6.  Quantitative muscle strength assessment in duchenne muscular dystrophy: longitudinal study and correlation with functional measures 
BMC Neurology  2012;12:91.
The aim of this study was to perform a longitudinal assessment using Quantitative Muscle Testing (QMT) in a cohort of ambulant boys affected by Duchenne muscular dystrophy (DMD) and to correlate the results of QMT with functional measures. This study is to date the most thorough long-term evaluation of QMT in a cohort of DMD patients correlated with other measures, such as the North Star Ambulatory Assessment (NSAA) or thee 6-min walk test (6MWT).
This is a single centre, prospective, non-randomised, study assessing QMT using the Kin Com® 125 machine in a study cohort of 28 ambulant DMD boys, aged 5 to 12 years. This cohort was assessed longitudinally over a 12 months period of time with 3 monthly assessments for QMT and with assessment of functional abilities, using the NSAA and the 6MWT at baseline and at 12 months only. QMT was also used in a control group of 13 healthy age-matched boys examined at baseline and at 12 months.
There was an increase in QMT over 12 months in boys below the age of 7.5 years while in boys above the age of 7.5 years, QMT showed a significant decrease. All the average one-year changes were significantly different than those experienced by healthy controls. We also found a good correlation between quantitative tests and the other measures that was more obvious in the stronger children.
Our longitudinal data using QMT in a cohort of DMD patients suggest that this could be used as an additional tool to monitor changes, providing additional information on segmental strength.
PMCID: PMC3482602  PMID: 22974002
7.  Motor Learning in Healthy Humans Is Associated to Gray Matter Changes: A Tensor-Based Morphometry Study 
PLoS ONE  2010;5(4):e10198.
We used tensor-based morphometry (TBM) to: 1) map gray matter (GM) volume changes associated with motor learning in young healthy individuals; 2) evaluate if GM changes persist three months after cessation of motor training; and 3) assess whether the use of different schemes of motor training during the learning phase could lead to volume modifications of specific GM structures. From 31 healthy subjects, motor functional assessment and brain 3D T1-weighted sequence were obtained: before motor training (time 0), at the end of training (two weeks) (time 2), and three months later (time 3). Fifteen subjects (group A) were trained with goal-directed motor sequences, and 16 (group B) with non purposeful motor actions of the right hand. At time 1 vs. time 0, the whole sample of subjects had GM volume increase in regions of the temporo-occipital lobes, inferior parietal lobule (IPL) and middle frontal gyrus, while at time 2 vs. time 1, an increased GM volume in the middle temporal gyrus was seen. At time 1 vs. time 0, compared to group B, group A had a GM volume increase of the hippocampi, while the opposite comparison showed greater GM volume increase in the IPL and insula in group B vs. group A. Motor learning results in structural GM changes of different brain areas which are part of specific neuronal networks and tend to persist after training is stopped. The scheme applied during the learning phase influences the pattern of such structural changes.
PMCID: PMC2855363  PMID: 20419166

Results 1-7 (7)