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: Different methods of obtaining information in medical and social research present problems of interpretation for the research er . However , there are few systematic studies on the extent of the lack of concordance yielded by different methods . This paper uses data from a r and omized controlled trial of social support in pregnancy to examine this issue in relation to three methods of data collection --medical records , home interviews and a postal question naire -- on the following topics : obstetric history ; smoking , alcohol use , number of antenatal hospital visits , bleeding and depression in pregnancy ; length of labour ; baby 's sex , birthweight and neonatal health problems ; and ethnicity . Considerable discrepancies are found comparing the different data sources . These suggest that mothers may be more reliable sources of information than medical records , and that the anonymity of a postal question naire may provide higher estimates than home interviews on some sensitive topics , such as smoking in pregnancy Background The Knee injury and Osteoarthritis Outcome Score ( KOOS ) is an extension of the Western Ontario and McMaster Universities Osteoarthrtis Index ( WOMAC ) , the most commonly used outcome instrument for assessment of patient-relevant treatment effects in osteoarthritis . KOOS was developed for younger and /or more active patients with knee injury and knee osteoarthritis and has in previous studies on these groups been the more responsive instrument compared to the WOMAC . Some patients eligible for total knee replacement have expectations of more dem and ing physical functions than required for daily living . This encouraged us to study the use of the Knee injury and Osteoarthritis Outcome Score ( KOOS ) to assess the outcome of total knee replacement . Methods We studied the test-retest reliability , validity and responsiveness of the Swedish version LK 1.0 of the KOOS when used to prospect ively evaluate the outcome of 105 patients ( mean age 71.3 , 66 women ) after total knee replacement .  The follow-up rates at 6 and 12 months were 92 % and 86 % , respectively . Results The intraclass correlation coefficients were over 0.75 for all subscales indicating sufficient test-retest reliability . Bl and -Altman plots confirmed this finding . Over 90 % of the patients regarded improvement in the subscales Pain , Symptoms , Activities of Daily Living , and knee-related Quality of Life to be extremely or very important when deciding to have their knee operated on indicating good content validity . The correlations found in comparison to the SF-36 indicated the KOOS measured expected constructs . The most responsive subscale was knee-related Quality of Life . The effect sizes of the five KOOS subscales at 12 months ranged from 1.08 to 3.54 and for the WOMAC from 1.65 to 2.56 . Conclusion The Knee injury and Osteoarthritis Outcome Score ( KOOS ) is a valid , reliable , and responsive outcome measure in total joint replacement . In comparison to the WOMAC , the KOOS improved validity and may be at least as responsive as the WOMAC Background Specially trained physiotherapists ( advanced practice physiotherapists ( APP ) ) are working in orthopaedic clinics to improve access to orthopaedic services and support chronic disease management . Little attention has been paid to the impact APPs may have on non-surgical patients . In non-surgical patients with hip or knee arthritis consulting an APP in an orthopaedic clinic , the objectives were to : 1 ) describe patients ’ recall of APP recommendations , use of self-management strategies , and barriers to management six weeks following consultation ; and , 2 ) compare exercise behaviour and self-efficacy at baseline and six weeks . Findings This was a single group pre- and post-intervention study of patients who saw an APP when consulting the orthopaedic departments of two hospitals . At baseline and six weeks participants completed the adapted Stanford Exercise Behaviour Scale ( response options : none , < 60 minutes/week , 1–3 hours/week or > 3 hours/week ) , and the Chronic Disease Self-efficacy Scale ( range 1–10 ; higher scores indicate higher self-efficacy ) . At follow-up participants completed questions on recall of APP recommendations , use of self-management strategies and barriers to management . Seventy three non-surgical patients with hip or knee arthritis participated , a response rate of 89 % at follow-up . Seventy one percent of patients reported that the APP recommended exercise , of whom 83 % reported exercising to manage their arthritis since the visit . Almost 50 % reported an increase in time spent stretching ; over 40 % reported an increase in time spent walking or doing strengthening exercises at follow-up . Common barriers to arthritis management were time , cost and other health problems . Mean chronic disease self-efficacy scores significantly improved from 6.3 to 7.2 ( p < 0.001 ) . The mean difference was 0.95 ( 95 % CI 0.43 , 1.62 ) ; the effect size was 0.51 . Conclusions This pilot study of an APP intervention for non-surgical patients referred for orthopaedic consultation showed promising results , particularly for enhancing use of conservative management strategies such as exercise PURPOSE To investigate the effectiveness of a physiotherapy triage service for orthopaedic surgery referrals from primary -care physicians . METHODS A prospect i ve , observational design was used with patients referred to an orthopaedic surgeon based out of two small urban centres in British Columbia . The level of agreement between the physiotherapist and surgeon was determined using a weighted kappa statistic ( κw ) with 95 % CI . A patient satisfaction question naire was administered , and the surgical conversion rate ( SCR ) was calculated to assess the level of appropriate referrals . RESULTS The analysis found substantial agreement ( κw=0.77 ; 95 % CI , 0.60 - 0.94 ) between surgeon and physiotherapist for surgical management decisions . All patients reported being " satisfied " or " very satisfied " with the overall care they received from the physiotherapist . The SCR of patients referred by the physiotherapist to the surgeon was 91 % , versus 22 % among patients referred by a general practitioner or emergency physician . CONCLUSION More than three-fourths of patients referred by primary -care physicians did not need to see a surgeon and were able to be managed by an experienced orthopaedic physiotherapist . This triage model could have considerable impact on orthopaedic wait times in Canada by minimizing unnecessary referrals ; the model could also promote timely and conservative management of non-surgical conditions by physiotherapists Background Role substitution is a strategy employed to assist health services manage the growing dem and for musculoskeletal care . Corticosteroid injection is a common treatment in this population but the efficacy of its prescription and delivery by physiotherapists has not been established against orthopaedic st and ards . This paper investigates whether corticosteroid injection given by a physiotherapist for shoulder pain is as clinical ly and cost effective as that from an orthopaedic surgeon . Methods A double blind non-inferiority r and omized controlled trial was conducted in an Australian public hospital orthopaedic outpatient service , from January 2013 to June 2014 . Adults with a General Practitioner referral to Orthopaedics for shoulder pain received subacromial corticosteroid and local anaesthetic injection prescribed and delivered independently by a physiotherapist or a consultant orthopaedic surgeon . The main outcome measure was total Shoulder Pain and Disability Index ( SPADI ) score at baseline , six and 12 weeks , applying a non-inferiority margin of 15 points . Secondary outcomes tested for superiority included pain , shoulder movement , perceived improvement , adverse events , satisfaction , quality of life and costs . Results 278 participants were independently assessed by the physiotherapist and the orthopaedic surgeon , with 64 r and omised ( physiotherapist 33 , orthopaedic surgeon 31 ) . There were no significant differences in baseline characteristics between groups . Non-inferiority of injection by the physiotherapist was declared from total SPADI scores at 6 and 12 weeks ( upper limit of the 95 % one-sided confidence interval 13.34 and 7.17 at 6 and 12 weeks , respectively ) . There were no statistically significant differences between groups on any outcome measures at 6 or 12 weeks . From the perspective of the health funder , the physiotherapist was less expensive . Conclusions Corticosteroid injection for shoulder pain , provided by a suitably qualified physiotherapist is at least as clinical ly effective , and less expensive , compared with similar care delivered by an orthopaedic surgeon . Policy makers and service providers should consider implementing this model of care . Trial Registration Australia and New Zeal and Clinical Trials Registry BACKGROUND CONTEXT Clinimetric properties of the EuroQol-5D ( EQ-5D ) in patients with nonspecific chronic low back pain ( CLBP ) are largely unknown . PURPOSE To study the criterion validity , responsiveness , and minimal clinical ly important change ( MCIC ) of EQ-5D in patients with CLBP . STUDY DESIGN Prospect i ve study design carried out in a multispecialist Spine Center in The Netherl and s. PATIENT SAMPLE One hundred fifty-one patients with CLBP . OUTCOME MEASURES Quality of life ( QOL ) was measured with EQ-5D , consisting of two scales : one scale measuring QOL with five categorical questions and the other measuring health state on a visual analog scale ( 0 - 100 ) . Criterion measures were disability , measured with the Pain Disability Index ( PDI ) and the Rol and Morris Disability Question naire ( RMDQ ) , and pain intensity , measured with a numeric rating scale ( NRS ) . METHODS Pearson correlation coefficients between the EQ-5D and RMDQ , PDI , and NRS were calculated to test the criterion validity . Correlations were interpreted based on predefined criteria . Responsiveness of the EQ-5D was calculated with area under the receiver operating characteristics ( ROC ) curve . Minimal clinical ly important change was calculated with the optimal cutoff point under the ROC curve , and sensitivity and specificity were also calculated . RESULTS Correlations between EQ-5D and criterion measures ranged between 0.39 and 0.59 and were considered moderate to good . Areas under the ROC curve ranged from 0.59 to 0.72 depending on the external criterion and EQ-5D subscale . The MCIC was 0.03 points for the categorical scales of the EQ-5D and 10.5 points for the EQ-5D visual analog scale . CONCLUSIONS The EQ-5D is a valid and responsive QOL scale in patients with CLBP Abstract . When measuring treatment effect in chronic low back pain with multi-item outcome instruments , it is necessary , both for clinical decision-making and research purpose s , to underst and the clinical importance of the outcome scores . The aims of the present study were three-fold . Firstly , it aim ed to estimate the minimal clinical ly important difference of three multi-item outcome instruments ( the Oswestry Disability Index , the General Function Score and the Zung Depression Scale )  and of the  visual analogue scale ( VAS ) of back pain .  Secondly , it aim ed to estimate the error of measurement of these instruments ; and its third aim was to describe the clinical meaning of score change . The study population consisted of 289 patients treated surgically or non-surgically in a r and omised controlled trial . The minimal clinical ly important difference was estimated with patient global assessment as the external criterion . It was compared with the st and ard error of measurement of the instruments . The individual items of the instruments were compared for score changes related to improvement and deterioration . The st and ard error of measurement of the Oswestry Disability Index , the General Function Score and the Zung Depression Scale was 4 , 6 and 3 units , respectively . The 95 % tolerance interval was 10 , 16 and 8 units , respectively . The minimal clinical ly important difference was 10 , 12 and 8–9 units , respectively , thus not significantly exceeding the tolerance interval . The minimal clinical ly important difference of VAS back pain was 18–19 units , well exceeding the 95 % tolerance interval , which was 15 units . Improvement after treatment for chronic low back pain tends to occur to a greater extent in sleep disturbance , ability to do usual things and psychological irritability , but to a lesser extent in the ability to sit , st and and lift . We conclude that the VAS of back pain is responsive enough to detect the minimal clinical ly important difference , whereas the smallest acceptable score changes of the Oswestry Disability Index , the General Function Score and the Zung Depression Scale may require an increase to exceed the 95 % tolerance interval when used for clinical decision making and for power calculation . Despite improvement after treatment , the ability to sit , st and and lift , remain notable problems OBJECTIVE : To evaluate the effectiveness and cost effectiveness of specially trained physiotherapists in the assessment and management of defined referrals to hospital orthopaedic departments . DESIGN : R and omised controlled trial . SETTING : Orthopaedic outpatient departments in two hospitals . SUBJECTS : 481 patients with musculoskeletal problems referred for specialist orthopaedic opinion . INTERVENTIONS : Initial assessment and management undertaken by post-Fellowship junior orthopaedic surgeons , or by specially trained physiotherapists working in an extended role ( orthopaedic physiotherapy specialists ) . MAIN OUTCOME MEASURES : Patient centred measures of pain , functional disability and perceived h and icap . RESULTS : A total of 654 patients were eligible to join the trial , 481 ( 73.6 % ) gave their consent to be r and omised . The two arms ( doctor n = 244 , physiotherapist n = 237 ) were similar at baseline . Baseline and follow up question na 
    Output:
    
agent
The quality of the PROMs varied greatly , with Satisfaction most commonly measured utilizing non-st and ardized locally-devised tools ; the EuroQol five-dimensions question naire ( EuroQoL-5D ) and 36-Item Short-Form ( SF-36 ) cited most frequently to capture QoL ; and the Visual Analogue Scale ( VAS ) to capture Pain .
APPs utilized a multiplicity of PROMs across a range of MSK disorders .
***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: Different methods of obtaining information in medical and social research present problems of interpretation for the research er . However , there are few systematic studies on the extent of the lack of concordance yielded by different methods . This paper uses data from a r and omized controlled trial of social support in pregnancy to examine this issue in relation to three methods of data collection --medical records , home interviews and a postal question naire -- on the following topics : obstetric history ; smoking , alcohol use , number of antenatal hospital visits , bleeding and depression in pregnancy ; length of labour ; baby 's sex , birthweight and neonatal health problems ; and ethnicity . Considerable discrepancies are found comparing the different data sources . These suggest that mothers may be more reliable sources of information than medical records , and that the anonymity of a postal question naire may provide higher estimates than home interviews on some sensitive topics , such as smoking in pregnancy Background The Knee injury and Osteoarthritis Outcome Score ( KOOS ) is an extension of the Western Ontario and McMaster Universities Osteoarthrtis Index ( WOMAC ) , the most commonly used outcome instrument for assessment of patient-relevant treatment effects in osteoarthritis . KOOS was developed for younger and /or more active patients with knee injury and knee osteoarthritis and has in previous studies on these groups been the more responsive instrument compared to the WOMAC . Some patients eligible for total knee replacement have expectations of more dem and ing physical functions than required for daily living . This encouraged us to study the use of the Knee injury and Osteoarthritis Outcome Score ( KOOS ) to assess the outcome of total knee replacement . Methods We studied the test-retest reliability , validity and responsiveness of the Swedish version LK 1.0 of the KOOS when used to prospect ively evaluate the outcome of 105 patients ( mean age 71.3 , 66 women ) after total knee replacement .  The follow-up rates at 6 and 12 months were 92 % and 86 % , respectively . Results The intraclass correlation coefficients were over 0.75 for all subscales indicating sufficient test-retest reliability . Bl and -Altman plots confirmed this finding . Over 90 % of the patients regarded improvement in the subscales Pain , Symptoms , Activities of Daily Living , and knee-related Quality of Life to be extremely or very important when deciding to have their knee operated on indicating good content validity . The correlations found in comparison to the SF-36 indicated the KOOS measured expected constructs . The most responsive subscale was knee-related Quality of Life . The effect sizes of the five KOOS subscales at 12 months ranged from 1.08 to 3.54 and for the WOMAC from 1.65 to 2.56 . Conclusion The Knee injury and Osteoarthritis Outcome Score ( KOOS ) is a valid , reliable , and responsive outcome measure in total joint replacement . In comparison to the WOMAC , the KOOS improved validity and may be at least as responsive as the WOMAC Background Specially trained physiotherapists ( advanced practice physiotherapists ( APP ) ) are working in orthopaedic clinics to improve access to orthopaedic services and support chronic disease management . Little attention has been paid to the impact APPs may have on non-surgical patients . In non-surgical patients with hip or knee arthritis consulting an APP in an orthopaedic clinic , the objectives were to : 1 ) describe patients ’ recall of APP recommendations , use of self-management strategies , and barriers to management six weeks following consultation ; and , 2 ) compare exercise behaviour and self-efficacy at baseline and six weeks . Findings This was a single group pre- and post-intervention study of patients who saw an APP when consulting the orthopaedic departments of two hospitals . At baseline and six weeks participants completed the adapted Stanford Exercise Behaviour Scale ( response options : none , < 60 minutes/week , 1–3 hours/week or > 3 hours/week ) , and the Chronic Disease Self-efficacy Scale ( range 1–10 ; higher scores indicate higher self-efficacy ) . At follow-up participants completed questions on recall of APP recommendations , use of self-management strategies and barriers to management . Seventy three non-surgical patients with hip or knee arthritis participated , a response rate of 89 % at follow-up . Seventy one percent of patients reported that the APP recommended exercise , of whom 83 % reported exercising to manage their arthritis since the visit . Almost 50 % reported an increase in time spent stretching ; over 40 % reported an increase in time spent walking or doing strengthening exercises at follow-up . Common barriers to arthritis management were time , cost and other health problems . Mean chronic disease self-efficacy scores significantly improved from 6.3 to 7.2 ( p < 0.001 ) . The mean difference was 0.95 ( 95 % CI 0.43 , 1.62 ) ; the effect size was 0.51 . Conclusions This pilot study of an APP intervention for non-surgical patients referred for orthopaedic consultation showed promising results , particularly for enhancing use of conservative management strategies such as exercise PURPOSE To investigate the effectiveness of a physiotherapy triage service for orthopaedic surgery referrals from primary -care physicians . METHODS A prospect i ve , observational design was used with patients referred to an orthopaedic surgeon based out of two small urban centres in British Columbia . The level of agreement between the physiotherapist and surgeon was determined using a weighted kappa statistic ( κw ) with 95 % CI . A patient satisfaction question naire was administered , and the surgical conversion rate ( SCR ) was calculated to assess the level of appropriate referrals . RESULTS The analysis found substantial agreement ( κw=0.77 ; 95 % CI , 0.60 - 0.94 ) between surgeon and physiotherapist for surgical management decisions . All patients reported being " satisfied " or " very satisfied " with the overall care they received from the physiotherapist . The SCR of patients referred by the physiotherapist to the surgeon was 91 % , versus 22 % among patients referred by a general practitioner or emergency physician . CONCLUSION More than three-fourths of patients referred by primary -care physicians did not need to see a surgeon and were able to be managed by an experienced orthopaedic physiotherapist . This triage model could have considerable impact on orthopaedic wait times in Canada by minimizing unnecessary referrals ; the model could also promote timely and conservative management of non-surgical conditions by physiotherapists Background Role substitution is a strategy employed to assist health services manage the growing dem and for musculoskeletal care . Corticosteroid injection is a common treatment in this population but the efficacy of its prescription and delivery by physiotherapists has not been established against orthopaedic st and ards . This paper investigates whether corticosteroid injection given by a physiotherapist for shoulder pain is as clinical ly and cost effective as that from an orthopaedic surgeon . Methods A double blind non-inferiority r and omized controlled trial was conducted in an Australian public hospital orthopaedic outpatient service , from January 2013 to June 2014 . Adults with a General Practitioner referral to Orthopaedics for shoulder pain received subacromial corticosteroid and local anaesthetic injection prescribed and delivered independently by a physiotherapist or a consultant orthopaedic surgeon . The main outcome measure was total Shoulder Pain and Disability Index ( SPADI ) score at baseline , six and 12 weeks , applying a non-inferiority margin of 15 points . Secondary outcomes tested for superiority included pain , shoulder movement , perceived improvement , adverse events , satisfaction , quality of life and costs . Results 278 participants were independently assessed by the physiotherapist and the orthopaedic surgeon , with 64 r and omised ( physiotherapist 33 , orthopaedic surgeon 31 ) . There were no significant differences in baseline characteristics between groups . Non-inferiority of injection by the physiotherapist was declared from total SPADI scores at 6 and 12 weeks ( upper limit of the 95 % one-sided confidence interval 13.34 and 7.17 at 6 and 12 weeks , respectively ) . There were no statistically significant differences between groups on any outcome measures at 6 or 12 weeks . From the perspective of the health funder , the physiotherapist was less expensive . Conclusions Corticosteroid injection for shoulder pain , provided by a suitably qualified physiotherapist is at least as clinical ly effective , and less expensive , compared with similar care delivered by an orthopaedic surgeon . Policy makers and service providers should consider implementing this model of care . Trial Registration Australia and New Zeal and Clinical Trials Registry BACKGROUND CONTEXT Clinimetric properties of the EuroQol-5D ( EQ-5D ) in patients with nonspecific chronic low back pain ( CLBP ) are largely unknown . PURPOSE To study the criterion validity , responsiveness , and minimal clinical ly important change ( MCIC ) of EQ-5D in patients with CLBP . STUDY DESIGN Prospect i ve study design carried out in a multispecialist Spine Center in The Netherl and s. PATIENT SAMPLE One hundred fifty-one patients with CLBP . OUTCOME MEASURES Quality of life ( QOL ) was measured with EQ-5D , consisting of two scales : one scale measuring QOL with five categorical questions and the other measuring health state on a visual analog scale ( 0 - 100 ) . Criterion measures were disability , measured with the Pain Disability Index ( PDI ) and the Rol and Morris Disability Question naire ( RMDQ ) , and pain intensity , measured with a numeric rating scale ( NRS ) . METHODS Pearson correlation coefficients between the EQ-5D and RMDQ , PDI , and NRS were calculated to test the criterion validity . Correlations were interpreted based on predefined criteria . Responsiveness of the EQ-5D was calculated with area under the receiver operating characteristics ( ROC ) curve . Minimal clinical ly important change was calculated with the optimal cutoff point under the ROC curve , and sensitivity and specificity were also calculated . RESULTS Correlations between EQ-5D and criterion measures ranged between 0.39 and 0.59 and were considered moderate to good . Areas under the ROC curve ranged from 0.59 to 0.72 depending on the external criterion and EQ-5D subscale . The MCIC was 0.03 points for the categorical scales of the EQ-5D and 10.5 points for the EQ-5D visual analog scale . CONCLUSIONS The EQ-5D is a valid and responsive QOL scale in patients with CLBP Abstract . When measuring treatment effect in chronic low back pain with multi-item outcome instruments , it is necessary , both for clinical decision-making and research purpose s , to underst and the clinical importance of the outcome scores . The aims of the present study were three-fold . Firstly , it aim ed to estimate the minimal clinical ly important difference of three multi-item outcome instruments ( the Oswestry Disability Index , the General Function Score and the Zung Depression Scale )  and of the  visual analogue scale ( VAS ) of back pain .  Secondly , it aim ed to estimate the error of measurement of these instruments ; and its third aim was to describe the clinical meaning of score change . The study population consisted of 289 patients treated surgically or non-surgically in a r and omised controlled trial . The minimal clinical ly important difference was estimated with patient global assessment as the external criterion . It was compared with the st and ard error of measurement of the instruments . The individual items of the instruments were compared for score changes related to improvement and deterioration . The st and ard error of measurement of the Oswestry Disability Index , the General Function Score and the Zung Depression Scale was 4 , 6 and 3 units , respectively . The 95 % tolerance interval was 10 , 16 and 8 units , respectively . The minimal clinical ly important difference was 10 , 12 and 8–9 units , respectively , thus not significantly exceeding the tolerance interval . The minimal clinical ly important difference of VAS back pain was 18–19 units , well exceeding the 95 % tolerance interval , which was 15 units . Improvement after treatment for chronic low back pain tends to occur to a greater extent in sleep disturbance , ability to do usual things and psychological irritability , but to a lesser extent in the ability to sit , st and and lift . We conclude that the VAS of back pain is responsive enough to detect the minimal clinical ly important difference , whereas the smallest acceptable score changes of the Oswestry Disability Index , the General Function Score and the Zung Depression Scale may require an increase to exceed the 95 % tolerance interval when used for clinical decision making and for power calculation . Despite improvement after treatment , the ability to sit , st and and lift , remain notable problems OBJECTIVE : To evaluate the effectiveness and cost effectiveness of specially trained physiotherapists in the assessment and management of defined referrals to hospital orthopaedic departments . DESIGN : R and omised controlled trial . SETTING : Orthopaedic outpatient departments in two hospitals . SUBJECTS : 481 patients with musculoskeletal problems referred for specialist orthopaedic opinion . INTERVENTIONS : Initial assessment and management undertaken by post-Fellowship junior orthopaedic surgeons , or by specially trained physiotherapists working in an extended role ( orthopaedic physiotherapy specialists ) . MAIN OUTCOME MEASURES : Patient centred measures of pain , functional disability and perceived h and icap . RESULTS : A total of 654 patients were eligible to join the trial , 481 ( 73.6 % ) gave their consent to be r and omised . The two arms ( doctor n = 244 , physiotherapist n = 237 ) were similar at baseline . Baseline and follow up question na 
    Output:
    