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[ARTICLE] Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period – Full Text


Background Context

In today’s health-care climate, magnetic resonance imaging (MRI) is often perceived as a commodity—a service where there are no meaningful differences in quality and thus an area in which patients can be advised to select a provider based on price and convenience alone. If this prevailing view is correct, then a patient should expect to receive the same radiological diagnosis regardless of which imaging center he or she visits, or which radiologist reviews the examination. Based on their extensive clinical experience, the authors believe that this assumption is not correct and that it can negatively impact patient care, outcomes, and costs.


This study is designed to test the authors’ hypothesis that radiologists’ reports from multiple imaging centers performing a lumbar MRI examination on the same patient over a short period of time will have (1) marked variability in interpretive findings and (2) a broad range of interpretive errors.

Study Design

This is a prospective observational study comparing the interpretive findings reported for one patient scanned at 10 different MRI centers over a period of 3 weeks to each other and to reference MRI examinations performed immediately preceding and following the 10 MRI examinations.

Patient Sample

The sample is a 63-year-old woman with a history of low back pain and right L5 radicular symptoms.

Outcome Measures

Variability was quantified using percent agreement rates and Fleiss kappa statistic. Interpretive errors were quantified using true-positive counts, false-positive counts, false-negative counts, true-positive rate (sensitivity), and false-negative rate (miss rate).


Interpretive findings from 10 study MRI examinations were tabulated and compared for variability and errors. Two of the authors, both subspecialist spine radiologists from different institutions, independently reviewed the reference examinations and then came to a final diagnosis by consensus. Errors of interpretation in the study examinations were considered present if a finding present or not present in the study examination’s report was not present in the reference examinations.


Across all 10 study examinations, there were 49 distinct findings reported related to the presence of a distinct pathology at a specific motion segment. Zero interpretive findings were reported in all 10 study examinations and only one finding was reported in nine out of 10 study examinations. Of the interpretive findings, 32.7% appeared only once across all 10 of the study examinations’ reports. A global Fleiss kappa statistic, computed across all reported findings, was 0.20±0.06, indicating poor overall agreement on interpretive findings. The average interpretive error count in the study examinations was 12.5±3.2 (both false-positives and false-negatives). The average false-negative count per examination was 10.9±2.9 out of 25 and the average false-positive count was 1.6±0.9, which correspond to an average true-positive rate (sensitivity) of 56.4%±11.7 and miss rate of 43.6%±11.7.


This study found marked variability in the reported interpretive findings and a high prevalence of interpretive errors in radiologists’ reports of an MRI examination of the lumbar spine performed on the same patient at 10 different MRI centers over a short time period. As a result, the authors conclude that where a patient obtains his or her MRI examination and which radiologist interprets the examination may have a direct impact on radiological diagnosis, subsequent choice of treatment, and clinical outcome.


In the clinical evaluation of a patient with back or leg pain unresponsive to conservative measures, clinicians may order a magnetic resonance imaging (MRI) examination to assist in explaining the patient’s symptoms to determine whether or not modification of the patient’s therapy is required, including referral for interventional pain management or surgical evaluation. Moreover, the results of MRI examinations play a central role when payers are reviewing whether or not to approve a recommended treatment. Therefore, an accurate diagnosis is paramount to timely and correct treatment. Several studies provide information as to the variability of interpretation of radiological examinations, including MRI examinations of the lumbar spine, and the importance of nomenclature when communicating radiological findings [[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11]]. However, these studies provide no information as to the variability and quality of interpretation of all MRI findings in a single patient imaged at different imaging centers. The authors believe that the study presented here is the first of its kind and provides critically important and novel insights into the variability and diagnostic performance between MRI examinations.[…]

Continue —> Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period – The Spine Journal

Fig. 3 Example from the reference examination for grading central canal stenosis. (Left) At the level of the L2 pedicles, the area of the thecal sac measures approximately 241 mm2. (Right) At the level of the L2–L3 disc space, the area of the thecal sac measures approximately 67 mm2. The reduction of the thecal sac is greater than two-thirds and was graded as severe stenosis.

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[Abstract+References] Interventions to improve real-world walking after stroke: a systematic review and meta-analysis

This study aimed to determine the effectiveness of current interventions to improve real-world walking for people with stroke and specifically whether benefits are sustained.

EBSCO Megafile, AMED, Cochrane, Scopus, PEDRO, OTSeeker and Psychbite databases were searched to identify relevant studies.

Proximity searching with keywords such as ambulat*, walk*, gait, mobility*, activit* was used. Randomized controlled trials that used measures of real-world walking were included. Two reviewers independently assessed methodological quality using the Cochrane Risk of Bias Tool and extracted the data.

Nine studies fitting the inclusion criteria were identified, most of high quality. A positive effect overall was found indicating a small effect of interventions on real-world walking (SMD 0.29 (0.17, 0.41)). Five studies provided follow-up data at >3–6 months, which demonstrated sustained benefits (SMD 0.32 (0.16, 0.48)). Subgroup analysis revealed studies using exercise alone were not effective (SMD 0.19 (–0.11, 0.49)), but those incorporating behavioural change techniques (SMD 0.27 (0.12, 0.41)) were.

A small but significant effect was found for current interventions and benefits can be sustained. Interventions that include behaviour change techniques appear more effective at improving real-world walking habits than exercise alone.

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Source: Interventions to improve real-world walking after stroke: a systematic review and meta-analysisClinical Rehabilitation – Caroline M Stretton, Suzie Mudge, Nicola M Kayes, Kathryn M McPherson, 2017

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[Thesis] The Effects of Limb Dominance on Cross-Education in a Four Week Resistance Training Program – Full Text PDF


Cross-education is known as the phenomenon of strength transfer from the trained side of the body to the untrained side of the body by unilateral resistance training. Research has shown that limb dominance has an effect on the amount of strength that is gained on the untrained side. Studies have found that there is a greater cross over effect in strength from the dominant side of the body to the non-dominant side of the body than vice versa. The present study examined this effect by taking 12 college females and splitting them into three groups: dominant training, nondominant training, and control group. The hypothesis was that the dominant training group would have a greater increase in peak grip strength in the untrained, non-dominant arm than the arm of the untrained, dominant group of the non-dominant training group. The dominant training group only trained their dominant arm with a hand dynamometer, while the non-dominant training group only trained their non-dominant arm with the same hand dynamometer. Both groups went through a 4-week, 13 sessions of grip strength training on the handy dynamometer.
They performed 3 sets of 6 maximal squeezes with a 2-minute rest in between sets. Pre-and post tests were taken of maximum grip strength squeeze. There was no significance difference in peak grip strength between the untrained arms of both groups. Also, there was no significance  difference in peak grip strength between the trained arms of both groups however there was a
trend in data in the untrained arm of the dominant training group showing a slight increase in  strength from baseline measurements. These findings do not directly support the hypothesis however, if the number of subjects’ value was greater, the trend in data in the dominant training group might have found significant effect from limb dominance.

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[Abstract] A pilot study on the optimal speeds for passive wrist movements by a rehabilitation robot of stroke patients: A functional NIRS study  


The optimal conditions inducing proper brain activation during performance of rehabilitation robots should be examined to enhance the efficiency of robot rehabilitation based on the concept of brain plasticity. In this study, we attempted to investigate differences in cortical activation according to the speeds of passive wrist movements performed by a rehabilitation robot for stroke patients. 9 stroke patients with right hemiparesis participated in this study. Passive movements of the affected wrist were performed by the rehabilitation robot at three different speeds: 0.25 Hz; slow, 0.5Hz; moderate and 0.75 Hz; fast. We used functional near-infrared spectroscopy to measure the brain activity during the passive movements performed by a robot. Group-average activation map and the relative changes in oxy-hemoglobin (ΔOxyHb) in two regions of interest: the primary sensory-motor cortex (SM1); premotor area (PMA) and region of all channels were measured. In the result of group-averaged activation map, the contralateral SM1, PMA and somatosensory association cortex (SAC) showed the greatest significant activation according to the movements at 0.75 Hz, while there is no significantly activated area at 0.5 Hz. Regarding ΔOxyHb, no significant diiference was observed among three speeds regardless of region. In conclusion, the contralateral SM1, PMA and SAC showed the greatest activation by a fast speed (0.75 Hz) rather than slow (0.25 Hz) and moderate (0. 5 Hz) speed. Our results suggest an optimal speed for execution of the wrist rehabilitation robot. Therefore, we believe that our findings might point to several promising applications for future research regarding useful and empirically-based robot rehabilitation therapy.

Source: A pilot study on the optimal speeds for passive wrist movements by a rehabilitation robot of stroke patients: A functional NIRS study – IEEE Xplore Document

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[Abstract] Immediate Effects of Mirror Therapy in Patients With Shoulder Pain and Decreased Range of Motion 



To determine the effects of a brief single component of the graded motor imagery (GMI) sequence (mirror therapy) on active range of motion (AROM), pain, fear avoidance, and pain catastrophization in patients with shoulder pain.


Single-blind case series.


Three outpatient physical therapy clinics.


Patients with shoulder pain and limited AROM (N=69).


Patients moved their unaffected shoulder through comfortable AROM in front of a mirror so that it appeared that they were moving their affected shoulder.

Main Outcome Measures

We measured pain, pain catastrophization, fear avoidance, and AROM in 69 consecutive patients with shoulder pain and limited AROM before and immediately after mirror therapy.


There were significant differences in self-reported pain (P=.014), pain catastrophization (P<.001), and the Tampa Scale of Kinesiophobia (P=.012) immediately after mirror therapy; however, the means did not meet or exceed the minimal detectable change (MDC) for each outcome measure. There was a significant increase (mean, 14.5°) in affected shoulder flexion AROM immediately postmirror therapy (P<.001), which exceeded the MDC of 8°.


A brief mirror therapy intervention can result in statistically significant improvements in pain, pain catastrophization, fear avoidance, and shoulder flexion AROM in patients presenting with shoulder pain with limited AROM. The immediate changes may allow a quicker transition to multimodal treatment, including manual therapy and exercise in these patients. Further studies, including randomized controlled trials, are needed to investigate these findings and determine longer-term effects.

Source: Immediate Effects of Mirror Therapy in Patients With Shoulder Pain and Decreased Range of Motion – Archives of Physical Medicine and Rehabilitation

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[Abstract] Robot-assisted arm training in physical and virtual environments: A case study of long-term chronic stroke


Robot-assisted training (RT) is a novel technique with promising results for stroke rehabilitation. However, benefits of RT on individuals with long-term chronic stroke have not been well studied. For this case study, we developed an arm-based RT protocol for reaching practice in physical and virtual environments and tracked the outcomes in an individual with a long-term chronic stroke (20+ years) over 10 half-hour sessions. We analyzed the performance of the reaching movement with kinematic measures and the arm motor function using the Fugl-Meyer Assessment-Upper Extremity scale (FMA-UE). The results showed significant improvements in the subject’s reaching performance accompanied by a small increase in FMA-UE score from 18 to 21. The improvements were also transferred into real life activities, as reported by the subject. This case study shows that even in long-term chronic stroke, improvements in motor function are still possible with RT, while the underlying mechanisms of motor learning capacity or neuroplastic changes need to be further investigated.

Source: Robot-assisted arm training in physical and virtual environments: A case study of long-term chronic stroke – IEEE Xplore Document

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[Abstract] Virtual reality and non-invasive brain stimulation in stroke: How effective is their combination for upper limb motor improvement?


Upper limb (UL) hemiparesis is frequently a disabling consequence of stroke. The ability to improve UL functioning is associated with motor relearning and experience dependent neuroplasticity. Interventions such as non-invasive brain stimulation (NIBS) and task-practice in virtual environments (VEs) can influence motor relearning as well as adaptive plasticity. However, the effectiveness of a combination of NIBS and task-practice in VEs on UL motor improvement has not been systematically examined. The objective of this review was to examine the evidence regarding the effectiveness of combining NIBS with task-practice in VEs on UL motor impairment and activity levels. A systematic review of the published literature was conducted using standard methodology. Study quality was assessed using the PEDro scale and Down’s and Black checklist. Four studies examining the effects of a combination of NIBS (involving transcranial direct current stimulation; tDCS and repetitive transcranial magnetic stimulation; rTMS) were retrieved. Of these, three studies were randomized controlled trials (RCTs) and one was a cross-sectional study. There was 1a level evidence that the combination of NIBS and task-practice in a VE was beneficial in the sub-acute stage. A combination of training in a VE with rTMS as well as tDCS was beneficial for motor improvements in the UL in sub-acute stage of stroke (1b level). The combination was not found to be superior compared to task practice in VEs alone in the chronic stage (1b level). The results suggest that people with stroke may be capable of improving levels of motor impairment and activity in the sub-acute stage if their rehabilitation program involves a combination on NIBS and VE training. Emergent questions regarding the use of more sensitive outcomes, different types of stimulation parameters, locations and training environments still need to be addressed.

Source: Virtual reality and non-invasive brain stimulation in stroke: How effective is their combination for upper limb motor improvement? – IEEE Xplore Document

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[Workshop] Evidence-Based Upper Limb Retraining after Stroke 2017 – Pre-Reading and Workshop Tasks – PDF

CHAPTER 40: Optimizing motor performance and sensation after brain impairment


This chapter provides a framework for optimizing motor performance and sensation in adults with brain impairment. Conditions such as stroke and traumatic brain injury are the main focus, however, the chapter content can apply to adults with other neurological conditions. The tasks of eating and drinking are used as examples throughout the chapter. Skills and knowledge required by graduates are identified, including knowledge of motor behaviour, the essential components of reaching to grasp and reaching in sitting, and how to identify compensatory strategies, develop and test movement hypotheses. Factors that enhance skill acquisition are discussed, including task specificity, practice intensity and timely feedback, with implications for therapists’ teaching skills. Finally, a summary is provided of evidence-based interventions to improve motor performance and sensation, including high intensity, task-specific training, mirror therapy, mental practice, electrical stimulation and constraint therapy.

Key Points:

  1. Essential knowledge in neurological rehabilitation includes an understanding of normal motor behaviour, muscle biology and skill acquisition.
  2. Abnormal motor performance can be observed during a task such as reaching for a cup, and compared with expected performance. Hypotheses about the cause(s) of observed movement differences can then be made and tested.

  3. Paralysis, weakness and loss of co-ordination affect upper limb motor performance. To improve performance after brain impairment, therapists should primarily focus on improving strength and co-ordination.

  4. Many people with brain impairment have difficulty understanding instructions, goals and feedback, and consequently may not practice well. To teach people to practice well and learn skills, therapists need to be good coaches.

  5. Motor performance and sensation can be improved using low-cost evidence-based strategies such as high intensity, repetitive, task-specific training, mirror therapy, mental practice, electrical stimulation and constraint-induced movement therapy.

1. Introduction

Upper motor neuron lesions typically cause impairments such as paralysis, muscle weakness and loss of sensation. These impairments can limit participation in everyday tasks such as eating a meal. Motor control is a term commonly used in rehabilitation (Shumway-Cook, 2012; van Vliet et al 2013) and refers to control of movements such as reaching to grasp a cup and standing up. Occupational therapists and physiotherapists retrain motor and sensory impairments that interfere with tasks such as grasping a cup and sitting safely on the toilet.

The aim of this chapter is to provide a framework that helps therapists to systematically observe, analyse and measure motor and sensory impairments. Targeted evidence-based interventions will be described that can drive neuroplasticity. Therapists need to proactively seek muscle activity and sensation. It is not enough to teach a person how to compensate using one-handed techniques, or to wait for recovery to possibly occur.[…]

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[WEB SITE] Efficacy of methylphenidate for the treatment of mental sequelae after traumatic brain injury

BACKGROUND: This study aimed to evaluate the effect of methylphenidate for treating mental sequelae after traumatic brain injury (TBI).
METHODS: Thirty-six patients with TBI were randomly divided into the intervention group and placebo group. The participants in the intervention group received methylphenidate, while subjects in the placebo group were administered a placebo.
This study was conducted from January 2014 to December 2016. The outcome measurements included Mental Fatigue Scale, Choice Reaction Time, Compensatory Tracking Task, Mental Arithmetic Test, Digit Symbol Substitution Test, Mini-Mental State Examination (MMSE), Beck Depression Inventory (BDI), and Hamilton Rating Scale for Depression. In addition, safety was also recorded and assessed.
RESULTS: A total of 33 subjects completed the study. Methylphenidate showed greater efficacy than placebo, with decreased scores on the Mental Fatigue Scale, Choice Reaction Time, and Compensatory Tracking Task in the intervention group compared to the placebo group (P < .01, respectively). Furthermore, increased scores on the Mental Arithmetic Test, Digit Symbol Substitution Test, and MMSE in the intervention group, compared to those in the placebo group (P < .01 respectively), were observed. In addition, a significant difference in the scores on the BDI (P = .04) and Hamilton Rating Scale for Depression (P = .005) was observed between the 2 groups. The safety at the end of the 30 week-treatment was similar between the 2 groups (P > .05).
CONCLUSION: The results of this study demonstrated that methylphenidate could effectively improve mental fatigue and cognitive functions in patients with TBI.

Source: Traumatic Brain Injury Resource Guide – Research Reports – Efficacy of methylphenidate for the treatment of mental sequelae after traumatic brain injury

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[Abstract] Enhancing clinical implementation of virtual reality


Despite an emerging evidence base and rapid increases in the development of clinically accessible virtual reality (VR) technologies for rehabilitation, clinical adoption remains low. This paper uses the Theoretical Domains Framework to structure an overview of the known barriers and facilitators to clinical uptake of VR and discusses knowledge translation strategies that have been identified or used to target these factors to facilitate adoption. Based on this discussion, we issue a ‘call to action’ to address identified gaps by providing actionable recommendations for development, research and clinical implementation.

Source: Enhancing clinical implementation of virtual reality – IEEE Xplore Document

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