***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND AND PURPOSE An active strategy was developed for the implementation of the clinical guidelines on physical therapy for patients with low back pain . The effect of this strategy on patients ' physical functioning , coping strategy , and beliefs regarding their low back pain was studied . SUBJECTS One hundred thirteen primary care physical therapists treated a total of 500 patients . METHODS The physical therapists were r and omly assigned to 1 of 2 groups . The control group received the guidelines by mail ( st and ard passive method of dissemination ) . The intervention group , in contrast , received an additional active training strategy consisting of 2 sessions with education , group discussion , role playing , feedback , and reminders .  Patients with low back pain , treated by the participating therapists , completed question naires on physical functioning , pain , sick leave , coping , and beliefs . RESULTS Physical functioning and pain in the 2 groups improved substantially in the first 12 weeks . Multilevel longitudinal analysis showed no differences between the 2 groups on any outcome measure during follow-up . DISCUSSION AND CONCLUSION The authors found no additional benefit to applying an active strategy to implement the physical therapy guidelines for patients with low back pain . Active implementation strategies are not recommended if patient outcomes are to be improved Background The effects of lumbosacral orthoses ( LSOs ) on neuromuscular control of the trunk are not known . There is a concern that wearing LSOs for a long period may adversely alter muscle control , making individuals more susceptible to injury if they discontinue wearing the LSOs . The purpose of this study was to document neuromuscular changes in healthy subjects during a 3-week period while they regularly wore a LSO .  Methods Fourteen subjects  wore LSOs 3 hrs a day for 3 weeks . Trunk muscle activity prior to and following a quick force release ( trunk perturbation ) was measured with EMG in 3 sessions on days 0 , 7 , and 21 . A longitudinal , repeated- measures , factorial design was used . Muscle reflex response to trunk perturbations , spine compression force , as well as effective trunk stiffness and damping were dependent variables . The LSO , direction of perturbation , and testing session were the independent variables . Results The LSO significantly ( P < 0.001 ) increased the effective trunk stiffness by 160 Nm/rad ( 27 % ) across all directions and testing sessions . The number of antagonist muscles that responded with an onset activity was significantly reduced after 7 days of wearing the LSO , but this difference disappeared on day 21 and is likely not clinical ly relevant . The average number of agonist muscles switching off following the quick force release was significantly greater with the LSO , compared to without the LSO ( P = 0.003 ) . Conclusions The LSO increased trunk stiffness and result ed in a greater number of agonist muscles shutting-off in response to a quick force release . However , these effects did not result in detrimental changes to the neuromuscular function of trunk muscles after 3 weeks of wearing a LSO 3 hours a day by healthy subjects BACKGROUND CONTEXT Although previous studies suggest braces/corsets can reduce acute pain , no prior study has assessed back function after bracing with both self-reported and objective measures . Use of both self-reported and objective measures of spine function together may be important given evidence they assess unique aspects of function . PURPOSE The aim was to assess both self-reported and objective measures of spinal function before , and after , use of a nonrigid , inelastic lumbar brace . STUDY DESIGN / SETTING This was a non-r and omized clinical trial . PATIENT SAMPLE The sample included acute low back pain ( LBP ) participants and asymptomatic controls . OUTCOME MEASURES Oswestry Disability Index ( ODI ) , spinal stiffness , and muscle endurance were the outcome measures . METHODS Three groups were studied : -LBP/-Brace ( n=19 ) , -LBP/+Brace ( n=18 ) , and + LBP/+Brace ( n=17 ) . Both groups of braced participants were instructed to wear the brace continually for 2 weeks with the exception of bedroom and bathroom activities . Before and after the 2-week period , three measures of spinal function were performed : spinal stiffness via motorized indentation of the L3 spinous process , a modified Sorensen test ( timed lumbar extension against gravity ) , and the ODI . Repeated measures analyses of variance were conducted for all three outcomes . RESULTS Among the groups , ODI scores decreased significantly for the + LBP/+Brace group ( p<.001 ) compared with the other two groups . The + LBP/+Brace mean ODI score decreased 3.71 points ( 95 % confidence interval [ CI ] 2.01 - 5.40 ) compared with the -LBP/-Brace group and decreased 3.48 points ( 95 % CI 1.77 - 5.20 ) compared with the -LBP/+Brace group . Change scores for the Sorensen test were significantly increased in the + LBP/+Brace group ( p=.037 ) compared with the -LBP/-Brace group ( 22.47s 95 % CI 8.14 - 36.80 ) . Spinal stiffness did not change significantly between groups . CONCLUSIONS This study demonstrates that lumbar function assessed by self-reported and objective measures does not worsen when nonrigid , inelastic bracing is used for short periods of time for those with , or without , back pain . These data add to the existing literature that suggests short-term use of nonrigid , inelastic bracing for acute LBP does not decrease spinal function when measured separately with subjective or objective tools Study Design . Multicentric , r and omized , and controlled study of clinical evaluation of medical device in subacute low back pain . Objective . To evaluate the effects of an elastic lumbar belt on functional capacity , pain intensity in low back pain treatment , and the benefice on medical cost . Summary of Background Data . There is limited evidence of efficiency of lumbar supports for treatment of low back pain . There is also a lack of the methodology in the studies reported on the efficiency of this device . Methods . This study is r and omized , multicentric , and controlled with 2 groups : a patient group treated with a lumbar belt ( BWG ) and a control group ( CG )  . The main criteria of clinical evaluation were the physical restoration assessed with the EIFEL scale , the pain assessed by a visual analogic scale , the main economical criteria was the overall cost of associated medical treatments . Results . One hundred ninety-seven patients have participated . The results show a higher decrease in EIFEL score in BWG than CG between days 0 and 90 ( 7.6 ± 4.4 vs. de 6.1 ± 4.7;P = 0.023 ) . Respectively significant reduction in visual analogic scale was also noticed ( 41.5 ± 21.4 vs. 32.0 ± 20 ; P = 0.002 ) . Pharmacologic consumption decreased at D90 ( the proportion of patients who did not take any medication in BWG is 60.8 % vs. 40 % in CG;P = 0.029 ) . Conclusion . Lumbar belt wearing is consequent in subacute low back pain to improve significantly the functional status , the pain level , and the pharmacologic consumption . This study may be useful to underline the interest of lumbar support as a complementary and nonpharmacologic treatment beside the classic medication use in low back pain treatment OBJECTIVES To evaluate the effect of lumbopelvic belts on the thickness of lateral abdominal muscles and the cross-sectional area ( CSA ) of lumbar multifidus ( LM ) muscles . DESIGN A single-blinded r and omized controlled trial . SETTING An academic and tertiary care referral spine and sports medicine center . PARTICIPANTS Sixty healthy volunteers with no history of low back pain in the previous year . METHODS The subjects were allocated into belt and control groups . Lumbar belts were given to the subjects in the belt group , and they were asked to use the belts during the study period except during sleeping hours . The subjects were assessed at baseline and at 4 and 8 weeks . MAIN OUTCOME MEASURES The thickness of lateral abdominal muscles and the CSA of the LM muscles were measured by ultrasound with the patient in the hook-lying position on an examination table . RESULTS The thickness of lateral abdominal muscles and the CSA of LM muscles on both sides decreased significantly among healthy subjects in the belt group after 8 weeks . CONCLUSION The results of this study show that lumbopelvic belts might influence the ultrasonographic measurements of lateral abdominal and LM muscles and thereby spine stability One of the major challenges for general practitioners is to manage individuals with acute low back pain appropriately to reduce the risk of chronicity . A prospect i ve study was design ed to assess the actual management of acute low back pain in one primary care setting and to determine whether existing practice patterns conform to published guidelines . Twenty-four family physicians from public primary care centers of the Basque Health Service in Bizkaia , Basque Country ( Spain ) , participated in the study . A total of 105 patients aged 18–65 years presenting with acute low back pain over a 6-month period were included . Immediately after consultation , a research assistant performed a structured clinical interview . The patients ’ care provided by the general practitioner was compared with the Agency for Health Care Policy and Research ( AHCPR ) guidelines and guidelines issued by the Royal College of General Practitioners . The diagnostic process showed a low rate of appropriate use of history ( 27 % ) , physical examination ( 32 % ) , lumbar radiographs ( 31 % ) , and referral to specialized care ( 33 % ) . Although the therapeutic process showed a relatively high rate of appropriateness in earlier mobilization ( 77 % ) and educational advice ( 65 % ) , only 23 % of patients were taught about the benign course of back pain . The study revealed that management of acute low back pain in the primary care setting is far from being in conformance with published clinical guidelines Study Design . Prospect i ve cohort study . Objective . To quantify which 3 common lumbar orthoses of varying rigidity restrict both full , active range of motion ( ROM ) and functional ROM required for activities of daily living ( ADL ) . Summary of Background Data . Spinal orthoses are implemented to restrict lumbar motion . Despite widespread prevalence of lumbar bracing , the efficacy of these appliances for immobilizing the spine has not been definitively established . Methods . The full , active ROM of 10 asymptomatic individuals was quantified using an electrogoniometer that registered maximum rotation in all planes . Subjects subsequently completed 15 simulated ADLs during which time their functional ROM was measured ; performed without a brace and while wearing a corset , semirigid lumbosacral orthosis ( LSO ) , and rigid custom-molded LSO . Results . For flexion/extension , the mean percentage decreases ( with SDs ) in full , active ROM that were recorded with corset , semirigid , and a custom orthosis were 24.1 ± 7.9 % , 46.8 ± 7.1 % , and 64.7 ± 8 % , respectively ( P < 0.001 relative to no brace ) . In the coronal plane , motion was restricted by 33.9 ± 8.8 % , 51.9 ± 9.4 % , and 49.1 ± 11.8 % , respectively ( P < 0.001 ) . Finally , rotation was limited by 39.6 ± 8.8 % , 59.2 ± 10.2 % , and 70.6 ± 5.4 % , respectively ( P < 0.001 ) . There were no significant discrepancies between the ROM recorded in the semirigid and custom LSOs for the ADLs . Likewise , functional ROM associated with corset and semirigid LSOs were only different for 2 ADLs whereas significant disparities between values with corset and custom LSOs were observed for 4 simulations . Conclusion . The full , active ROM allowed by lumbar braces evaluated was greater than employed during ADLs in absence of any brace . The motion decrease beyond actual restriction of the braces suggests they will act primarily as proprioceptive guides to regulate movement This article introduces the approach of GRADE to rating  quality of evidence .  GRADE specifies four categories-high , moderate , low , and very low-that are applied to a body of evidence , not to individual studies . In the context of a systematic review , quality reflects our confidence that the estimates of the effect are correct . In the context of recommendations , quality reflects our confidence that the effect estimates are adequate to support a particular recommendation . R and omized trials begin as high- quality evidence , observational studies as low quality . " Quality " as used in GRADE means more than risk of bias and so may also be compromised by imprecision , inconsistency , indirectness of study results , and publication bias . In addition , several factors can increase our confidence in an estimate of effect . GRADE provides a systematic approach for considering and reporting each of these factors . GRADE separates the process of assessing quality of evidence from the process of making recommendations . Judgments about the strength of a recommendation depend on more than just the quality of evidence Study Design . Cluster r and omized controlled trial for a multifaceted implementation strategy . Objectives . To assess the effectiveness of tailored  interventions ( multifaceted implementation strategy ) to implement the  Dutch low back pain guideline for general practitioners with regard to adherence to guideline recommendations . Summary of Background Data . Guidelines for the management of low back pain in primary care have been developed in various countries , but little is known about the optimal implementation strategy . A multifaceted implementation strategy was developed to overcome identified barriers to the implementation of the Dutch low back pain guideline for general practitioners . Methods . General practitioners were r and omized to an intervention or a control group . The general practition 
    Output:
    
The most common measures for motor performances were the maximum strength of the trunk flexors and extensors and the endurance and fatigability of the trunk extensors .
The meta-analyses demonstrated no negative effect by the continuous use of an LSO for 1 - 6 months .
However , the quality of evidence ranged from low to very low , and more high- quality trials are required to draw a definitive conclusion on the impact of the continuous use of an LSO on trunk motor performances