***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: OBJECTIVE Joint protection aims to reduce pain and local inflammation , preserve the integrity of joint structures and improve function . There is evidence that it can improve pain and function in the short term , but the long-term effects are uncertain . This study evaluated the effects of joint protection in early rheumatoid arthritis ( RA ) . METHODS A r and omized , controlled , assessor-blinded trial of duration 1 yr was conducted . Two interventions ( both 8 h ) were compared : st and ard arthritis education , including 2.5 h of joint protection education based on typical UK practice ; and a joint protection arthritis education programme , using educational-behavioural teaching methods . Assessment s were made at entry and 6 and 12 months . RESULTS Sixty-five people with RA attended the joint protection programme and 62 the st and ard programme . The groups were matched for age ( 51 and 49 yr ) , disease duration ( 21 and 17.5 months ) and use of non-steroidal anti-inflammatory drugs and disease-modifying anti-rheumatic drugs . In comparison with the st and ard group , the joint protection group significantly improved with respect to adherence to the joint protection programme ( P=0.001 ) , h and pain ( P=0.02 ) , general pain ( P=0.05 ) , early morning stiffness ( P=0.01 ) , self-reported number of disease flare-ups ( P=0.004 ) , visits to the doctor for arthritis ( P<0.01 ) , and the AIMS 2 ( Arthritis Impact Measurement Scales ) activities of daily living scale ( P=0.04 ) . A trend to improved swollen joint counts was identified ( P=0.07 ) . Within-group analyses also showed improvements in arthritis self-efficacy and perceived control . H and deformity scores continued to increase in both groups . CONCLUSION We found significant improvements in adherence , pain , disease status and functional ability amongst those attending the joint protection programme . Benefits became more apparent with time , suggesting that joint protection can help slow the progression of the effects of RA over and above the effects of drug therapy In 90 % of patients with rheumatoid arthritis ( RA ) , the joints of the h and are affected . Studies of grip strength training have not indicated a negative effect on disease activity after training . Introduction of ultrasound Doppler ( USD ) to measure increased blood flow induced by inflammation has made it possible to investigate the direct effect on blood supply in the synovium after training . In this case – control study , 24 patients with RA with USD activity in the wrist joint participated . The USD activity was measured by the color fraction ( CF ) ( CF = colored pixels/total number of pixels in ROI ) . Twenty-four patients were assigned to an 8-week grip strength training program . At baseline and after 8 weeks of training , an USD examination of the wrist joint was performed . In the training group , we measured grip strength and pain in the wrist joint . Six patients withdrew from the training because of pain or change in medication . Eighteen patients served as control group . There was a modest , not significant , decrease in the CF in response to training ( 1.86 % ; P = 0.08 ) . Grip strength increased 8.8 % after training ( P = 0.055 ) . Pain in motion deceased after training ( P = 0.04 ) . No difference in the CF was seen between the training and control groups , neither at baseline nor at follow-up ( P = 0.82 and P = 0.48 ) . Patients withdrawing from training had a significantly higher CF than the other patients ( P > 0.001 ) . The results in this study might indicate that the flow in the synovium assessed by USD is not affected by grip strength training OBJECTIVE To evaluate the short term efficacy of a community based physical therapy ( PT ) program for people with rheumatoid arthritis ( RA ) through a single blind r and omized controlled trial . METHODS Adults with active RA were referred by their physician for community based PT . Participants were r and omized to either an  immediate intervention group [ experimental group ( EG ) ] or a wait list control group  ( CG ) . The intervention was a st and ardized program of education and exercise consisting of at least 4 visits or 3 h of PT over 6 weeks . Baseline , 6 , and 12 week assessment s were by a blinded independent assessor . The primary outcome instrument was the Stanford Arthritis Self-Efficacy Scale ( SES ) and secondary outcome measures included the ACREU Rheumatoid Arthritis Knowledge Question naire ( KQ ) and visual analog scale for pain ( VAS ) . Duration of morning stiffness , grip strength , and tender joint count were also collected at each assessment . Outcome analysis was conducted using analysis of variance . RESULTS Of 150 eligible and r and omized participants , 127 completed the study according to protocol . Baseline analysis showed no differences between the EG and CG for demographics , disease status , or other characteristics . At the 6 week assessment , primary outcome analysis for those who completed the protocol identified a mean change ( improvement ) of 13.5 % in the EG and 5.8 % in the CG , representing a 7.7 % difference in change scores between the 2 groups [ F(1,121 ) = 6.03 ; p = 0.015 ] . A statistically significant difference in change scores was also identified for the KQ [ F(1,120 ) = 6.67 ; p = 0.011 ] , but not for the VAS . Disease status measures did not change , except for duration of morning stiffness , which improved by 68.8 min in the EG and 8.3 min in the CG ( F(1,121 ) = 4.50 ; p = 0.036 ] . CONCLUSION Four hours of a community based PT intervention delivered over 6 weeks significantly improved self-efficacy , disease management knowledge and morning stiffness in people with RA & NA ; Physical therapists seeking to use evidence to guide their practice may have limited time to read research reports . One way to reduce the time required to identify and read about the research that is relevant to a particular clinical question is to read a systematic review that summarizes multiple studies . This paper explains the process that is used to conduct systematic review s , which includes the establishment of a protocol , comprehensive search ing , appraisal of the quality of the included studies , data extraction and meta analysis , and consideration of the clinical and research implication s of the findings . We also consider how the reader of a systematic review can determine whether the review is likely to provide an unbiased ( believable ) estimate of the treatment effect . A systematic review of r and omized trials of a  cardiopulmonary physical therapy intervention is used as an example . The issue of appraisal of quality is then discussed further , with a demonstration of how one vali date d tool for quality appraisal ‐‐the PEDro scale‐‐can be used to evaluate a r and omized trial in cardiopulmonary physical therapy Rheumatoid arthritis ( RA ) is a systemic inflammatory and chronic disease of joints , which may result in irreversible deformities . To evaluate the effects of an exercise programme aim ed at improving the h and strength in individuals with h and deformities result ing from RA and to analyse the impact these exercises have on functionality .  Twenty women with RA h and deformities participated in the study . They were r and omly divided into two groups as follows : Group 1 ( n = 13 ) had women participating in the exercise programme  aim ed at improving h and grip ( HS ) and pinch strengths ( PS ) as well as the motor coordination of the h and ; Group 2 ( n = 7 ) had women with RA who received no treatment for their h and s ( control ) . The treatment programme for h and s consisted of 20 sessions , twice a week and at-home exercises . Both groups were su bmi tted to Health Assessment Question naire ( HAQ ) and evaluation of HS and PS by means of dynamometry . Re-evaluations were performed after 10 and 20 sessions in Group 1 and after 2 months in Group 2 . After 20 sessions of physiotherapy , Group 1 had a significant gain in HS and PS ( p < 0.05 ) in addition to the improvement of functionality as assessed by HAQ ( p = 0.016 ) . For Group 2 , no difference was found between the variables analysed ( p > 0.05 ) . The strengthening exercises for individuals with RA h and deformity are beneficial to improve h and grip and pinch strengths as well as functionality OBJECTIVE The aim of this study was to conduct a cost-utility analysis of the Education , Self-management and Upper Limb Exercise Training in People with RA ( EXTRA ) programme compared with usual care . METHODS A within-trial incremental cost-utility analysis was conducted with 108 participants r and omized to either the EXTRA programme ( n = 52 ) or usual care ( n = 56 ) . A health care perspective was assumed for the primary analysis with a 36 week follow-up . Re source use information was collected on interventions , medication , primary and secondary care contacts , private health care and social care costs . Quality -adjusted life years ( QALYs ) were calculated from the EuroQol five-dimension three-level ( EQ-5D-3L ) question naire responses at baseline , 12 and 36 weeks . RESULTS Compared with usual care , total QALYs gained were higher in the EXTRA programme , leading to an increase of 0.0296 QALYs . The mean National Health Service ( NHS ) costs per participant were slightly higher in the EXTRA programme ( by £ 82 ) , result ing in an incremental cost-effectiveness ratio of £ 2770 per additional QALY gained . Thus the EXTRA programme was cost effective from an NHS perspective when assessed against the threshold of £ 20 000-£30 000/QALY gained . Overall , costs were lower in the EXTRA programme compared with usual care , suggesting it was the dominant treatment option from a societal perspective . At a willingness-to-pay of £ 20 000/QALY gained , there was a 65 % probability that the EXTRA programme was the most cost-effective option . These results were robust to sensitivity analyses accounting for missing data , changing the cost perspective and removing cost outliers . CONCLUSION The physiotherapist-led EXTRA programme represents a cost-effective use of re sources compared with usual care and leads to lower health care costs and work absence . TRIAL REGISTRATION International St and ard R and omized Controlled Trial Number Register ; http://www.controlled-trials.com/is rct n/ ( IS RCT N14268051 ) The effects of evening exercises on arthrographic measures of elastic stiffness , subjective ratings of stiffness , and graphic goniometric measures of mobility were examined in 30 patients with rheumatoid arthritis . Measures were obtained on 2 consecutive mornings , one of which was r and omly determined to be preceded by evening exercise . Each morning ,  elastic stiffness and mobility were measured before and after morning exercise . After the final measurements of elastic stiffness and mobility on the second day , patients compared stiffness on the 2 days . Elastic stiffness and subjective ratings of stiffness were less and mobility was greater when evening exercises were performed ( p less than 0.001 ) . The relationships between elastic stiffness and subjective ratings of stiffness indicated that the effect of evening exercise was perceived as greater when elastic stiffness was greater , and 21 patients reported less stiffness with evening exercise ( p less than .05 ) Objective : To evaluate the long-term effects of joint protection on health status of people with early rheumatoid arthritis ( RA ) . Design : A four-year follow-up of a r and omized , controlled , assessor-blinded trial was conducted . Setting : Two rheumatology outpatient departments . Participants : People with rheumatoid arthritis less than five years since diagnosis . Interventions : Two 8-hour interventions were originally compared : a st and ard arthritis education programme , including 21/2 hours of joint protection based on typical UK occupational therapy practice ( plus 51/2 hours on RA , exercise , pain management , diet and foot care ) ; and a joint protection programme , using educational-behavioural training . Main measures : Adherence to joint protection , pain , h and pain on activity , Arthritis Impact Measurement Scales 2 and Arthritis Self-efficacy were recorded at 0 and 4 years . Results : Sixty-five people attended the joint protection and 62 the st and ard programmes . Groups at entry were similar in age ( 51 years ; 49 years ) , disease duration ( 21 months : 17.5 months ) and use of nonsteroidal anti-inflammatory and disease-modifying drugs . At four years , the joint protection group continued to have significantly better : joint protection adherence ( p=0.001 ) ; early morning stiffness ( p=0.01 ) ; AIMS 2 activities of daily living ( ADL ) scores ( p=0.04 ) compared with the st and ard group . The joint protection group also had significantly fewer h and deformities : metacarpophalangeal ( MCP ) ( p=0.02 ) and wrist joints ( p=0.04 ) . Conclusion : Attending an educational = behavioural joint protection programme significantly improves joint protection adherence and maintains functional ability long term . This approach is more effective than st and ard methods of training and should be more widely adopted Etude sur 30 malades pendant 3 semaines . Les ultrasons et les bains faradiques ne semblent pas presenter d'avantages par rapport aux exercices conventionnels avec traitement par la cire fondue . Le traitement conventionnel est moins OBJECTIVE To evaluate the effectiveness of three different physiotherapeutic approaches in the management of the  rheumatoid h and . METHODS In a r and omized controlled trial , participants with rhe 
    Output:
    
Significant short-term improvements occurred in h and function , pain and grip strength , with long-term improvements in h and and upper limb function and pinch strength .
GROWING POINTS Evaluation of low and moderate risk of bias trials indicated high-intensity home h and exercise programmes led to better short-term outcomes than low-intensity programmes .
Such programmes are cost-effective .
AREAS TIMELY FOR DEVELOPING RESEARCH Further research is required to evaluate methods of helping people with RA maintain long-term home h and exercise