human
***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: Purpose To construct and vali date a prediction instrument for early identification of patients with a high risk of delayed recovery after whiplash injuries ( PPS-WAD ) in an insurance company setting . Methods Prospect i ve cohort study . On the basis of a historic cohort ( n = 130 ) of patients with a whiplash injury identified in an emergency room ( ER , model-building set ) , we used logistic regression to construct an instrument consisting of two demographic variables ( i.e. questions of educational level and work status ) and the patient-rated physical and mental status during the acute phase to predict self-reported nonrecovery after 6 months . We evaluated the instrument ’s ability to predict nonrecovery in a new cohort ( n = 204 ) of patients originating from an insurance company setting ( IC , validation set ) . Results The prediction instrument had low reproducibility when the setting was changed from the ER cohort to the IC cohort . The overall percentage of correct predictions of nonrecovery in the ER cohort was 78 % compared with 62 % in the IC cohort . The sensitivity and specificity in relation to nonrecovery were both 78 % in the ER cohort . The sensitivity and specificity in the insurance company setting was lower , 67 and 50 % . Conclusion Clinical decision rules need validation before they are used in a new setting . An instrument consisting of four questions with an excellent possibility of identifying patients with a high risk of nonrecovery after a whiplash injury in the emergency room was not as useful in an insurance company setting . The importance and type of the risk factors for not recovering probably differ between the setting s , as well as the individuals PURPOSE We systematic ally review ed r and omized and quasi-r and omized clinical trials in the literature to assess the efficacy of neck stabilization and postural exercises on pain , neck range of motion , and time off work in adults with acute whiplash-associated disorders . METHODS Electronic data bases , reference lists of relevant Cochrane review s , reference lists of studies selected for inclusion , and tables of contents of relevant journals were systematic ally search ed for r and omized and quasi-r and omized controlled trials . Two independent review ers selected studies for inclusion , assessed method ological quality , and extracted data . Because of the heterogeneity of the interventions , a qualitative synthesis was performed using " levels of evidence " as recommended by van Tulder et al. RESULTS Eight studies representing five clinical trials were selected for inclusion . Two trials were grade d as high quality , two as moderate quality , and one as low quality . Many of these studies had mixed results , demonstrating significant differences on some outcome measures but not on others . CONCLUSIONS There is moderate evidence to support the use of postural exercises for decreasing pain and time off work in the treatment of patients with acute whiplash-associated disorders . However , no evidence exists to support the use of postural exercises for increasing neck range of motion . There is conflicting evidence in support of neck stabilization exercises in the treatment of patients with acute whiplash-associated disorders The aim of the prospect i ve cohort study was to investigate the outcome of acute whiplash injury first treated either by junior doctors ( JD ) [ ≤3 postgraduate years ( PGY ) ] or more experienced doctors ( MED ) ( > 3 PGY ) . At baseline , crash-related data and health parameters including the SF36 were evaluated in whiplash patients ( WP ) , who fulfilled criteria for whiplash-associated disorders grade I – II and presented up to 48 h after motor vehicle accident to our Emergency Department . 81 WP were recruited and treated by either one of 14 JD ( 35 WP ) or one of 22 MED ( 46 WP ) . The follow-up examination included the course of pain intensity [ numeric rating scale ( NRS ) 0–10 ] by the use of a 28 days-pain-diary  and the incidence of symptoms ( st and ardized-telephone-interview at 1 , 3 , and 6 months post trauma ) in terms of neck pain NRS > 2 , analgesic medication , work-off , and utilization of further medical services as well as SF36 evaluated at the end of the study . Although the entry population seemed similar , all outcome parameters were comparable between the JD- and MED-group ( p > 0.05 ) . Therefore , we conclude that seniority of the first-treating physician does not influence the outcome of acute whiplash injury OBJECTIVE To investigate whether  whiplash injury may be a trigger for the onset of fibromyalgia ( FM ) . METHODS One hundred fifty-three patients presenting to the emergency room with the diagnosis of whiplash injury were examined . The control group included 53 patients hospitalized with fractures of the limbs , spine , and ribs due to road accident . The study and control groups were interviewed shortly after presenting and then followed prospect ively . Patients complaining of musculoskeletal symptoms during followup were examined and a count of 18 tender points was conducted . FM was diagnosed if the patient fulfilled currently accepted 1990 American College of Rheumatology criteria . RESULTS The mean followup period for the study and control groups was 14.5 months ( range 12 - 18 ) and 9 months ( range 6 - 14 ) , respectively . There were no differences between the groups with regard to age , sex , marital , education , or employment status . During the followup period only one patient in the study group and no patients in the control group developed signs and symptoms of FM . Three patients in the study group ( 2 % ) and 15 patients in the control group ( 16 % ) filed insurance cl aims ; none was associated with FM . CONCLUSION Whiplash injury and road accident trauma were not associated with an increased rate of FM after more than 14.5 months of followup Neck pain is the cardinal symptom following whiplash injuries . The trauma mechanism could theoretically lead to both soft tissue and bone injury that could be visualised by means of MRI . From previous quite small trials it seems that MRI does not demonstrate significant tissue damage . Large prospect ively followed cohorts are needed to identify possible clinical ly relevant MRI findings . The objective of this trial was to evaluate ( 1 ) the predictive value of cervical MRI  after whiplash injuries and ( 2 ) the value of repeating MRI examinations after 3 months including sequences with flexion and extension of the cervical spine . Participants were included after rear-end or frontal car collisions . Patients with fractures or dislocations diagnosed by st and ard procedures at the emergency unit were not included .  MRI scans of the cervical spine were performed at baseline and repeated after 3 months . Clinical follow-ups were performed after 3 and 12 months . Outcome parameters were neck pain , headache , neck disability and working ability .  A total of 178 participants had a cervical MRI scan on average 13 days after the injury . Traumatic findings were observed in seven participants . Signs of disc degeneration were common and most frequent at the C5–6 and C6–7 levels . Findings were not associated with outcome after 3 or 12 months . The population had no considerable neck trouble prior to the whiplash injury and the non-traumatic findings represent findings to be expected in the background population . Trauma-related MRI findings are rare in a whiplash population screened for serious injuries in the emergency unit and not related to a specific symptomatology . Also , pre-existing degeneration is not associated with prognosis Summary Background Back pain remains a challenge for primary care internationally . One model that has not been tested is stratification of the management according to the patient 's prognosis ( low , medium , or high risk ) . We compared the clinical effectiveness and cost-effectiveness of stratified primary care ( intervention ) with non-stratified current best practice ( control ) . Methods 1573 adults ( aged ≥18 years ) with back pain ( with or without radiculopathy ) consultations at ten general practice s in Engl and responded to invitations to attend an assessment clinic . Eligible participants were r and omly assigned by use of computer-generated stratified blocks with a 2:1 ratio to intervention or control group . Primary outcome was the effect of treatment on the Rol and Morris Disability Question naire ( RMDQ ) score at 12 months . In the economic evaluation , we focused on estimating incremental quality -adjusted life years ( QALYs ) and health-care costs related to back pain . Analysis was by intention to treat . This study is registered , number IS RCT N37113406 . Findings 851 patients were assigned to the intervention ( n=568 ) and control groups ( n=283 ) . Overall , adjusted mean changes in RMDQ scores were significantly higher in the intervention group than in the control group at 4 months ( 4·7 [ SD 5·9 ] vs 3·0 [ 5·9 ] , between-group difference 1·81 [ 95 % CI 1·06–2·57 ] ) and at 12 months ( 4·3 [ 6·4 ] vs 3·3 [ 6·2 ] , 1·06 [ 0·25–1·86 ] ) , equating to effect sizes of 0·32 ( 0·19–0·45 ) and 0·19 ( 0·04–0·33 ) , respectively . At 12 months , stratified care was associated with a mean increase in generic health benefit ( 0·039 additional QALYs ) and cost savings ( £ 240·01 vs £ 274·40 ) compared with the control group . Interpretation The results show that a stratified approach , by use of prognostic screening with matched pathways , will have important implication s for the future management of back pain in primary care . Funding Arthritis Research UK Objective To evaluate the effectiveness of an active strategy to implement the vali date d Canadian C-Spine Rule into multiple emergency departments . Design Matched pair cluster r and omised trial . Setting University and community emergency departments in Canada . Participants 11 824 alert and stable adults presenting with blunt trauma to the head or neck at one of 12 hospitals . Interventions Six hospitals were r and omly allocated to the intervention and six to the control . At the intervention sites , active strategies were used to implement the Canadian C-Spine Rule , including education , policy , and real time reminders on radiology requisitions . No specific intervention was introduced to alter the behaviour of doctors requesting cervical spine imaging at the control sites . Main outcome measure Diagnostic imaging rate of the cervical spine during two 12 month before and after periods . Results Patients were balanced between control and intervention sites . From the before to the after periods , the intervention group showed a relative reduction in cervical spine imaging of 12.8 % ( 95 % confidence interval 9 % to 16 % ; 61.7 % v 53.3 % ; P=0.01 ) and the control group a relative increase of 12.5 % ( 7 % to 18 % ; 52.8 % v 58.9 % ; P=0.03 ) . These changes were significant when both groups were compared ( P<0.001 ) . No fractures were missed and no adverse outcomes occurred . Conclusions Implementation of the Canadian C-Spine Rule led to a significant decrease in imaging without injuries being missed or patient morbidity . Final imaging rates were much lower at intervention sites than at most US hospitals . Widespread implementation of this rule could lead to reduced healthcare costs and more efficient patient flow in busy emergency departments worldwide . Trial registration Clinical trials NCT00290875 Summary This r and omised trial showed that multiprofessional stratified management had no effect beyond usual care in reducing transition rates to chronicity in patients with acute whiplash . ABSTRACT Acute whiplash is a heterogeneous disorder that becomes persistent in 40 % to 60 % of cases . Estimates of recovery have not changed in recent decades . This r and omized , single‐blind , controlled trial tested whether multidisciplinary individualized treatments for patients with acute whiplash ( < 4 weeks postinjury ) could reduce the incidence of chronicity at 6 mo by 50 % compared to usual care . Participants ( n = 101 ) were recruited from accident and emergency centres and the community . It was hypothesized that better recovery rates were achievable if the heterogeneity was recognised and patients received individualised interventions . Patients r and omized to pragmatic intervention ( n = 49 ) could receive pharmaceutical management ( ranging from simple medications to opioid analgesia ) , multimodal physiotherapy and psychology for post‐traumatic stress according to their presentations . The treatment period was 10 wks with follow‐up at 11 weeks and 6 and 12‐months . The primary outcome was neck pain and disability ( Neck Disability Index ( NDI ) ) . Analysis revealed no significant differences in frequency of recovery ( NDI ≤8 % ) between pragmatic and usual care groups at 6 months ( OR 95 % , CI = 0.55 , 0.23–1.29 ) , P = 0.163 ) or 12 mo ( OR 95 % , CI = 0.65 , 0.28–1.47 , P = 0.297 ) . There was no improvement in current nonrecovery rates at 6 mo ( 63.6 % , pragmatic care ; 48.8 % , usual care ) , indicating no advantage of the early multiprofessional intervention . Baseline levels of pain and disability had a significant bearing on recovery both at 6 and 12 mo in both groups , suggesting that future research focus on finding early effective pain management , particularly for the subgroup of patients with initial high levels of pain and  disability , towards improving recovery rates Study Design . A prospect i ve observational cohort study of alert , neurologically intact trauma patients presenting to the emergency department with midline cervical tenderness . Screening cervical magnetic resonance imaging ( MRI ) had been conducted after negative computed tomography ( CT ) when tenderness was persistent . Objective . To 
    Output:
    
agent
Consistent evidence was found to support the use of ' red flags ' to screen for serious pathologies , judicious use of imaging through clinical decision rule application and promotion of functional exercise coupled with advice and reassurance .
***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: Purpose To construct and vali date a prediction instrument for early identification of patients with a high risk of delayed recovery after whiplash injuries ( PPS-WAD ) in an insurance company setting . Methods Prospect i ve cohort study . On the basis of a historic cohort ( n = 130 ) of patients with a whiplash injury identified in an emergency room ( ER , model-building set ) , we used logistic regression to construct an instrument consisting of two demographic variables ( i.e. questions of educational level and work status ) and the patient-rated physical and mental status during the acute phase to predict self-reported nonrecovery after 6 months . We evaluated the instrument ’s ability to predict nonrecovery in a new cohort ( n = 204 ) of patients originating from an insurance company setting ( IC , validation set ) . Results The prediction instrument had low reproducibility when the setting was changed from the ER cohort to the IC cohort . The overall percentage of correct predictions of nonrecovery in the ER cohort was 78 % compared with 62 % in the IC cohort . The sensitivity and specificity in relation to nonrecovery were both 78 % in the ER cohort . The sensitivity and specificity in the insurance company setting was lower , 67 and 50 % . Conclusion Clinical decision rules need validation before they are used in a new setting . An instrument consisting of four questions with an excellent possibility of identifying patients with a high risk of nonrecovery after a whiplash injury in the emergency room was not as useful in an insurance company setting . The importance and type of the risk factors for not recovering probably differ between the setting s , as well as the individuals PURPOSE We systematic ally review ed r and omized and quasi-r and omized clinical trials in the literature to assess the efficacy of neck stabilization and postural exercises on pain , neck range of motion , and time off work in adults with acute whiplash-associated disorders . METHODS Electronic data bases , reference lists of relevant Cochrane review s , reference lists of studies selected for inclusion , and tables of contents of relevant journals were systematic ally search ed for r and omized and quasi-r and omized controlled trials . Two independent review ers selected studies for inclusion , assessed method ological quality , and extracted data . Because of the heterogeneity of the interventions , a qualitative synthesis was performed using " levels of evidence " as recommended by van Tulder et al. RESULTS Eight studies representing five clinical trials were selected for inclusion . Two trials were grade d as high quality , two as moderate quality , and one as low quality . Many of these studies had mixed results , demonstrating significant differences on some outcome measures but not on others . CONCLUSIONS There is moderate evidence to support the use of postural exercises for decreasing pain and time off work in the treatment of patients with acute whiplash-associated disorders . However , no evidence exists to support the use of postural exercises for increasing neck range of motion . There is conflicting evidence in support of neck stabilization exercises in the treatment of patients with acute whiplash-associated disorders The aim of the prospect i ve cohort study was to investigate the outcome of acute whiplash injury first treated either by junior doctors ( JD ) [ ≤3 postgraduate years ( PGY ) ] or more experienced doctors ( MED ) ( > 3 PGY ) . At baseline , crash-related data and health parameters including the SF36 were evaluated in whiplash patients ( WP ) , who fulfilled criteria for whiplash-associated disorders grade I – II and presented up to 48 h after motor vehicle accident to our Emergency Department . 81 WP were recruited and treated by either one of 14 JD ( 35 WP ) or one of 22 MED ( 46 WP ) . The follow-up examination included the course of pain intensity [ numeric rating scale ( NRS ) 0–10 ] by the use of a 28 days-pain-diary  and the incidence of symptoms ( st and ardized-telephone-interview at 1 , 3 , and 6 months post trauma ) in terms of neck pain NRS > 2 , analgesic medication , work-off , and utilization of further medical services as well as SF36 evaluated at the end of the study . Although the entry population seemed similar , all outcome parameters were comparable between the JD- and MED-group ( p > 0.05 ) . Therefore , we conclude that seniority of the first-treating physician does not influence the outcome of acute whiplash injury OBJECTIVE To investigate whether  whiplash injury may be a trigger for the onset of fibromyalgia ( FM ) . METHODS One hundred fifty-three patients presenting to the emergency room with the diagnosis of whiplash injury were examined . The control group included 53 patients hospitalized with fractures of the limbs , spine , and ribs due to road accident . The study and control groups were interviewed shortly after presenting and then followed prospect ively . Patients complaining of musculoskeletal symptoms during followup were examined and a count of 18 tender points was conducted . FM was diagnosed if the patient fulfilled currently accepted 1990 American College of Rheumatology criteria . RESULTS The mean followup period for the study and control groups was 14.5 months ( range 12 - 18 ) and 9 months ( range 6 - 14 ) , respectively . There were no differences between the groups with regard to age , sex , marital , education , or employment status . During the followup period only one patient in the study group and no patients in the control group developed signs and symptoms of FM . Three patients in the study group ( 2 % ) and 15 patients in the control group ( 16 % ) filed insurance cl aims ; none was associated with FM . CONCLUSION Whiplash injury and road accident trauma were not associated with an increased rate of FM after more than 14.5 months of followup Neck pain is the cardinal symptom following whiplash injuries . The trauma mechanism could theoretically lead to both soft tissue and bone injury that could be visualised by means of MRI . From previous quite small trials it seems that MRI does not demonstrate significant tissue damage . Large prospect ively followed cohorts are needed to identify possible clinical ly relevant MRI findings . The objective of this trial was to evaluate ( 1 ) the predictive value of cervical MRI  after whiplash injuries and ( 2 ) the value of repeating MRI examinations after 3 months including sequences with flexion and extension of the cervical spine . Participants were included after rear-end or frontal car collisions . Patients with fractures or dislocations diagnosed by st and ard procedures at the emergency unit were not included .  MRI scans of the cervical spine were performed at baseline and repeated after 3 months . Clinical follow-ups were performed after 3 and 12 months . Outcome parameters were neck pain , headache , neck disability and working ability .  A total of 178 participants had a cervical MRI scan on average 13 days after the injury . Traumatic findings were observed in seven participants . Signs of disc degeneration were common and most frequent at the C5–6 and C6–7 levels . Findings were not associated with outcome after 3 or 12 months . The population had no considerable neck trouble prior to the whiplash injury and the non-traumatic findings represent findings to be expected in the background population . Trauma-related MRI findings are rare in a whiplash population screened for serious injuries in the emergency unit and not related to a specific symptomatology . Also , pre-existing degeneration is not associated with prognosis Summary Background Back pain remains a challenge for primary care internationally . One model that has not been tested is stratification of the management according to the patient 's prognosis ( low , medium , or high risk ) . We compared the clinical effectiveness and cost-effectiveness of stratified primary care ( intervention ) with non-stratified current best practice ( control ) . Methods 1573 adults ( aged ≥18 years ) with back pain ( with or without radiculopathy ) consultations at ten general practice s in Engl and responded to invitations to attend an assessment clinic . Eligible participants were r and omly assigned by use of computer-generated stratified blocks with a 2:1 ratio to intervention or control group . Primary outcome was the effect of treatment on the Rol and Morris Disability Question naire ( RMDQ ) score at 12 months . In the economic evaluation , we focused on estimating incremental quality -adjusted life years ( QALYs ) and health-care costs related to back pain . Analysis was by intention to treat . This study is registered , number IS RCT N37113406 . Findings 851 patients were assigned to the intervention ( n=568 ) and control groups ( n=283 ) . Overall , adjusted mean changes in RMDQ scores were significantly higher in the intervention group than in the control group at 4 months ( 4·7 [ SD 5·9 ] vs 3·0 [ 5·9 ] , between-group difference 1·81 [ 95 % CI 1·06–2·57 ] ) and at 12 months ( 4·3 [ 6·4 ] vs 3·3 [ 6·2 ] , 1·06 [ 0·25–1·86 ] ) , equating to effect sizes of 0·32 ( 0·19–0·45 ) and 0·19 ( 0·04–0·33 ) , respectively . At 12 months , stratified care was associated with a mean increase in generic health benefit ( 0·039 additional QALYs ) and cost savings ( £ 240·01 vs £ 274·40 ) compared with the control group . Interpretation The results show that a stratified approach , by use of prognostic screening with matched pathways , will have important implication s for the future management of back pain in primary care . Funding Arthritis Research UK Objective To evaluate the effectiveness of an active strategy to implement the vali date d Canadian C-Spine Rule into multiple emergency departments . Design Matched pair cluster r and omised trial . Setting University and community emergency departments in Canada . Participants 11 824 alert and stable adults presenting with blunt trauma to the head or neck at one of 12 hospitals . Interventions Six hospitals were r and omly allocated to the intervention and six to the control . At the intervention sites , active strategies were used to implement the Canadian C-Spine Rule , including education , policy , and real time reminders on radiology requisitions . No specific intervention was introduced to alter the behaviour of doctors requesting cervical spine imaging at the control sites . Main outcome measure Diagnostic imaging rate of the cervical spine during two 12 month before and after periods . Results Patients were balanced between control and intervention sites . From the before to the after periods , the intervention group showed a relative reduction in cervical spine imaging of 12.8 % ( 95 % confidence interval 9 % to 16 % ; 61.7 % v 53.3 % ; P=0.01 ) and the control group a relative increase of 12.5 % ( 7 % to 18 % ; 52.8 % v 58.9 % ; P=0.03 ) . These changes were significant when both groups were compared ( P<0.001 ) . No fractures were missed and no adverse outcomes occurred . Conclusions Implementation of the Canadian C-Spine Rule led to a significant decrease in imaging without injuries being missed or patient morbidity . Final imaging rates were much lower at intervention sites than at most US hospitals . Widespread implementation of this rule could lead to reduced healthcare costs and more efficient patient flow in busy emergency departments worldwide . Trial registration Clinical trials NCT00290875 Summary This r and omised trial showed that multiprofessional stratified management had no effect beyond usual care in reducing transition rates to chronicity in patients with acute whiplash . ABSTRACT Acute whiplash is a heterogeneous disorder that becomes persistent in 40 % to 60 % of cases . Estimates of recovery have not changed in recent decades . This r and omized , single‐blind , controlled trial tested whether multidisciplinary individualized treatments for patients with acute whiplash ( < 4 weeks postinjury ) could reduce the incidence of chronicity at 6 mo by 50 % compared to usual care . Participants ( n = 101 ) were recruited from accident and emergency centres and the community . It was hypothesized that better recovery rates were achievable if the heterogeneity was recognised and patients received individualised interventions . Patients r and omized to pragmatic intervention ( n = 49 ) could receive pharmaceutical management ( ranging from simple medications to opioid analgesia ) , multimodal physiotherapy and psychology for post‐traumatic stress according to their presentations . The treatment period was 10 wks with follow‐up at 11 weeks and 6 and 12‐months . The primary outcome was neck pain and disability ( Neck Disability Index ( NDI ) ) . Analysis revealed no significant differences in frequency of recovery ( NDI ≤8 % ) between pragmatic and usual care groups at 6 months ( OR 95 % , CI = 0.55 , 0.23–1.29 ) , P = 0.163 ) or 12 mo ( OR 95 % , CI = 0.65 , 0.28–1.47 , P = 0.297 ) . There was no improvement in current nonrecovery rates at 6 mo ( 63.6 % , pragmatic care ; 48.8 % , usual care ) , indicating no advantage of the early multiprofessional intervention . Baseline levels of pain and disability had a significant bearing on recovery both at 6 and 12 mo in both groups , suggesting that future research focus on finding early effective pain management , particularly for the subgroup of patients with initial high levels of pain and  disability , towards improving recovery rates Study Design . A prospect i ve observational cohort study of alert , neurologically intact trauma patients presenting to the emergency department with midline cervical tenderness . Screening cervical magnetic resonance imaging ( MRI ) had been conducted after negative computed tomography ( CT ) when tenderness was persistent . Objective . To 
    Output:
    