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: OBJECTIVE The aim of this study was to investigate the construct validity of 6 physical performance tests that had already been shown to have acceptable repeatability . DESIGN Data were collected in a r and omized controlled multi-centre study . SUBJECTS 126 women and 105 men sick-listed for spinal pain carried out the tests and provided personal and background data at inclusion in the study . METHODS One test measured stepping up onto and down from a stool , 2 measured lifting ability and 3 walking speed . Construct validity was examined by analysing the influence of some variables on test performance . RESULTS High-rated pain behaviour and perceived high pain intensity during testing or during the previous 4 weeks were connected with low test performance . Exercise twice a week was connected with high test performance . The test with the highest ability to detect disability in the women with lumbar pain was a lumbar lifting test , while for the men , it was a cervical lifting test . The test with the highest ability to detect disability in the participants with neck pain was the cervical lifting test in addition to a gait test with burden for the women . CONCLUSION Back pain hampered the test performance more than neck pain . Impairments and activity limitations expressed by the patient should guide the choice of test Background Reproducibility measurements of the range of motion are an important prerequisite for the interpretation of study results . The aim of the study is to assess the intra-rater and inter-rater reproducibility of the measurement of active Range of Motion ( ROM ) in patients with neck pain using the Cybex Electronic Digital Inclinometer-320 ( EDI-320 ) . Methods In an outpatient clinic in a primary care setting 32 patients with at least 2 weeks of pain and /or stiffness in the neck were r and omly assessed , in a test- retest design with blinded raters using a st and ardized measurement protocol . Cervical flexion-extension , lateral flexion and rotation were assessed . Results Reliability expressed by the Intraclass Correlation Coefficient ( ICC ) was 0.93 ( lateral flexion ) or higher for intra-rater reliability and 0.89 ( lateral flexion ) or higher for inter-rater reliability . The 95 % limits of agreement for intra-rater agreement , expressing the range of the differences between two ratings were -2.5 ± 11.1 ° for flexion-extension , -0.1 ± 10.4 ° for lateral flexion and -5.9 ± 13.5 ° for rotation . For inter-rater agreement the limits of agreement were 3.3 ± 17.0 ° for flexion-extension , 0.5 ± 17.0 ° for lateral flexion and -1.3 ± 24.6 ° for rotation . Conclusion In general , the intra-rater reproducibility and the inter-rater reproducibility were good . We recommend to compare the reproducibility and clinical applicability of the EDI-320 inclinometer with other cervical ROM measures in symptomatic patients OBJECTIVE To assess the sensitivity to change of three algofunctional scales for neck pain . METHODS Observational , prospect i ve study . Patients with neck disorders were included .  Pain and patients ' perceived h and icap assessed on visual analogue scales ( VAS Pain , VAS H and icap ) , and functional disability measures ( Neck Disability Index , Neck Pain and Disability Scale , Northwick Park Neck Pain Question naire  )  were recorded twice , at baseline and at an 11-month follow-up assessment . Sensitivity to change was assessed using the effect size ( ES ) and the st and ardised response mean ( SRM ) , and the non-parametric Spearman 's rank correlation coefficient ( r ) was used to assess the correlation between quantitative variable changes and patients ' overall opinion . Analysis of variance ( ANOVA ) followed by a Tukey-test was performed to determine if the scales distinguished improved , stable , and deteriorated patients . RESULTS Seventy-one patients ( 43 women , mean age 49 years ) were included and evaluated twice at an interval of 11 + /- 2 months . The three scales showed good sensitivity to change . The ANOVA showed a group effect , and individual changes in the scales scores were statistically different in two-by-two comparisons ( improved , stable or deteriorated patients ) . Changes in NPDS scores had the highest correlation with patient 's overall assessment ( r = 0.592 ) . CONCLUSION The three scales can detect changes in patients with neck disorders . Changes in NPDS score had the best correlation with patients ' overall opinion concerning their neck disorder and this question naire should be given preference in clinical trials BACKGROUND The National Emergency X-Radiography Utilization Study ( NEXUS ) recently vali date d the ability of a decision instrument to define a population with an extremely low risk of cervical spine injury ( CSI ) after blunt trauma . It is unclear whether each of the 5 individual criteria is necessary for the decision instrument to maintain its high sensitivity . METHODS NEXUS was a prospect i ve observational study at 21 emergency departments , which enrolled all patients with blunt trauma for whom cervical spine radiographs were ordered . In this sub study , we examined the NEXUS data base to determine the contribution of each of the 5 individual low-risk clinical criteria to the overall sensitivity of the decision instrument . RESULTS All but 8 of 818 patients with CSI , and all but 2 of 578 patients with significant CSI , were identified by using the decision instrument . A substantial number of patients with CSI ( 236/818 [ 29 % ] ) and patients with significant CSI ( 175/578 [ 30 % ] ) met only 1 of the 5 non -- low-risk criteria , and each of the 5 criteria was the only indicator of non -- low-risk status in at least 8 patients with CSI and at least 5 patients with significant CSI . CONCLUSION Because each of the 5 low-risk criteria was the only marker of non -- low-risk status in at least a few patients with significant CSI , modification of the overall NEXUS decision instrument by eliminating any one of the criteria would markedly reduce sensitivity and make the instrument unacceptable for clinical use Abstract The aim of this study is to assess the accuracy of MRI alone in the differentiation of soft cervical disc protrusion from osteophytic compression in cervical disc disease . In a retrospective study , the  MRI scans of 41 patients with cervical disc disease , who had previously undergone surgery , were presented to three independent observers , r and omly on two different occasions , to identify the accuracy of the diagnosis of the presence of hard or soft disc or both as a cause of compression . The observers ( two neurosurgeons and one neuroradiologist ) were not involved with the treatment of the cases at any stage and were unaware of the surgical findings . Their observations were compared with those of the surgeon recorded at operation . The intra-observer agreement was poor for diagnosis into three categories as hard or soft disc or both . In distinguishing between the presence or absence of hard disc , there was moderate to good ( Kappa = 0.6 ) intra observer and fair to moderate ( Kappa = 0.4 ) interobserver agreement . The sensitivity of diagnosis of a hard disc was high ( 87 % ) but specificity was low ( 44 % ) , due to the overestimation of the presence of hard disc . There was a significantly higher incidence of hard disc in the elderly age group ( 76 % over the fifth decade , P = 0.0073 ) . It is concluded that MRI alone is not a very efficient diagnostic tool in distinguishing between hard and soft disc in the cervical disc disease CONTEXT High levels of variation and inefficiency exist in current clinical practice regarding use of cervical spine ( C-spine ) radiography in alert and stable trauma patients . OBJECTIVE To derive a clinical decision rule that is highly sensitive for detecting acute C-spine injury and will allow emergency department ( ED ) physicians to be more selective in use of radiography in alert and stable trauma patients . DESIGN Prospect i ve cohort study conducted from October 1996 to April 1999 , in which physicians evaluated patients for 20 st and ardized clinical findings prior to radiography .  In some cases , a second physician performed independent interobserver assessment s. SETTING Ten EDs in large Canadian community and university hospitals . PATIENTS Convenience sample of 8924 adults ( mean age , 37 years ) who presented to the ED with blunt trauma to the head/neck , stable vital signs , and a Glasgow Coma Scale score of 15 . MAIN OUTCOME MEASURE Clinical ly important C-spine injury , evaluated by plain radiography , computed tomography , and a structured follow-up telephone interview .  The clinical decision rule was derived using the kappa coefficient , logistic regression analysis , and chi(2 ) recursive partitioning techniques . RESULTS Among the study sample , 151 ( 1.7 % ) had important C-spine injury . The result ant model and final Canadian C-Spine Rule comprises 3 main questions : ( 1 ) is there any high-risk factor present that m and ates radiography ( ie , age > /=65 years , dangerous mechanism , or paresthesias in extremities ) ? ( 2 ) is there any low-risk factor present that allows safe assessment of range of motion ( ie , simple rear-end motor vehicle collision , sitting position in ED , ambulatory at any time since injury , delayed onset of neck pain , or absence of midline C-spine tenderness ) ? and ( 3 ) is the patient able to actively rotate neck 45 degrees to the left and right ? By cross-validation , this rule had 100 % sensitivity ( 95 % confidence interval [ CI ] , 98%-100 % ) and 42.5 % specificity ( 95 % CI , 40%-44 % ) for identifying 151 clinical ly important C-spine injuries . The potential radiography ordering rate would be 58.2 % . CONCLUSION We have derived the Canadian C-Spine Rule , a highly sensitive decision rule for use of C-spine radiography in alert and stable trauma patients . If prospect ively vali date d in other cohorts , this rule has the potential to significantly reduce practice variation and inefficiency in ED use of C-spine radiography In the present study , we compared magnetic resonance imaging ( MRI ) findings of soft tissue structures in the upper cervical spine between whiplash-associated disorder ( WAD ) patients and population -based control persons , and examined whether MRI-verified abnormalities in WAD patients were related to accident-related factors hypothesized to be of importance for severity of injury . A total of 92 whiplash patients and 30 control persons , r and omly drawn , were included . Information on the accident-related factors ( i.e. , head position and impact direction ) was obtained by a question naire that was answered within 1 week after the accident . The MRI examination was performed 2 - 9 ( mean 6 ) years after the accident . Focus was on MRI abnormalities of the alar and the transverse ligaments , and the tectorial and posterior atlanto-occipital membranes , grade d 0 - 3 . For all neck structures , the whiplash patients had more high- grade lesions ( grade 2 or 3 ) than the control persons ( Chi-square test , p < 0.055 ) . An abnormal alar ligament was most common ( 66.3 % grade d 2 or 3 ) . Whiplash patients who had been sitting with their head/neck turned to one side at the moment of collision more often had high- grade lesions of the alar and transverse ligaments ( p < 0.001 , p = 0.040 , respectively ) . Severe injuries to the transverse ligament and the posterior atlanto-occipital membrane were more common in front than in rear end collisions ( p < 0.001 , p = 0.001 , respectively ) . In conclusion , the difference in MRI-verified lesions between WAD patients and control persons , and in particular the association with head position and impact direction at time of accident , indicate that these lesions are caused by the whiplash trauma STUDY HYPOTHESIS Cervical-spine radiography does not need to be performed on selected blunt trauma patients who are awake , alert , nonintoxicated , do not complain of midline neck pain , and have no tenderness over the bony cervical spine . STUDY POPULATION One thous and consecutive patients seen in the UCLA Emergency Medicine Center with a chief complaint of blunt trauma , for whom cervical-spine films were ordered and for whom prospect i ve data question naires were completed . METHODS Clinicians completed data forms for each patient before radiograph results were known . Data items included mechanism of injury , evidence of intoxication , presence of cervical-spine pain and /or tenderness , level of alertness , presence of focal neurologic deficits , and presence of other severely painful injuries unrelated to the cervical spine . Physicians were also asked to estimate likelihood of significant cervical-spine injury . RESULTS Twenty-seven patients with cervical-spine fracture were among the 974 patients for whom data forms were completed . A number of findings were statistically more common in the group of patients with fracture than without , but no single or paired findings identified all patients with fracture . All 27 patients with fracture had at least one of the following four characteristics : midline neck tenderness , evidence of intoxication , altered level of alertness , or a severely painful injury elsewhere . Three hundred fifty-three of 947 ( 37.3 % ) patients without cervical-spine fracture had none of these findings . CONCLUSION Cervical-spine radiology may not be necessary in patients without spinous tenderness in the neck , intoxication , altered level of alertness , or other severely painful injury . A policy to limit films in such patients would have decreased film ordering by more than one third in this series , while identifying all patients with fracture One hundred and seven women participated in a clinical study of an age-stratified r and om sample of sewing machine operators compared to 
    Output:
    
agent
Screening protocol s have high predictive values to detect cervical spine fracture in alert , low-risk patients seeking emergency care after blunt neck trauma .
Computerized tomography ( CT ) scans had better validity ( in adults and elderly ) than radiographs in assessing high-risk and /or multi-injured blunt trauma neck patients .
In the absence of serious pathology , clinical physical examinations are more predictive at excluding than confirming structural lesions causing neurologic compression .
One exception is the manual provocation test for cervical radiculopathy , which has high positive predictive value .
There was no evidence that specific MRI findings are associated with neck pain , cervicogenic headache , or whiplash exposure .
No evidence supports using cervical provocative discography , anesthetic facet , or medial branch blocks in evaluating neck pain .
Reliable and valid self-report question naires are useful in assessing pain , function , disability , and psychosocial status in individuals with neck pain .
CONCLUSION The scientific evidence supports screening protocol s in emergency care for low-risk patients ; and CT-scans for high-risk patients with blunt trauma to the neck .
In nonemergency neck pain without radiculopathy , the validity of most commonly used objective tests is lacking .
***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 The aim of this study was to investigate the construct validity of 6 physical performance tests that had already been shown to have acceptable repeatability . DESIGN Data were collected in a r and omized controlled multi-centre study . SUBJECTS 126 women and 105 men sick-listed for spinal pain carried out the tests and provided personal and background data at inclusion in the study . METHODS One test measured stepping up onto and down from a stool , 2 measured lifting ability and 3 walking speed . Construct validity was examined by analysing the influence of some variables on test performance . RESULTS High-rated pain behaviour and perceived high pain intensity during testing or during the previous 4 weeks were connected with low test performance . Exercise twice a week was connected with high test performance . The test with the highest ability to detect disability in the women with lumbar pain was a lumbar lifting test , while for the men , it was a cervical lifting test . The test with the highest ability to detect disability in the participants with neck pain was the cervical lifting test in addition to a gait test with burden for the women . CONCLUSION Back pain hampered the test performance more than neck pain . Impairments and activity limitations expressed by the patient should guide the choice of test Background Reproducibility measurements of the range of motion are an important prerequisite for the interpretation of study results . The aim of the study is to assess the intra-rater and inter-rater reproducibility of the measurement of active Range of Motion ( ROM ) in patients with neck pain using the Cybex Electronic Digital Inclinometer-320 ( EDI-320 ) . Methods In an outpatient clinic in a primary care setting 32 patients with at least 2 weeks of pain and /or stiffness in the neck were r and omly assessed , in a test- retest design with blinded raters using a st and ardized measurement protocol . Cervical flexion-extension , lateral flexion and rotation were assessed . Results Reliability expressed by the Intraclass Correlation Coefficient ( ICC ) was 0.93 ( lateral flexion ) or higher for intra-rater reliability and 0.89 ( lateral flexion ) or higher for inter-rater reliability . The 95 % limits of agreement for intra-rater agreement , expressing the range of the differences between two ratings were -2.5 ± 11.1 ° for flexion-extension , -0.1 ± 10.4 ° for lateral flexion and -5.9 ± 13.5 ° for rotation . For inter-rater agreement the limits of agreement were 3.3 ± 17.0 ° for flexion-extension , 0.5 ± 17.0 ° for lateral flexion and -1.3 ± 24.6 ° for rotation . Conclusion In general , the intra-rater reproducibility and the inter-rater reproducibility were good . We recommend to compare the reproducibility and clinical applicability of the EDI-320 inclinometer with other cervical ROM measures in symptomatic patients OBJECTIVE To assess the sensitivity to change of three algofunctional scales for neck pain . METHODS Observational , prospect i ve study . Patients with neck disorders were included .  Pain and patients ' perceived h and icap assessed on visual analogue scales ( VAS Pain , VAS H and icap ) , and functional disability measures ( Neck Disability Index , Neck Pain and Disability Scale , Northwick Park Neck Pain Question naire  )  were recorded twice , at baseline and at an 11-month follow-up assessment . Sensitivity to change was assessed using the effect size ( ES ) and the st and ardised response mean ( SRM ) , and the non-parametric Spearman 's rank correlation coefficient ( r ) was used to assess the correlation between quantitative variable changes and patients ' overall opinion . Analysis of variance ( ANOVA ) followed by a Tukey-test was performed to determine if the scales distinguished improved , stable , and deteriorated patients . RESULTS Seventy-one patients ( 43 women , mean age 49 years ) were included and evaluated twice at an interval of 11 + /- 2 months . The three scales showed good sensitivity to change . The ANOVA showed a group effect , and individual changes in the scales scores were statistically different in two-by-two comparisons ( improved , stable or deteriorated patients ) . Changes in NPDS scores had the highest correlation with patient 's overall assessment ( r = 0.592 ) . CONCLUSION The three scales can detect changes in patients with neck disorders . Changes in NPDS score had the best correlation with patients ' overall opinion concerning their neck disorder and this question naire should be given preference in clinical trials BACKGROUND The National Emergency X-Radiography Utilization Study ( NEXUS ) recently vali date d the ability of a decision instrument to define a population with an extremely low risk of cervical spine injury ( CSI ) after blunt trauma . It is unclear whether each of the 5 individual criteria is necessary for the decision instrument to maintain its high sensitivity . METHODS NEXUS was a prospect i ve observational study at 21 emergency departments , which enrolled all patients with blunt trauma for whom cervical spine radiographs were ordered . In this sub study , we examined the NEXUS data base to determine the contribution of each of the 5 individual low-risk clinical criteria to the overall sensitivity of the decision instrument . RESULTS All but 8 of 818 patients with CSI , and all but 2 of 578 patients with significant CSI , were identified by using the decision instrument . A substantial number of patients with CSI ( 236/818 [ 29 % ] ) and patients with significant CSI ( 175/578 [ 30 % ] ) met only 1 of the 5 non -- low-risk criteria , and each of the 5 criteria was the only indicator of non -- low-risk status in at least 8 patients with CSI and at least 5 patients with significant CSI . CONCLUSION Because each of the 5 low-risk criteria was the only marker of non -- low-risk status in at least a few patients with significant CSI , modification of the overall NEXUS decision instrument by eliminating any one of the criteria would markedly reduce sensitivity and make the instrument unacceptable for clinical use Abstract The aim of this study is to assess the accuracy of MRI alone in the differentiation of soft cervical disc protrusion from osteophytic compression in cervical disc disease . In a retrospective study , the  MRI scans of 41 patients with cervical disc disease , who had previously undergone surgery , were presented to three independent observers , r and omly on two different occasions , to identify the accuracy of the diagnosis of the presence of hard or soft disc or both as a cause of compression . The observers ( two neurosurgeons and one neuroradiologist ) were not involved with the treatment of the cases at any stage and were unaware of the surgical findings . Their observations were compared with those of the surgeon recorded at operation . The intra-observer agreement was poor for diagnosis into three categories as hard or soft disc or both . In distinguishing between the presence or absence of hard disc , there was moderate to good ( Kappa = 0.6 ) intra observer and fair to moderate ( Kappa = 0.4 ) interobserver agreement . The sensitivity of diagnosis of a hard disc was high ( 87 % ) but specificity was low ( 44 % ) , due to the overestimation of the presence of hard disc . There was a significantly higher incidence of hard disc in the elderly age group ( 76 % over the fifth decade , P = 0.0073 ) . It is concluded that MRI alone is not a very efficient diagnostic tool in distinguishing between hard and soft disc in the cervical disc disease CONTEXT High levels of variation and inefficiency exist in current clinical practice regarding use of cervical spine ( C-spine ) radiography in alert and stable trauma patients . OBJECTIVE To derive a clinical decision rule that is highly sensitive for detecting acute C-spine injury and will allow emergency department ( ED ) physicians to be more selective in use of radiography in alert and stable trauma patients . DESIGN Prospect i ve cohort study conducted from October 1996 to April 1999 , in which physicians evaluated patients for 20 st and ardized clinical findings prior to radiography .  In some cases , a second physician performed independent interobserver assessment s. SETTING Ten EDs in large Canadian community and university hospitals . PATIENTS Convenience sample of 8924 adults ( mean age , 37 years ) who presented to the ED with blunt trauma to the head/neck , stable vital signs , and a Glasgow Coma Scale score of 15 . MAIN OUTCOME MEASURE Clinical ly important C-spine injury , evaluated by plain radiography , computed tomography , and a structured follow-up telephone interview .  The clinical decision rule was derived using the kappa coefficient , logistic regression analysis , and chi(2 ) recursive partitioning techniques . RESULTS Among the study sample , 151 ( 1.7 % ) had important C-spine injury . The result ant model and final Canadian C-Spine Rule comprises 3 main questions : ( 1 ) is there any high-risk factor present that m and ates radiography ( ie , age > /=65 years , dangerous mechanism , or paresthesias in extremities ) ? ( 2 ) is there any low-risk factor present that allows safe assessment of range of motion ( ie , simple rear-end motor vehicle collision , sitting position in ED , ambulatory at any time since injury , delayed onset of neck pain , or absence of midline C-spine tenderness ) ? and ( 3 ) is the patient able to actively rotate neck 45 degrees to the left and right ? By cross-validation , this rule had 100 % sensitivity ( 95 % confidence interval [ CI ] , 98%-100 % ) and 42.5 % specificity ( 95 % CI , 40%-44 % ) for identifying 151 clinical ly important C-spine injuries . The potential radiography ordering rate would be 58.2 % . CONCLUSION We have derived the Canadian C-Spine Rule , a highly sensitive decision rule for use of C-spine radiography in alert and stable trauma patients . If prospect ively vali date d in other cohorts , this rule has the potential to significantly reduce practice variation and inefficiency in ED use of C-spine radiography In the present study , we compared magnetic resonance imaging ( MRI ) findings of soft tissue structures in the upper cervical spine between whiplash-associated disorder ( WAD ) patients and population -based control persons , and examined whether MRI-verified abnormalities in WAD patients were related to accident-related factors hypothesized to be of importance for severity of injury . A total of 92 whiplash patients and 30 control persons , r and omly drawn , were included . Information on the accident-related factors ( i.e. , head position and impact direction ) was obtained by a question naire that was answered within 1 week after the accident . The MRI examination was performed 2 - 9 ( mean 6 ) years after the accident . Focus was on MRI abnormalities of the alar and the transverse ligaments , and the tectorial and posterior atlanto-occipital membranes , grade d 0 - 3 . For all neck structures , the whiplash patients had more high- grade lesions ( grade 2 or 3 ) than the control persons ( Chi-square test , p < 0.055 ) . An abnormal alar ligament was most common ( 66.3 % grade d 2 or 3 ) . Whiplash patients who had been sitting with their head/neck turned to one side at the moment of collision more often had high- grade lesions of the alar and transverse ligaments ( p < 0.001 , p = 0.040 , respectively ) . Severe injuries to the transverse ligament and the posterior atlanto-occipital membrane were more common in front than in rear end collisions ( p < 0.001 , p = 0.001 , respectively ) . In conclusion , the difference in MRI-verified lesions between WAD patients and control persons , and in particular the association with head position and impact direction at time of accident , indicate that these lesions are caused by the whiplash trauma STUDY HYPOTHESIS Cervical-spine radiography does not need to be performed on selected blunt trauma patients who are awake , alert , nonintoxicated , do not complain of midline neck pain , and have no tenderness over the bony cervical spine . STUDY POPULATION One thous and consecutive patients seen in the UCLA Emergency Medicine Center with a chief complaint of blunt trauma , for whom cervical-spine films were ordered and for whom prospect i ve data question naires were completed . METHODS Clinicians completed data forms for each patient before radiograph results were known . Data items included mechanism of injury , evidence of intoxication , presence of cervical-spine pain and /or tenderness , level of alertness , presence of focal neurologic deficits , and presence of other severely painful injuries unrelated to the cervical spine . Physicians were also asked to estimate likelihood of significant cervical-spine injury . RESULTS Twenty-seven patients with cervical-spine fracture were among the 974 patients for whom data forms were completed . A number of findings were statistically more common in the group of patients with fracture than without , but no single or paired findings identified all patients with fracture . All 27 patients with fracture had at least one of the following four characteristics : midline neck tenderness , evidence of intoxication , altered level of alertness , or a severely painful injury elsewhere . Three hundred fifty-three of 947 ( 37.3 % ) patients without cervical-spine fracture had none of these findings . CONCLUSION Cervical-spine radiology may not be necessary in patients without spinous tenderness in the neck , intoxication , altered level of alertness , or other severely painful injury . A policy to limit films in such patients would have decreased film ordering by more than one third in this series , while identifying all patients with fracture One hundred and seven women participated in a clinical study of an age-stratified r and om sample of sewing machine operators compared to 
    Output:
    