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: OBJECTIVES This study aims to assess the impact of a structured education and home exercise programme in daily practice patients with ankylosing spondylitis . METHODS A total of 756 patients with ankylosing spondylitis ( 72 % males , mean age 45 years ) participated in a 6-month prospect i ve multicentre controlled study , 381 of whom were r and omised to an education intervention ( a 2-hour informative session about the disease and the implementation of a non-supervised physical activity programme at home ) and 375 to st and ard care ( controls ) . Main outcome measures included Bath Ankylosing Spondylitis Disease Activity and Functional Index ( BASDAI , BASFI ) . Secondary outcome measures were 0 - 10 cm visual analog scale ( VAS ) for total pain , nocturnal pain and global disease activity and quality of life ( ASQoL ) , knowledge of disease ( self-evaluation ordinal scale ) and daily exercise ( diary card ) . RESULTS At 6 months , the adjusted mean difference between control and educational groups for BASDAI was 0.32 , 95 % confidence interval ( CI ) 0.10 - 0.54 , p=0.005 , and for BASFI 0.31 , 95%CI 0.12 - 0.51 , p=0.002 . Significant differences were found also in VAS for total pain , patient´s global assessment and in ASQoL. Patients in the education group increased their knowledge about the disease and its treatments significantly ( p<0.001 ) and practised more regular exercise than controls ( p<0.001 ) . CONCLUSIONS A structured education and home exercise programme for patients with ankylosing spondylitis in daily practice was feasible and helped to increase knowledge and exercise . Although statistically significant , the magnitudes of the clinical benefits in terms of disease activity and physical function were poor Fernández-de-las-Peñas C , Alonso-Blanco C , Morales-Cabezas M , Miangolarra-Page JC : Two exercise interventions for the management of patients with ankylosing spondylitis : A r and omized controlled trial . Am J Phys Med Rehabil 2005;84:407–419 . Objective : The purpose of this clinical trial was to evaluate the impact of a 4-month comprehensive protocol of strengthening and flexibility exercises developed by our research group versus conventional exercises for patients with Ankylosing Spondylitis ( AS ) on functional and mobility outcomes . Design : R and omized controlled trial . Forty-five patients diagnosed with AS according to the modified criteria of New York were allocated to control or experimental groups using a r and om numbers table . The control group was treated with a conventional protocol of physical therapy in AS , whereas the experimental group was treated with the protocol suggested by our research group . The conventional intervention consisted of 20 exercises : motion and flexibility exercises of the cervical , thoracic , and lumbar spine ; stretching of the shortened muscles ; and chest expansion exercises . The experimental protocol is based on the postural affectation of the AS and the treatment of the shortened muscle chains in these patients according to the Global Posture Reeducation ( GPR ) method . This intervention employs specific strengthening and flexibility exercises in which the shortened muscle chains are stretched and strengthened . The study lasted 4 mos . During this period , patients received a weekly group session managed by an experienced physiotherapist . Each session lasted an hour , and there were 15 total sessions . Changes in activity , mobility , and functional capacity were evaluated by an assessor blinded to the intervention , using the following previously vali date d scores from the Bath group : BASMI ( tragus to wall distance , modified Schöber test , cervical rotation , lumbar side flexion , and intermalleolar distance ) , BASDAI ( The Bath Ankylosing Spondylitis Disease Activity Index ) , and BASFI ( The Bath Ankylosing Spondylitis Functional Index ) . Results : Both groups showed an improvement ( prepost scores ) in all the outcome measures , mobility measures of the BASMI index , as well as in BASFI and BASDAI indexes . In the control group , the improvement in tragus to wall distance ( P = 0.009 ) and in lumbar side flexion ( P = 0.02 ) was statistically significant . Although the rest of the outcomes also improved , they did not reach a significant level ( P > 0.05 ) . In the experimental group , the improvement in all the clinical measures of the BASMI index ( P < 0.01 ) and in the BASFI index ( P = 0.003 ) was statistically significant . The intergroup comparison between the improvement ( prepost scores ) in both groups showed that the experimental group obtained a greater improvement than the control group in all the clinical measures of the BASMI index , except in tragus to wall distance , as well as in the BASFI index . Conclusions : The experimental protocol developed by our research group , based on the GPR method and specific strengthening and flexibility exercises of the muscle chains , offers promising results in the management of patients suffering from AS . Further trials on this topic are required Background The heterogeneity statistic I2 , interpreted as the percentage of variability due to heterogeneity between studies rather than sampling error , depends on precision , that is , the size of the studies included . Methods Based on a real meta- analysis , we simulate artificially ' inflating ' the sample size under the r and om effects model . For a given inflation factor M = 1 , 2 , 3 , ... and for each trial i , we create a M-inflated trial by drawing a treatment effect estimate from the r and om effects model , using si2MathType@MTEF@5@5@+=feaagaart1ev2aaatCvAUfKttLearuWrP9MDH5MBPbIqV92AaeXatLxBI9gBaebbnrfifHhDYfgasaacPC6xNi = xH8viVGI8Gi = hEeeu0xXdbba9frFj0xb9qqpG0dXdb9aspeI8k8fiI+fsY = rqGqVepae9pg0db9vqaiVgFr0xfr = xfr = xc9adbaqaaeGaciGaaiaabeqaaeqabiWaaaGcbaGaem4Cam3aa0baaSqaaiabdMgaPbqaaiabikdaYaaaaaa@2FBE@/M as within-trial sampling variance . Results As precision increases , while estimates of the heterogeneity variance τ2 remain unchanged on average , estimates of I2 increase rapidly to nearly 100 % . A similar phenomenon is apparent in a sample of 157 meta-analyses . Conclusion When deciding whether or not to pool treatment estimates in a meta- analysis , the yard-stick should be the clinical relevance of any heterogeneity present . τ2 , rather than I2 , is the appropriate measure for this purpose Objective : To investigate the effect of high-intensity exercise on emotional distress , fatigue , and ability to do a full day ’s activities in patients with axial spondyloarthritis ( axSpA ) . Method : A total of 28 physically inactive axSpA patients were r and omized to either an exercise group ( EG ) , which performed 12 weeks of cardiorespiratory and strength exercises , or a control group ( CG ) , which received treatment as usual . The outcomes reported in this paper are secondary outcomes in the trial and included emotional distress ( General Health Question naire-12 , 0–36 , 36 = worst ) , fatigue [ numeric rating scale ( NRS ) , 0–10 , 10 = worst ] , and ability to do a full day ’s activities ( NRS , 0–10 , 10 = worst ) . Post-intervention differences were assessed by analysis of covariance with baseline values as covariates . Results : Twenty-four patients were included in the analyses . All patients in the EG followed the exercise protocol . The EG had a statistically significant beneficial effect [ mean group differences ( 95 % confidence interval ) ] on emotional distress [ −5.8 , ( −9.7 , −1.9 ) , p < 0.01 ] , fatigue [ −2.4 , ( −4.3 , −0.4 ) , p = 0.02 ] , and ability to do a full day ’s work [ −2.2 , ( −3.9 , −0.4 ) , p = 0.02 ] compared to the CG . Conclusion : This pilot study showed promising effects of cardiorespiratory and strength exercises  on emotional distress , fatigue , and ability to do a full day ’s activities in patients with axSpA. The findings need to be confirmed in a larger trial We investigated the effects of home-based daily exercise on joint mobility , functional capacity , pain , and depression in patients with ankylosing spondylitis ( AS ) . The patients were r and omly assigned to a wait-list control group or to an exercise-therapy group . The exercise-therapy group performed a 20-min exercise program once per day for 8 consecutive weeks . After 8 weeks , compared with the control group , the exercise group showed improvements in joint mobility ( cervical flexion , extension , shoulder flexion , abduction , hip abduction , and knee flexion ) , finger – floor distance , and functional capacity . Pain and depression scores were significantly lower after the exercise program in the exercise group than in the control group . These findings indicate that exercise therapy increases joint mobility and functional capacity , and decreases pain and depression in patients with AS .  Home-based exercise , which is easily accessible to patients , might be an effective intervention for AS IMPORTANCE The 2008 Physical Activity Guidelines for Americans recommended a minimum of 75 vigorous-intensity or 150 moderate-intensity minutes per week ( 7.5 metabolic-equivalent hours per week ) of aerobic activity for substantial health benefit and suggested additional benefits by doing more than double this amount . However , the upper limit of longevity benefit or possible harm with more physical activity is unclear . OBJECTIVE To quantify the dose-response association between leisure time physical activity and mortality and define the upper limit of benefit or harm associated with increased levels of physical activity . DESIGN , SETTING , AND PARTICIPANTS We pooled data from 6 studies in the National Cancer Institute Cohort Consortium ( baseline 1992 - 2003 ) . Population -based prospect i ve cohorts in the United States and Europe with self-reported physical activity were analyzed in 2014 . A total of 661,137 men and women ( median age , 62 years ; range , 21 - 98 years ) and 116,686 deaths were included . We used Cox proportional hazards regression with cohort stratification to generate multivariable-adjusted hazard ratios ( HRs ) and 95 % CIs . Median follow-up time was 14.2 years . EXPOSURES Leisure time moderate- to vigorous-intensity physical activity . MAIN OUTCOMES AND MEASURES The upper limit of mortality benefit from high levels of leisure time physical activity . RESULTS Compared with individuals reporting no leisure time physical activity , we observed a 20 % lower mortality risk among those performing less than the recommended minimum of 7.5 metabolic-equivalent hours per week ( HR , 0.80 [ 95 % CI , 0.78 - 0.82 ] ) , a 31 % lower risk at 1 to 2 times the recommended minimum ( HR , 0.69 [ 95 % CI , 0.67 - 0.70 ] ) , and a 37 % lower risk at 2 to 3 times the minimum ( HR , 0.63 [ 95 % CI , 0.62 - 0.65 ] ) . An upper threshold for mortality benefit occurred at 3 to 5 times the physical activity recommendation ( HR , 0.61 [ 95 % CI , 0.59 - 0.62 ] ) ; however , compared with the recommended minimum , the additional benefit was modest ( 31 % vs 39 % ) . There was no evidence of harm at 10 or more times the recommended minimum ( HR , 0.69 [ 95 % CI , 0.59 - 0.78 ] ) . A similar dose-response relationship was observed for mortality due to cardiovascular disease and to cancer . CONCLUSIONS AND RELEVANCE Meeting the 2008 Physical Activity Guidelines for Americans minimum by either moderate- or vigorous-intensity activities was associated with nearly the maximum longevity benefit . We observed a benefit threshold at approximately 3 to 5 times the recommended leisure time physical activity minimum and no excess risk at 10 or more times the minimum . In regard to mortality , health care professionals should encourage inactive adults to perform leisure time physical activity and do not need to discourage adults who already participate in high-activity levels Despite advances in pharmacological therapy , physical treatment continues to be important in the management of ankylosing spondylitis ( AS ) . The objective of the present study was to evaluate the effects and tolerability of combined spa therapy and rehabilitation in a group of AS patients being treated with TNF inhibitors . Thirty AS patients attending the Rheumatology Unit of the University of Padova being treated with TNF inhibitors for at least 3 months were r and omized and assessed by an investigator independent from the spa staff : 15 were prescribed 10 sessions of spa therapy ( mud packs and thermal baths ) and  rehabilitation ( exercises in a thermal pool ) and the other 15 were considered controls . The patients in both groups had been receiving anti-TNF agents for at least three months . The outcome measures utilized were BASFI , BASDAI , BASMI , VAS for back pain and HAQ . The evaluations were performed in all patients at the entry to the study , at the end of the spa treatment , and after 3 and 6 months . Most of the evaluation indices were significantly improved at the end of the spa treatment , as well as at the 3 and 6 months follow-up assessment s. No significant alterations in the evaluation indices were found in the control group . Combined spa therapy and 
    Output:
    
agent
There was no important clinical meaningful benefit .
Adverse effectsWe found very low- quality evidence of the effect of exercise versus either no intervention , or usual care .
We found moderate- to low- quality evidence that exercise programmes probably slightly improve function , may reduce pain , and probably slightly reduce global patient assessment of disease activity , when compared with no intervention , and measured upon completion of the programme .
We found moderate- to low- quality evidence that exercise programmes probably have little or no effect on improving function or reducing pain , when compared with usual care , and may have little or no effect on reducing patient assessment of disease activity , when measured upon completion of the programmes .
We are uncertain whether exercise programmes improve spinal mobility , reduce fatigue , or induce adverse effects
***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: OBJECTIVES This study aims to assess the impact of a structured education and home exercise programme in daily practice patients with ankylosing spondylitis . METHODS A total of 756 patients with ankylosing spondylitis ( 72 % males , mean age 45 years ) participated in a 6-month prospect i ve multicentre controlled study , 381 of whom were r and omised to an education intervention ( a 2-hour informative session about the disease and the implementation of a non-supervised physical activity programme at home ) and 375 to st and ard care ( controls ) . Main outcome measures included Bath Ankylosing Spondylitis Disease Activity and Functional Index ( BASDAI , BASFI ) . Secondary outcome measures were 0 - 10 cm visual analog scale ( VAS ) for total pain , nocturnal pain and global disease activity and quality of life ( ASQoL ) , knowledge of disease ( self-evaluation ordinal scale ) and daily exercise ( diary card ) . RESULTS At 6 months , the adjusted mean difference between control and educational groups for BASDAI was 0.32 , 95 % confidence interval ( CI ) 0.10 - 0.54 , p=0.005 , and for BASFI 0.31 , 95%CI 0.12 - 0.51 , p=0.002 . Significant differences were found also in VAS for total pain , patient´s global assessment and in ASQoL. Patients in the education group increased their knowledge about the disease and its treatments significantly ( p<0.001 ) and practised more regular exercise than controls ( p<0.001 ) . CONCLUSIONS A structured education and home exercise programme for patients with ankylosing spondylitis in daily practice was feasible and helped to increase knowledge and exercise . Although statistically significant , the magnitudes of the clinical benefits in terms of disease activity and physical function were poor Fernández-de-las-Peñas C , Alonso-Blanco C , Morales-Cabezas M , Miangolarra-Page JC : Two exercise interventions for the management of patients with ankylosing spondylitis : A r and omized controlled trial . Am J Phys Med Rehabil 2005;84:407–419 . Objective : The purpose of this clinical trial was to evaluate the impact of a 4-month comprehensive protocol of strengthening and flexibility exercises developed by our research group versus conventional exercises for patients with Ankylosing Spondylitis ( AS ) on functional and mobility outcomes . Design : R and omized controlled trial . Forty-five patients diagnosed with AS according to the modified criteria of New York were allocated to control or experimental groups using a r and om numbers table . The control group was treated with a conventional protocol of physical therapy in AS , whereas the experimental group was treated with the protocol suggested by our research group . The conventional intervention consisted of 20 exercises : motion and flexibility exercises of the cervical , thoracic , and lumbar spine ; stretching of the shortened muscles ; and chest expansion exercises . The experimental protocol is based on the postural affectation of the AS and the treatment of the shortened muscle chains in these patients according to the Global Posture Reeducation ( GPR ) method . This intervention employs specific strengthening and flexibility exercises in which the shortened muscle chains are stretched and strengthened . The study lasted 4 mos . During this period , patients received a weekly group session managed by an experienced physiotherapist . Each session lasted an hour , and there were 15 total sessions . Changes in activity , mobility , and functional capacity were evaluated by an assessor blinded to the intervention , using the following previously vali date d scores from the Bath group : BASMI ( tragus to wall distance , modified Schöber test , cervical rotation , lumbar side flexion , and intermalleolar distance ) , BASDAI ( The Bath Ankylosing Spondylitis Disease Activity Index ) , and BASFI ( The Bath Ankylosing Spondylitis Functional Index ) . Results : Both groups showed an improvement ( prepost scores ) in all the outcome measures , mobility measures of the BASMI index , as well as in BASFI and BASDAI indexes . In the control group , the improvement in tragus to wall distance ( P = 0.009 ) and in lumbar side flexion ( P = 0.02 ) was statistically significant . Although the rest of the outcomes also improved , they did not reach a significant level ( P > 0.05 ) . In the experimental group , the improvement in all the clinical measures of the BASMI index ( P < 0.01 ) and in the BASFI index ( P = 0.003 ) was statistically significant . The intergroup comparison between the improvement ( prepost scores ) in both groups showed that the experimental group obtained a greater improvement than the control group in all the clinical measures of the BASMI index , except in tragus to wall distance , as well as in the BASFI index . Conclusions : The experimental protocol developed by our research group , based on the GPR method and specific strengthening and flexibility exercises of the muscle chains , offers promising results in the management of patients suffering from AS . Further trials on this topic are required Background The heterogeneity statistic I2 , interpreted as the percentage of variability due to heterogeneity between studies rather than sampling error , depends on precision , that is , the size of the studies included . Methods Based on a real meta- analysis , we simulate artificially ' inflating ' the sample size under the r and om effects model . For a given inflation factor M = 1 , 2 , 3 , ... and for each trial i , we create a M-inflated trial by drawing a treatment effect estimate from the r and om effects model , using si2MathType@MTEF@5@5@+=feaagaart1ev2aaatCvAUfKttLearuWrP9MDH5MBPbIqV92AaeXatLxBI9gBaebbnrfifHhDYfgasaacPC6xNi = xH8viVGI8Gi = hEeeu0xXdbba9frFj0xb9qqpG0dXdb9aspeI8k8fiI+fsY = rqGqVepae9pg0db9vqaiVgFr0xfr = xfr = xc9adbaqaaeGaciGaaiaabeqaaeqabiWaaaGcbaGaem4Cam3aa0baaSqaaiabdMgaPbqaaiabikdaYaaaaaa@2FBE@/M as within-trial sampling variance . Results As precision increases , while estimates of the heterogeneity variance τ2 remain unchanged on average , estimates of I2 increase rapidly to nearly 100 % . A similar phenomenon is apparent in a sample of 157 meta-analyses . Conclusion When deciding whether or not to pool treatment estimates in a meta- analysis , the yard-stick should be the clinical relevance of any heterogeneity present . τ2 , rather than I2 , is the appropriate measure for this purpose Objective : To investigate the effect of high-intensity exercise on emotional distress , fatigue , and ability to do a full day ’s activities in patients with axial spondyloarthritis ( axSpA ) . Method : A total of 28 physically inactive axSpA patients were r and omized to either an exercise group ( EG ) , which performed 12 weeks of cardiorespiratory and strength exercises , or a control group ( CG ) , which received treatment as usual . The outcomes reported in this paper are secondary outcomes in the trial and included emotional distress ( General Health Question naire-12 , 0–36 , 36 = worst ) , fatigue [ numeric rating scale ( NRS ) , 0–10 , 10 = worst ] , and ability to do a full day ’s activities ( NRS , 0–10 , 10 = worst ) . Post-intervention differences were assessed by analysis of covariance with baseline values as covariates . Results : Twenty-four patients were included in the analyses . All patients in the EG followed the exercise protocol . The EG had a statistically significant beneficial effect [ mean group differences ( 95 % confidence interval ) ] on emotional distress [ −5.8 , ( −9.7 , −1.9 ) , p < 0.01 ] , fatigue [ −2.4 , ( −4.3 , −0.4 ) , p = 0.02 ] , and ability to do a full day ’s work [ −2.2 , ( −3.9 , −0.4 ) , p = 0.02 ] compared to the CG . Conclusion : This pilot study showed promising effects of cardiorespiratory and strength exercises  on emotional distress , fatigue , and ability to do a full day ’s activities in patients with axSpA. The findings need to be confirmed in a larger trial We investigated the effects of home-based daily exercise on joint mobility , functional capacity , pain , and depression in patients with ankylosing spondylitis ( AS ) . The patients were r and omly assigned to a wait-list control group or to an exercise-therapy group . The exercise-therapy group performed a 20-min exercise program once per day for 8 consecutive weeks . After 8 weeks , compared with the control group , the exercise group showed improvements in joint mobility ( cervical flexion , extension , shoulder flexion , abduction , hip abduction , and knee flexion ) , finger – floor distance , and functional capacity . Pain and depression scores were significantly lower after the exercise program in the exercise group than in the control group . These findings indicate that exercise therapy increases joint mobility and functional capacity , and decreases pain and depression in patients with AS .  Home-based exercise , which is easily accessible to patients , might be an effective intervention for AS IMPORTANCE The 2008 Physical Activity Guidelines for Americans recommended a minimum of 75 vigorous-intensity or 150 moderate-intensity minutes per week ( 7.5 metabolic-equivalent hours per week ) of aerobic activity for substantial health benefit and suggested additional benefits by doing more than double this amount . However , the upper limit of longevity benefit or possible harm with more physical activity is unclear . OBJECTIVE To quantify the dose-response association between leisure time physical activity and mortality and define the upper limit of benefit or harm associated with increased levels of physical activity . DESIGN , SETTING , AND PARTICIPANTS We pooled data from 6 studies in the National Cancer Institute Cohort Consortium ( baseline 1992 - 2003 ) . Population -based prospect i ve cohorts in the United States and Europe with self-reported physical activity were analyzed in 2014 . A total of 661,137 men and women ( median age , 62 years ; range , 21 - 98 years ) and 116,686 deaths were included . We used Cox proportional hazards regression with cohort stratification to generate multivariable-adjusted hazard ratios ( HRs ) and 95 % CIs . Median follow-up time was 14.2 years . EXPOSURES Leisure time moderate- to vigorous-intensity physical activity . MAIN OUTCOMES AND MEASURES The upper limit of mortality benefit from high levels of leisure time physical activity . RESULTS Compared with individuals reporting no leisure time physical activity , we observed a 20 % lower mortality risk among those performing less than the recommended minimum of 7.5 metabolic-equivalent hours per week ( HR , 0.80 [ 95 % CI , 0.78 - 0.82 ] ) , a 31 % lower risk at 1 to 2 times the recommended minimum ( HR , 0.69 [ 95 % CI , 0.67 - 0.70 ] ) , and a 37 % lower risk at 2 to 3 times the minimum ( HR , 0.63 [ 95 % CI , 0.62 - 0.65 ] ) . An upper threshold for mortality benefit occurred at 3 to 5 times the physical activity recommendation ( HR , 0.61 [ 95 % CI , 0.59 - 0.62 ] ) ; however , compared with the recommended minimum , the additional benefit was modest ( 31 % vs 39 % ) . There was no evidence of harm at 10 or more times the recommended minimum ( HR , 0.69 [ 95 % CI , 0.59 - 0.78 ] ) . A similar dose-response relationship was observed for mortality due to cardiovascular disease and to cancer . CONCLUSIONS AND RELEVANCE Meeting the 2008 Physical Activity Guidelines for Americans minimum by either moderate- or vigorous-intensity activities was associated with nearly the maximum longevity benefit . We observed a benefit threshold at approximately 3 to 5 times the recommended leisure time physical activity minimum and no excess risk at 10 or more times the minimum . In regard to mortality , health care professionals should encourage inactive adults to perform leisure time physical activity and do not need to discourage adults who already participate in high-activity levels Despite advances in pharmacological therapy , physical treatment continues to be important in the management of ankylosing spondylitis ( AS ) . The objective of the present study was to evaluate the effects and tolerability of combined spa therapy and rehabilitation in a group of AS patients being treated with TNF inhibitors . Thirty AS patients attending the Rheumatology Unit of the University of Padova being treated with TNF inhibitors for at least 3 months were r and omized and assessed by an investigator independent from the spa staff : 15 were prescribed 10 sessions of spa therapy ( mud packs and thermal baths ) and  rehabilitation ( exercises in a thermal pool ) and the other 15 were considered controls . The patients in both groups had been receiving anti-TNF agents for at least three months . The outcome measures utilized were BASFI , BASDAI , BASMI , VAS for back pain and HAQ . The evaluations were performed in all patients at the entry to the study , at the end of the spa treatment , and after 3 and 6 months . Most of the evaluation indices were significantly improved at the end of the spa treatment , as well as at the 3 and 6 months follow-up assessment s. No significant alterations in the evaluation indices were found in the control group . Combined spa therapy and 
    Output:
    