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: The interexaminer reliability of noninvasive methods of examining lumbar spinal segments is not well established . In this project the interexaminer reliability of three experienced chiropractic examiners , who evaluated 21 symptomatic and 25 asymptomatic subjects , was explored . Eight noninvasive segmental examination strategies ( dimensions ) were employed at each spinal segment from T11/T12 through L5/S1 . Marginal to good agreement beyond chance was noted for palpatory pain over osseous structures and in paraspinal soft-tissues . Weaker and less frequently , significant concordance between examiners was noted for detection of temperature differences ( greater than or equal to 1.5 degrees F ) between adjacent segments and for visual inspection for segmental abnormality . Little significant agreement between examiner was found for active and passive motion palpation , muscle tension palpation and misalignment palpation . This study suggests that " subjective " findings ( pain ) may be among the most reliable of conservative spinal observations . Weak but significant correlations were found when positive findings for the eight dimensions at each lumbar segment were summed to form a composite joint abnormality index . When the multidimension index was developed using the four most reliable dimensions , slightly stronger correlations were found . The strongest agreement between examiners tended to be found in the lower lumbar spine Study Design This prospect i ve study evaluated the diagnostic utility of historically accepted sacroiliac joint tests . A multidisciplinary expert panel recommended 12 of the “ best ” sacroiliac joint tests to be evaluated against a criterion st and ard of unequivocal pain relief after an intra‐articular injection of local anesthetic into the sacroiliac joint . Objectives To identify a single sacroiliac joint test or ensemble of tests that are sufficiently useful in diagnosing sacroiliac joint disorders to be clinical ly valuable . Summary of Background Data No previous research has been done to evaluate any physical test of sacroiliac joint pain against an accepted criterion st and ard . Methods Historical data was obtained , and the 12 tests were performed by two examiners on 85 patients who subsequently underwent sacroiliac joint blocks .  Ninety percent or more relief was considered a positive response , and less then 90 % relief was considered a negative response . Results There were 45 positive and 40 negative responses . No historical feature , none of the 12 sacroiliac joint tests , and no ensemble of these 12 tests demonstrated worthwhile diagnostic value . Conclusion Sacroiliac joint pain is resistant to identification by the historical and physical examination data from tests evaluated in this study Study Design . Cohort study of patients with acute low back pain undergoing physical therapy .  Objectives . Examine the reliability and validity of the Physical Impairment Index in a group of patients with acute low back pain and determine the responsiveness and minimum detectable change of the index and its component tests . Summary of the Background Data . The Physical Impairment Index was originally described as a reliable and valid means of assessing physical impairment in patients with low back pain . The psychometric properties of the index have not been reported in patients with acute low back pain , nor has its responsiveness been examined . Methods . Seventy-eight patients with acute ( <3 weeks duration ) low back pain participating in a clinical trial were assessed at baseline and after 4 weeks .  Interrater reliability of the index was examined in a subgroup of 20 patients . Validity was examined through correlations with concurrent measures of pain , disability , and psychosocial variables . Changes in the index over 4 weeks were used to assess responsiveness and minimum detectable change . Results . Interrater reliability of the index was high ( intraclass correlation coefficient = 0.89 ) , and its validity was generally supported by the pattern of correlations . The index was more responsive to change than any of its component tests but was less responsive than the Oswestry disability score . The minimum detectable change on the index was approximately 1 point . Conclusions . The Physical Impairment Index appears to be a reliable and valid measure of physical impairment for patients with acute low back pain and may be useful as an adjunct outcome measure for studies involving these patients . Further research on patients with chronic pain is needed before it can be advocated for outcomes research with this population Sixty student volunteers were assessed for fixation in the lumbar spine using a passive motion palpation protocol . Subjects were examined in r and om order by two experienced chiropractors . Every subject was evaluated twice by each examiner . Fixations were judged present or absent for each of five lumbar motion segments . Moderate test-retest agreement beyond chance was noted at L1/2 , minimal reliability at L4/5 , and no significant agreement within examiners was detected for mid-lumbar segments . Interexaminer agreement beyond chance was poor for all segments assessed . When segments were grouped regionally and re-evaluated , some increase in intrarater agreement was evident , especially at L4/5/S , but interrater agreement was still absent STUDY DESIGN A prospect i ve method ological interrater reliability study . OBJECTIVES To calculate the interrater reliability among clinicians newly trained in a classification system for acute low back pain and to determine the level of agreement at key junctures within the classification algorithm . BACKGROUND The utility of a classification system for patients with low back pain depends on its reliability and generalizability . To be practical , clinicians must be able to apply the system after a reasonable amount of training . Identifying key points in the classification algorithm where disagreement occurs can lead to better operational definitions . METHODS Four physical therapists read an article and attended a 1-day training session in the classification system .  R and omly paired therapists classified patients referred for treatment of acute low back pain and noted decisions at key junctures in the system algorithm . RESULTS Forty-five patients were classified . Repeated examinations did not increase the patient 's pain ( P>.05 ) . For 3 out of the 4 therapists , the interrater reliability showed a kappa value of 0.45 . The fourth therapist , excluded from the overall analysis , exhibited a bias towards the immobilization classification . Among the 3 therapists , major disagreement occurred with the determination of symmetry with trunk side bending and the effects of repeated movements . CONCLUSIONS Three out of 4 clinicians newly trained in the system showed moderate reliability . The reliability was slight when the fourth therapist was included . Refinement of the operational definitions and criteria for determining lumbar capsular patterns are needed . One day of training is probably not adequate for all therapists , especially for those biased towards specific low back pain syndromes BACKGROUND AND PURPOSE McKenzie described a two-step process for assessing patients with low back pain for a lateral shift . The purpose of this study was to determine whether reliable judgments about lateral shifts could be obtained . SUBJECTS Forty-nine patients with low back pain were each examined separately by two r and omly paired physical therapists . METHODS Assessment s of the presence and direction of lateral  shifts ( step 1 ) were obtained by use of a simple instrument . The relevance of the lateral shifts to the patients ' pain complaints ( step 1 ) also was assessed by use of the side-glide test sequence . RESULTS Generalized kappa coefficients were calculated to determine reliability . The kappa value for the two-step process of lateral shift assessment was .16 . The percentage of agreement was 47 % . CONCLUSION AND DISCUSSION Each step in this two-step process was examined separately for possible sources of error . The kappa value for determinations of the presence and direction of lateral shifts was .00 , indicating very poor reliability . The kappa value for the determination of the presence of a positive side-glide test sequence was .74 , indicating high reliability . The role of lateral shift assessment in the McKenzie system should be reconsidered , given the strong research evidence for poor reliability of determinations of the presence and direction of lateral shifts The purpose of this study was to determine the intertester reliability of assessment s of the presence of trigger points in the region of the lumbar spine of patients with low back pain ( LBP ) . A total of six trigger points described by Travell and Simons were studied . The trigger point examination procedures described by Travell and Simons were used by 12 physical therapists . R and omly paired therapists examined 50 patients for 197 trigger points . The Kappa coefficient , percent agreement , the observed proportion of positive agreement ( Ppos ) , and the observed proportion of negative agreement ( Pneg ) were used to describe reliability . Kappa values ranged from .29 to .38 . Percent agreement ranged from 76 % to 79 % . Ppos ranged from .43 to .52 . The low Kappa and Ppos values suggest different therapists are unable to reliably determine when a trigger point is present in a patient with LBP . This study suggests the usefulness of examining for the presence of trigger points in patients with LBP should be question ed The presence of a trigger point is essential to the myofascial pain syndrome . This study centres on identifying clearer criteria for the presence of trigger points in the quadratus lumborum and gluteus medius muscle by investigating the occurrence and inter-rater reliability of trigger point symptoms . Using the symptoms and signs as described by Simons ' 1990 definition and two other former sets of criteria , 61 non-specific low back pain patients and 63 controls were examined in general practice by 5 observers , working in pairs . From the two major criteria of Simons ' 1990 definition only ' localized tenderness ' has good discriminative ability and inter-rater reliability ( kappa > 0.5 ) . This study does not find proof for the clinical usefulness of ' referred pain ' , which has neither of these two abilities . The criteria ' jump sign ' and ' recognition ' , on the condition that localized tenderness is present , also have good discriminative ability and inter-rater reliability . Trigger points defined by the criteria found eligible in this study allow significant distinction between non-specific low back pain patients and controls . This is not the case with trigger points defined by Simons ' 1990 criteria . Concerning reliability there is also a significant difference between the two different criteria sets . This study suggests that the clinical usefulness of trigger points is increased when localized tenderness and the presence of either jump sign or patient 's recognition of his pain complaint are used as criteria for the presence of trigger points in the M. quadratus lumborum and the M. gluteus medius BACKGROUND AND PURPOSE The purpose of this study was to examine the interrater reliability of measurements obtained by examiners administering tests proposed to be important for classifying low back pain ( LBP ) problems . SUBJECTS Ninety-five subjects with LBP ( 41 men , 54 women ) and 43 subjects without LBP ( 17 men , 26 women ) were examined by 5 therapists trained in the techniques used . METHODS A manual was developed by the first author that described the clinical examination procedures . The therapists were trained by the first author in the test procedures and definitions . The training included instruction through videotapes , practice and a written examination . Each examination was conducted by a pair of therapists . Within a pair , a therapist was the primary examiner for half of the subjects and an observer was the primary examiner for half of the subjects . Examination findings were recorded independently , without discussion . RESULTS Percentage of agreement and generalized kappa coefficients were used to analyzed the data . Kappa values were > or = .75 for all 28 items related to the symptoms elicited and > or = .40 for 72 % of the 25 items related to alignment and movement . CONCLUSION AND DISCUSSION The results suggest that experienced therapist who had trained together were able to agree on the results of examinations and obtain an acceptable level of reliability . Future work should focus on testing of reliability when more than one therapist performs the examination and when therapist not trained by the test developer to administer the examination perform the tests . [ Van Dillen LR , Sahrmann SA , Norton BJ , et al. Reliability of physical examination items used for classification of patients with low back pain Study Design . A test – retest design was used . Objective . To assess interexaminer reliability of the McKenzie method for performing clinical tests and classifying patients with low back pain . Summary of Background Data . Clinical methods and tests classifying patients with nonspecific low back pain have been based mainly on symptom duration or extent of pain referral . The McKenzie mechanical diagnostic and classification approach is a widely used noninvasive , low-technology method of assessing patients with low back pain . However , little is known about the interexaminer reliability of the method , previous studies having yielded conflicting results . Methods . For this study , 39 volunteers with low back pain , mean age 40 years ( range , 24–55 years ) , were blindly assessed by two physical therapists trained in the McKenzie method .  The variability of two examiners for binary decisions was expressed by the kappa coefficient , and by the proportion of observed agreement , as calculated from a 2 × 2 contingency table of concordance . Results . On the basis of pure observation alone , agreement among clinical tests on the presence and direction of lateral shift was 77 % ( & kgr ; = 0.2;P < 0.248 ) and 79 % ( & kgr ; = 0.4;P < 0.003 ) , respectively . Agreement on the relevance of lateral shift and the lateral component according to symptom responses was 85 % ( & kgr ; = 0.7;P < 0.000 ) and 92 % ( & kgr;= 0.4;P < 0.021 ) , respectively . Using the repeated movements and static end-range loading strategy to define the central ization phenomenon and directional preference , agreement was 95 % ( & kgr ; = 0.7;P < 0.002 ) and 90 % ( & kgr ; = 0.9;P < 0.000 ) , respectively . When patients with low back pain were classified into the McKenzie main syndromes and into specific subgroups , agreement was 95 % ( & kgr ; = 0.6;P < 0.000 ) and 74 % ( & kgr ; = 0.7;P < 0.000 ) , respectively . Conclusions . Interexaminer reliability of the McKen 
    Output:
    
agent
Based on the upper threshold used ( kappa/ICC > 0.85 ) most procedures demonstrated either conflicting evidence or moderate to strong evidence of low reliability .
When the lower threshold was used ( kappa/ICC > 0.70 ) evidence about pain response to repeated movements changed from contradictory to moderate evidence for high reliability .
Most procedures commonly used by clinicians in the examination of patients with back pain demonstrate low reliability
***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: The interexaminer reliability of noninvasive methods of examining lumbar spinal segments is not well established . In this project the interexaminer reliability of three experienced chiropractic examiners , who evaluated 21 symptomatic and 25 asymptomatic subjects , was explored . Eight noninvasive segmental examination strategies ( dimensions ) were employed at each spinal segment from T11/T12 through L5/S1 . Marginal to good agreement beyond chance was noted for palpatory pain over osseous structures and in paraspinal soft-tissues . Weaker and less frequently , significant concordance between examiners was noted for detection of temperature differences ( greater than or equal to 1.5 degrees F ) between adjacent segments and for visual inspection for segmental abnormality . Little significant agreement between examiner was found for active and passive motion palpation , muscle tension palpation and misalignment palpation . This study suggests that " subjective " findings ( pain ) may be among the most reliable of conservative spinal observations . Weak but significant correlations were found when positive findings for the eight dimensions at each lumbar segment were summed to form a composite joint abnormality index . When the multidimension index was developed using the four most reliable dimensions , slightly stronger correlations were found . The strongest agreement between examiners tended to be found in the lower lumbar spine Study Design This prospect i ve study evaluated the diagnostic utility of historically accepted sacroiliac joint tests . A multidisciplinary expert panel recommended 12 of the “ best ” sacroiliac joint tests to be evaluated against a criterion st and ard of unequivocal pain relief after an intra‐articular injection of local anesthetic into the sacroiliac joint . Objectives To identify a single sacroiliac joint test or ensemble of tests that are sufficiently useful in diagnosing sacroiliac joint disorders to be clinical ly valuable . Summary of Background Data No previous research has been done to evaluate any physical test of sacroiliac joint pain against an accepted criterion st and ard . Methods Historical data was obtained , and the 12 tests were performed by two examiners on 85 patients who subsequently underwent sacroiliac joint blocks .  Ninety percent or more relief was considered a positive response , and less then 90 % relief was considered a negative response . Results There were 45 positive and 40 negative responses . No historical feature , none of the 12 sacroiliac joint tests , and no ensemble of these 12 tests demonstrated worthwhile diagnostic value . Conclusion Sacroiliac joint pain is resistant to identification by the historical and physical examination data from tests evaluated in this study Study Design . Cohort study of patients with acute low back pain undergoing physical therapy .  Objectives . Examine the reliability and validity of the Physical Impairment Index in a group of patients with acute low back pain and determine the responsiveness and minimum detectable change of the index and its component tests . Summary of the Background Data . The Physical Impairment Index was originally described as a reliable and valid means of assessing physical impairment in patients with low back pain . The psychometric properties of the index have not been reported in patients with acute low back pain , nor has its responsiveness been examined . Methods . Seventy-eight patients with acute ( <3 weeks duration ) low back pain participating in a clinical trial were assessed at baseline and after 4 weeks .  Interrater reliability of the index was examined in a subgroup of 20 patients . Validity was examined through correlations with concurrent measures of pain , disability , and psychosocial variables . Changes in the index over 4 weeks were used to assess responsiveness and minimum detectable change . Results . Interrater reliability of the index was high ( intraclass correlation coefficient = 0.89 ) , and its validity was generally supported by the pattern of correlations . The index was more responsive to change than any of its component tests but was less responsive than the Oswestry disability score . The minimum detectable change on the index was approximately 1 point . Conclusions . The Physical Impairment Index appears to be a reliable and valid measure of physical impairment for patients with acute low back pain and may be useful as an adjunct outcome measure for studies involving these patients . Further research on patients with chronic pain is needed before it can be advocated for outcomes research with this population Sixty student volunteers were assessed for fixation in the lumbar spine using a passive motion palpation protocol . Subjects were examined in r and om order by two experienced chiropractors . Every subject was evaluated twice by each examiner . Fixations were judged present or absent for each of five lumbar motion segments . Moderate test-retest agreement beyond chance was noted at L1/2 , minimal reliability at L4/5 , and no significant agreement within examiners was detected for mid-lumbar segments . Interexaminer agreement beyond chance was poor for all segments assessed . When segments were grouped regionally and re-evaluated , some increase in intrarater agreement was evident , especially at L4/5/S , but interrater agreement was still absent STUDY DESIGN A prospect i ve method ological interrater reliability study . OBJECTIVES To calculate the interrater reliability among clinicians newly trained in a classification system for acute low back pain and to determine the level of agreement at key junctures within the classification algorithm . BACKGROUND The utility of a classification system for patients with low back pain depends on its reliability and generalizability . To be practical , clinicians must be able to apply the system after a reasonable amount of training . Identifying key points in the classification algorithm where disagreement occurs can lead to better operational definitions . METHODS Four physical therapists read an article and attended a 1-day training session in the classification system .  R and omly paired therapists classified patients referred for treatment of acute low back pain and noted decisions at key junctures in the system algorithm . RESULTS Forty-five patients were classified . Repeated examinations did not increase the patient 's pain ( P>.05 ) . For 3 out of the 4 therapists , the interrater reliability showed a kappa value of 0.45 . The fourth therapist , excluded from the overall analysis , exhibited a bias towards the immobilization classification . Among the 3 therapists , major disagreement occurred with the determination of symmetry with trunk side bending and the effects of repeated movements . CONCLUSIONS Three out of 4 clinicians newly trained in the system showed moderate reliability . The reliability was slight when the fourth therapist was included . Refinement of the operational definitions and criteria for determining lumbar capsular patterns are needed . One day of training is probably not adequate for all therapists , especially for those biased towards specific low back pain syndromes BACKGROUND AND PURPOSE McKenzie described a two-step process for assessing patients with low back pain for a lateral shift . The purpose of this study was to determine whether reliable judgments about lateral shifts could be obtained . SUBJECTS Forty-nine patients with low back pain were each examined separately by two r and omly paired physical therapists . METHODS Assessment s of the presence and direction of lateral  shifts ( step 1 ) were obtained by use of a simple instrument . The relevance of the lateral shifts to the patients ' pain complaints ( step 1 ) also was assessed by use of the side-glide test sequence . RESULTS Generalized kappa coefficients were calculated to determine reliability . The kappa value for the two-step process of lateral shift assessment was .16 . The percentage of agreement was 47 % . CONCLUSION AND DISCUSSION Each step in this two-step process was examined separately for possible sources of error . The kappa value for determinations of the presence and direction of lateral shifts was .00 , indicating very poor reliability . The kappa value for the determination of the presence of a positive side-glide test sequence was .74 , indicating high reliability . The role of lateral shift assessment in the McKenzie system should be reconsidered , given the strong research evidence for poor reliability of determinations of the presence and direction of lateral shifts The purpose of this study was to determine the intertester reliability of assessment s of the presence of trigger points in the region of the lumbar spine of patients with low back pain ( LBP ) . A total of six trigger points described by Travell and Simons were studied . The trigger point examination procedures described by Travell and Simons were used by 12 physical therapists . R and omly paired therapists examined 50 patients for 197 trigger points . The Kappa coefficient , percent agreement , the observed proportion of positive agreement ( Ppos ) , and the observed proportion of negative agreement ( Pneg ) were used to describe reliability . Kappa values ranged from .29 to .38 . Percent agreement ranged from 76 % to 79 % . Ppos ranged from .43 to .52 . The low Kappa and Ppos values suggest different therapists are unable to reliably determine when a trigger point is present in a patient with LBP . This study suggests the usefulness of examining for the presence of trigger points in patients with LBP should be question ed The presence of a trigger point is essential to the myofascial pain syndrome . This study centres on identifying clearer criteria for the presence of trigger points in the quadratus lumborum and gluteus medius muscle by investigating the occurrence and inter-rater reliability of trigger point symptoms . Using the symptoms and signs as described by Simons ' 1990 definition and two other former sets of criteria , 61 non-specific low back pain patients and 63 controls were examined in general practice by 5 observers , working in pairs . From the two major criteria of Simons ' 1990 definition only ' localized tenderness ' has good discriminative ability and inter-rater reliability ( kappa > 0.5 ) . This study does not find proof for the clinical usefulness of ' referred pain ' , which has neither of these two abilities . The criteria ' jump sign ' and ' recognition ' , on the condition that localized tenderness is present , also have good discriminative ability and inter-rater reliability . Trigger points defined by the criteria found eligible in this study allow significant distinction between non-specific low back pain patients and controls . This is not the case with trigger points defined by Simons ' 1990 criteria . Concerning reliability there is also a significant difference between the two different criteria sets . This study suggests that the clinical usefulness of trigger points is increased when localized tenderness and the presence of either jump sign or patient 's recognition of his pain complaint are used as criteria for the presence of trigger points in the M. quadratus lumborum and the M. gluteus medius BACKGROUND AND PURPOSE The purpose of this study was to examine the interrater reliability of measurements obtained by examiners administering tests proposed to be important for classifying low back pain ( LBP ) problems . SUBJECTS Ninety-five subjects with LBP ( 41 men , 54 women ) and 43 subjects without LBP ( 17 men , 26 women ) were examined by 5 therapists trained in the techniques used . METHODS A manual was developed by the first author that described the clinical examination procedures . The therapists were trained by the first author in the test procedures and definitions . The training included instruction through videotapes , practice and a written examination . Each examination was conducted by a pair of therapists . Within a pair , a therapist was the primary examiner for half of the subjects and an observer was the primary examiner for half of the subjects . Examination findings were recorded independently , without discussion . RESULTS Percentage of agreement and generalized kappa coefficients were used to analyzed the data . Kappa values were > or = .75 for all 28 items related to the symptoms elicited and > or = .40 for 72 % of the 25 items related to alignment and movement . CONCLUSION AND DISCUSSION The results suggest that experienced therapist who had trained together were able to agree on the results of examinations and obtain an acceptable level of reliability . Future work should focus on testing of reliability when more than one therapist performs the examination and when therapist not trained by the test developer to administer the examination perform the tests . [ Van Dillen LR , Sahrmann SA , Norton BJ , et al. Reliability of physical examination items used for classification of patients with low back pain Study Design . A test – retest design was used . Objective . To assess interexaminer reliability of the McKenzie method for performing clinical tests and classifying patients with low back pain . Summary of Background Data . Clinical methods and tests classifying patients with nonspecific low back pain have been based mainly on symptom duration or extent of pain referral . The McKenzie mechanical diagnostic and classification approach is a widely used noninvasive , low-technology method of assessing patients with low back pain . However , little is known about the interexaminer reliability of the method , previous studies having yielded conflicting results . Methods . For this study , 39 volunteers with low back pain , mean age 40 years ( range , 24–55 years ) , were blindly assessed by two physical therapists trained in the McKenzie method .  The variability of two examiners for binary decisions was expressed by the kappa coefficient , and by the proportion of observed agreement , as calculated from a 2 × 2 contingency table of concordance . Results . On the basis of pure observation alone , agreement among clinical tests on the presence and direction of lateral shift was 77 % ( & kgr ; = 0.2;P < 0.248 ) and 79 % ( & kgr ; = 0.4;P < 0.003 ) , respectively . Agreement on the relevance of lateral shift and the lateral component according to symptom responses was 85 % ( & kgr ; = 0.7;P < 0.000 ) and 92 % ( & kgr;= 0.4;P < 0.021 ) , respectively . Using the repeated movements and static end-range loading strategy to define the central ization phenomenon and directional preference , agreement was 95 % ( & kgr ; = 0.7;P < 0.002 ) and 90 % ( & kgr ; = 0.9;P < 0.000 ) , respectively . When patients with low back pain were classified into the McKenzie main syndromes and into specific subgroups , agreement was 95 % ( & kgr ; = 0.6;P < 0.000 ) and 74 % ( & kgr ; = 0.7;P < 0.000 ) , respectively . Conclusions . Interexaminer reliability of the McKen 
    Output:
    