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: Measures of both generic and disease-specific health status are being developed and used with increasing frequency for the appraisal of musculoskeletal conditions . The purpose of this study was to compare prospect ively the validity of five question naires in the assessment of function of the shoulder . Ninety subjects who had various problems related to the shoulder agreed to enter the study . All of the subjects completed a question naire package that included the  Shoulder Pain and Disability Index , the Simple Shoulder Test , the Subjective Shoulder Rating Scale , the Modified American Shoulder and Elbow Surgeons Shoulder Patient Self-Evaluation Form , and the Shoulder Severity Index as well as a measure of generic health status ( the acute version of the Short Form 36 [ SF-36 ] ) and two questions that asked the patient to rate the severity of the problem and his or her over-all health . Frequency distributions were created and compared among question naires . Spearman rank correlations were calculated to compare the question naires with each other and with other assessment s. One-way analysis of variance was used to determine the ability of the question naires to discriminate between self-rated severity of the problem and over-all health . The frequency distributions were similar among the five shoulder question naires , but those of the five shoulder question naires differed from that of the SF-36 . The correlations were good ( 0.73 ⩽ r ⩽ 0.80 ) among all of the five shoulder question naires except the Subjective Shoulder Rating Scale ; they were lower with the Subjective Shoulder Rating Scale and the physical function dimension of the SF-36 ( 0.12 ⩽ r ⩽ 0.60 ) . The shoulder question naires discriminated between levels of severity ( p < 0.0001 ) but not between levels of over-all health ( 0.10 ⩽ p ⩽ 0.86 ) . In this concurrent comparison of measures of shoulder-specific outcome in the same subjects , the shoulder question naires performed similarly , both in describing function of the shoulder and in discriminating between levels of severity . The shoulder question naires performed differently than the SF-36 , which confirms the need to use both disease-specific and generic health-status measures to evaluate patients who have a problem related to the shoulder Blinding embodies a rich history spanning over two centuries . Most research ers worldwide underst and blinding terminology , but confusion lurks beyond a general comprehension . Terms such as single blind , double blind , and triple blind mean different things to different people . Moreover , many medical research ers confuse blinding with allocation concealment . Such confusion indicates misunderst and ings of both . The term blinding refers to keeping trial participants , investigators ( usually health-care providers ) , or assessors ( those collecting outcome data ) unaware of the assigned intervention , so that they will not be influenced by that knowledge . Blinding usually reduces differential assessment of outcomes ( information bias ) , but can also improve compliance and retention of trial participants while reducing biased supplemental care or treatment ( sometimes called co-intervention ) . Many investigators and readers naïvely consider a r and omised trial as high quality simply because it is double blind , as if double-blinding is the sine qua non of a r and omised controlled trial . Although double blinding ( blinding investigators , participants , and outcome assessors ) indicates a strong design , trials that are not double blinded should not automatically be deemed inferior . Rather than solely relying on terminology like double blinding , research ers should explicitly state who was blinded , and how . We recommend placing greater credence in results when investigators at least blind outcome assessment s , except with objective outcomes , such as death , which leave little room for bias . If investigators properly report their blinding efforts , readers can judge them . Unfortunately , many articles do not contain proper reporting . If an article cl aims blinding without any accompanying clarification , readers should remain sceptical about its effect on bias reduction The principle aim of the present work is the evaluation of the importance of the variable " depth " of needle insertion in the determination of acupuncture 's therapeutic results . A r and omized clinical trial carried out on 44 patients belonging to two groups of 22 each , suffering from shoulder myofascial pain : group A : superficial acupuncture ; group B : deep acupuncture .  All of them subjected to the same model of treatment with 13 needles and the treatment of the most painful 4 trigger points ( TP ) found in the shoulder 's area . In the group A patients , the needles were introduced in the skin at a depth of 2 mm , on the TP . In the group B patients , the needles were placed deeply both in the muscular acupuncture points and in the TP . The treatment was planned for a cycle of 8 sessions , the first 4 to be performed twice a week , the last 4 weekly . The intensity of pain was evaluated with the McGill Pain Question naire before beginning the therapy , at the end of the therapy , and at the follow-up after 1 and 3 months . Both techniques had efficacy in controlling pain . A statistically significant difference rose between the two needling techniques at the end of the treatment and at the follow up after one and three months . Deep acupuncture shows to be better at all times and this underlines the importance of the muscular afferences in acupunctural stimulation in the control of pain OBJECTIVES To compare the effects of real acupuncture to tender points for neck and shoulder pain and stiffness ( Japanese : katakori ) with those of sham acupuncture . DESIGN R and omized-controlled trial . METHODS Thirty-four volunteers from an acupuncture school with complaints of chronic pain and stiffness , who had no arm symptoms and gave informed consent , were r and omly allocated to acupuncture or sham groups . Acupuncture or sham acupuncture was applied to the tender points once a week for 3 weeks . In the acupuncture group the acupuncture needle was inserted to the muscle , then the sparrow pecking technique was applied five times . Sham acupuncture was done without insertion of the needle . Dull pain and stiffness were evaluated by visual analog scale ( VAS ) before , and every 2 days after the first needling for 1 month . Pressure pain threshold on the tender points was measured before and after each treatment . RESULTS There was no statistical difference of VAS scores between acupuncture and sham groups 9 days after the last treatment . However , the acupuncture group showed significant reduction of VAS scores immediately after and /or 1 day after the real acupuncture treatments ( P<0.01 ) . The effect tended to be prolonged after repeated treatment . Pressure pain thresholds tended to increase after real acupuncture treatment but not after sham acupuncture . CONCLUSIONS Acupuncture applied to tender points appears to have short-term effects on neck and shoulder pain and stiffness , but this study was unable to demonstrate any long-term superiority over sham acupuncture In a single-blind trial , five treatments for painful stiff shoulder were compared for a 4-week assessment period in 60 patients . The treatments were acupuncture , steroid injection with placebo and with active tolmetin sodium , physiotherapy in the form of ultrasound and ' placebo ' physiotherapy with placebo tolmetin sodium . Objective assessment was gained by use of goniometer readings to monitor shoulder abduction . Pain was measured by visual analogue scales and by a 4-point scale . Comparative assessment was also recorded and at the end of the study a success or failure was recorded for each patient 's treatment . With very few exceptions all patients improved markedly , both in terms of the subjective and objective parameters . No differences between the treatments were detected . The incidence and severity of side-effects was low . It is suggested that the results show that the painful stiff shoulder may be a self-limiting condition and that any beneficial effect was really due to natural recovery . This is an important consideration because patients do not always receive immediate attention when referred to an out-patient department and the use of physiotherapy and acupuncture in such cases , perhaps , should be critically examined OBJECTIVE To establish basic epidemiological data on  chronic pain ( duration > 3 months ) in a defined population . Relationships between age , gender , and social class were tested . DESIGN A survey of pain symptoms , including location , intensity , duration , and functional capacity , was conducted by means of a mail question naire . SETTING General population s in two Swedish primary health care districts . Medical care was provided in a state health system . SUBJECTS A r and om sample ( from the population register ) of 15 % of the population aged 25 - 74 ( n = 1,806 ) . The response rate was 90 % . OUTCOME MEASURES Descriptive epidemiologic data in relation to objectives of the study . RESULTS Without sex differences , 55 % ( 95 % confidence interval , 53 - 58 % ) of the population had perceived persistent pain for 3 months and 49 % for 6 months . Among individuals with chronic pain , 90 % localized their pain to the musculoskeletal system to a variable extent . Women experienced more multiple localizations of pain and had pain in the neck , shoulder , arm , and thigh to a greater extent than men . Prevalence of pain increased by age up to 50 - 59 years for both genders and then slowly decreased . The neck-shoulder area was the most common site of pain ( 30.2 % ) , followed by the lower back ( 23.2 % ) . Even in the youngest age groups more than one of four reported chronic pain . Blue-collar workers and employers ( including farmers ) reported chronic pain to a greater extent than other groups . In 13 % of the population , manifest pain problems were associated with reduced functional capacity . CONCLUSION Chronic pain symptoms are common but unevenly distributed in a general population . The results may influence planning and consultation in primary health care as well as warranting selective prevention activities OBJECTIVE To determine the effectiveness of acupuncture and Trager Psychophysical Integration ( a form of manual therapy ) in decreasing chronic shoulder pain in wheelchair users with spinal cord injury ( SCI ) . DESIGN A prospect i ve clinical trial , with subjects r and omized to acupuncture or Trager treatment condition . Subjects served as their own controls by including a 5-week pretreatment baseline period and a 5-week posttreatment follow-up period . SETTING Rehabilitation hospital research department . PARTICIPANTS Eighteen subjects with chronic SCI and chronic shoulder pain who used manual wheelchairs as their primary means of mobility . INTERVENTION Ten acupuncture or 10 Trager treatments over a 5-week period . MAIN OUTCOME MEASURES Changes in performance-corrected Wheelchair User 's Shoulder Pain Index ( PC-WUSPI ) scores during baseline , treatment , and follow-up periods were assessed by using analysis of variance . RESULTS The mean PC-WUSPI score + /- st and ard deviation of the 18 subjects at entry was 48.9 + /- 24.6 ( range , 8.0 - 94 ) . No significant change in mean PC-WUSPI scores occurred during the pretreatment baseline period . Mean PC-WUSPI scores decreased significantly during the treatment period in both the acupuncture ( 53.4 % ; 23.3 points ) and Trager ( 53.8 % ; 21.7 points ) treatment groups . The reduced PC-WUSPI scores were maintained in both groups throughout the 5-week posttreatment follow-up period . CONCLUSION Acupuncture and Trager are both effective treatments for reducing chronic shoulder pain associated with functional activities in persons with SCI This r and omised controlled trial was undertaken to evaluate the effectiveness of  acupuncture  as a treatment for frozen shoulder . Thirty-five patients with a diagnosis of frozen shoulder were r and omly allocated to an exercise group or an exercise plus acupuncture group and treated for a period of 6 weeks . Functional mobility , power , and pain were assessed by a blinded assessor using the Constant Shoulder Assessment , at baseline , 6 weeks and 20 weeks . Analysis was based on the intention-to-treat principle . Compared with the exercise group , the exercise plus acupuncture group experienced significantly greater improvement with treatment . Improvements in scores by 39.8 % ( st and ard deviation , 27.1 ) and 76.4 % ( 55.0 ) were seen for the exercise and the exercise plus acupuncture groups , respectively at 6 weeks ( P=0.048 ) , and were sustained at the 20-week re- assessment ( 40.3 % [ 26.7 ] and 77.2 % [ 54.0 ] , respectively ; P=0.025 ) . We conclude that the combination of acupuncture with shoulder exercise may offer effective treatment for frozen shoulder One half of 42 subjects treated for painful shoulders received classic acupuncture , and one half received a placebo in which the needles did not penetrate the skin . Half of each of these groups was treated in a positive setting to encourage the subject , and half in a negative setting design ed to keep encouragement at a minimum . All patients were independently rated for  susceptibility to hypnosis .  Although range of motion did not improve , the majority of patients reported significant improvement in shoulder discomfort to a blind evaluator after treatment ; placebo and acupuncture groups did not differ in this respect , however . The positive and negative setting s did not affect treatment outcome . In all groups , those who were not rated as highly susceptible to hypnosis tended to fail to achieve the highest levels of relief , but such differences were not statistically significant Acupuncture has gained increasing attention in the treatment of  chronic pain .  The lack of a satisfying placebo method has made it impossible to show whether needling is an important part of the method or whether the improvement felt by the patient is due to the therapeutic setting and psychological phenomena . Also , the effectiveness of acupuncture has not been demonstrated sufficiently . We treated 52 sportsmen with rotator cuff tendinitis in a r and omised single-blind clinical trial using a new placebo-needle as control . Patients were treated for 4 weeks . The primary endpoint of the trial was the change in the modified Constant-Murley-score from the baseline . Assessment of the treatment outcome was made by experienced orthopaedists not informed of the treatment allocation . Acupuncture with penetration of the skin was shown to be more effective 
    Output:
    
agent
***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: Measures of both generic and disease-specific health status are being developed and used with increasing frequency for the appraisal of musculoskeletal conditions . The purpose of this study was to compare prospect ively the validity of five question naires in the assessment of function of the shoulder . Ninety subjects who had various problems related to the shoulder agreed to enter the study . All of the subjects completed a question naire package that included the  Shoulder Pain and Disability Index , the Simple Shoulder Test , the Subjective Shoulder Rating Scale , the Modified American Shoulder and Elbow Surgeons Shoulder Patient Self-Evaluation Form , and the Shoulder Severity Index as well as a measure of generic health status ( the acute version of the Short Form 36 [ SF-36 ] ) and two questions that asked the patient to rate the severity of the problem and his or her over-all health . Frequency distributions were created and compared among question naires . Spearman rank correlations were calculated to compare the question naires with each other and with other assessment s. One-way analysis of variance was used to determine the ability of the question naires to discriminate between self-rated severity of the problem and over-all health . The frequency distributions were similar among the five shoulder question naires , but those of the five shoulder question naires differed from that of the SF-36 . The correlations were good ( 0.73 ⩽ r ⩽ 0.80 ) among all of the five shoulder question naires except the Subjective Shoulder Rating Scale ; they were lower with the Subjective Shoulder Rating Scale and the physical function dimension of the SF-36 ( 0.12 ⩽ r ⩽ 0.60 ) . The shoulder question naires discriminated between levels of severity ( p < 0.0001 ) but not between levels of over-all health ( 0.10 ⩽ p ⩽ 0.86 ) . In this concurrent comparison of measures of shoulder-specific outcome in the same subjects , the shoulder question naires performed similarly , both in describing function of the shoulder and in discriminating between levels of severity . The shoulder question naires performed differently than the SF-36 , which confirms the need to use both disease-specific and generic health-status measures to evaluate patients who have a problem related to the shoulder Blinding embodies a rich history spanning over two centuries . Most research ers worldwide underst and blinding terminology , but confusion lurks beyond a general comprehension . Terms such as single blind , double blind , and triple blind mean different things to different people . Moreover , many medical research ers confuse blinding with allocation concealment . Such confusion indicates misunderst and ings of both . The term blinding refers to keeping trial participants , investigators ( usually health-care providers ) , or assessors ( those collecting outcome data ) unaware of the assigned intervention , so that they will not be influenced by that knowledge . Blinding usually reduces differential assessment of outcomes ( information bias ) , but can also improve compliance and retention of trial participants while reducing biased supplemental care or treatment ( sometimes called co-intervention ) . Many investigators and readers naïvely consider a r and omised trial as high quality simply because it is double blind , as if double-blinding is the sine qua non of a r and omised controlled trial . Although double blinding ( blinding investigators , participants , and outcome assessors ) indicates a strong design , trials that are not double blinded should not automatically be deemed inferior . Rather than solely relying on terminology like double blinding , research ers should explicitly state who was blinded , and how . We recommend placing greater credence in results when investigators at least blind outcome assessment s , except with objective outcomes , such as death , which leave little room for bias . If investigators properly report their blinding efforts , readers can judge them . Unfortunately , many articles do not contain proper reporting . If an article cl aims blinding without any accompanying clarification , readers should remain sceptical about its effect on bias reduction The principle aim of the present work is the evaluation of the importance of the variable " depth " of needle insertion in the determination of acupuncture 's therapeutic results . A r and omized clinical trial carried out on 44 patients belonging to two groups of 22 each , suffering from shoulder myofascial pain : group A : superficial acupuncture ; group B : deep acupuncture .  All of them subjected to the same model of treatment with 13 needles and the treatment of the most painful 4 trigger points ( TP ) found in the shoulder 's area . In the group A patients , the needles were introduced in the skin at a depth of 2 mm , on the TP . In the group B patients , the needles were placed deeply both in the muscular acupuncture points and in the TP . The treatment was planned for a cycle of 8 sessions , the first 4 to be performed twice a week , the last 4 weekly . The intensity of pain was evaluated with the McGill Pain Question naire before beginning the therapy , at the end of the therapy , and at the follow-up after 1 and 3 months . Both techniques had efficacy in controlling pain . A statistically significant difference rose between the two needling techniques at the end of the treatment and at the follow up after one and three months . Deep acupuncture shows to be better at all times and this underlines the importance of the muscular afferences in acupunctural stimulation in the control of pain OBJECTIVES To compare the effects of real acupuncture to tender points for neck and shoulder pain and stiffness ( Japanese : katakori ) with those of sham acupuncture . DESIGN R and omized-controlled trial . METHODS Thirty-four volunteers from an acupuncture school with complaints of chronic pain and stiffness , who had no arm symptoms and gave informed consent , were r and omly allocated to acupuncture or sham groups . Acupuncture or sham acupuncture was applied to the tender points once a week for 3 weeks . In the acupuncture group the acupuncture needle was inserted to the muscle , then the sparrow pecking technique was applied five times . Sham acupuncture was done without insertion of the needle . Dull pain and stiffness were evaluated by visual analog scale ( VAS ) before , and every 2 days after the first needling for 1 month . Pressure pain threshold on the tender points was measured before and after each treatment . RESULTS There was no statistical difference of VAS scores between acupuncture and sham groups 9 days after the last treatment . However , the acupuncture group showed significant reduction of VAS scores immediately after and /or 1 day after the real acupuncture treatments ( P<0.01 ) . The effect tended to be prolonged after repeated treatment . Pressure pain thresholds tended to increase after real acupuncture treatment but not after sham acupuncture . CONCLUSIONS Acupuncture applied to tender points appears to have short-term effects on neck and shoulder pain and stiffness , but this study was unable to demonstrate any long-term superiority over sham acupuncture In a single-blind trial , five treatments for painful stiff shoulder were compared for a 4-week assessment period in 60 patients . The treatments were acupuncture , steroid injection with placebo and with active tolmetin sodium , physiotherapy in the form of ultrasound and ' placebo ' physiotherapy with placebo tolmetin sodium . Objective assessment was gained by use of goniometer readings to monitor shoulder abduction . Pain was measured by visual analogue scales and by a 4-point scale . Comparative assessment was also recorded and at the end of the study a success or failure was recorded for each patient 's treatment . With very few exceptions all patients improved markedly , both in terms of the subjective and objective parameters . No differences between the treatments were detected . The incidence and severity of side-effects was low . It is suggested that the results show that the painful stiff shoulder may be a self-limiting condition and that any beneficial effect was really due to natural recovery . This is an important consideration because patients do not always receive immediate attention when referred to an out-patient department and the use of physiotherapy and acupuncture in such cases , perhaps , should be critically examined OBJECTIVE To establish basic epidemiological data on  chronic pain ( duration > 3 months ) in a defined population . Relationships between age , gender , and social class were tested . DESIGN A survey of pain symptoms , including location , intensity , duration , and functional capacity , was conducted by means of a mail question naire . SETTING General population s in two Swedish primary health care districts . Medical care was provided in a state health system . SUBJECTS A r and om sample ( from the population register ) of 15 % of the population aged 25 - 74 ( n = 1,806 ) . The response rate was 90 % . OUTCOME MEASURES Descriptive epidemiologic data in relation to objectives of the study . RESULTS Without sex differences , 55 % ( 95 % confidence interval , 53 - 58 % ) of the population had perceived persistent pain for 3 months and 49 % for 6 months . Among individuals with chronic pain , 90 % localized their pain to the musculoskeletal system to a variable extent . Women experienced more multiple localizations of pain and had pain in the neck , shoulder , arm , and thigh to a greater extent than men . Prevalence of pain increased by age up to 50 - 59 years for both genders and then slowly decreased . The neck-shoulder area was the most common site of pain ( 30.2 % ) , followed by the lower back ( 23.2 % ) . Even in the youngest age groups more than one of four reported chronic pain . Blue-collar workers and employers ( including farmers ) reported chronic pain to a greater extent than other groups . In 13 % of the population , manifest pain problems were associated with reduced functional capacity . CONCLUSION Chronic pain symptoms are common but unevenly distributed in a general population . The results may influence planning and consultation in primary health care as well as warranting selective prevention activities OBJECTIVE To determine the effectiveness of acupuncture and Trager Psychophysical Integration ( a form of manual therapy ) in decreasing chronic shoulder pain in wheelchair users with spinal cord injury ( SCI ) . DESIGN A prospect i ve clinical trial , with subjects r and omized to acupuncture or Trager treatment condition . Subjects served as their own controls by including a 5-week pretreatment baseline period and a 5-week posttreatment follow-up period . SETTING Rehabilitation hospital research department . PARTICIPANTS Eighteen subjects with chronic SCI and chronic shoulder pain who used manual wheelchairs as their primary means of mobility . INTERVENTION Ten acupuncture or 10 Trager treatments over a 5-week period . MAIN OUTCOME MEASURES Changes in performance-corrected Wheelchair User 's Shoulder Pain Index ( PC-WUSPI ) scores during baseline , treatment , and follow-up periods were assessed by using analysis of variance . RESULTS The mean PC-WUSPI score + /- st and ard deviation of the 18 subjects at entry was 48.9 + /- 24.6 ( range , 8.0 - 94 ) . No significant change in mean PC-WUSPI scores occurred during the pretreatment baseline period . Mean PC-WUSPI scores decreased significantly during the treatment period in both the acupuncture ( 53.4 % ; 23.3 points ) and Trager ( 53.8 % ; 21.7 points ) treatment groups . The reduced PC-WUSPI scores were maintained in both groups throughout the 5-week posttreatment follow-up period . CONCLUSION Acupuncture and Trager are both effective treatments for reducing chronic shoulder pain associated with functional activities in persons with SCI This r and omised controlled trial was undertaken to evaluate the effectiveness of  acupuncture  as a treatment for frozen shoulder . Thirty-five patients with a diagnosis of frozen shoulder were r and omly allocated to an exercise group or an exercise plus acupuncture group and treated for a period of 6 weeks . Functional mobility , power , and pain were assessed by a blinded assessor using the Constant Shoulder Assessment , at baseline , 6 weeks and 20 weeks . Analysis was based on the intention-to-treat principle . Compared with the exercise group , the exercise plus acupuncture group experienced significantly greater improvement with treatment . Improvements in scores by 39.8 % ( st and ard deviation , 27.1 ) and 76.4 % ( 55.0 ) were seen for the exercise and the exercise plus acupuncture groups , respectively at 6 weeks ( P=0.048 ) , and were sustained at the 20-week re- assessment ( 40.3 % [ 26.7 ] and 77.2 % [ 54.0 ] , respectively ; P=0.025 ) . We conclude that the combination of acupuncture with shoulder exercise may offer effective treatment for frozen shoulder One half of 42 subjects treated for painful shoulders received classic acupuncture , and one half received a placebo in which the needles did not penetrate the skin . Half of each of these groups was treated in a positive setting to encourage the subject , and half in a negative setting design ed to keep encouragement at a minimum . All patients were independently rated for  susceptibility to hypnosis .  Although range of motion did not improve , the majority of patients reported significant improvement in shoulder discomfort to a blind evaluator after treatment ; placebo and acupuncture groups did not differ in this respect , however . The positive and negative setting s did not affect treatment outcome . In all groups , those who were not rated as highly susceptible to hypnosis tended to fail to achieve the highest levels of relief , but such differences were not statistically significant Acupuncture has gained increasing attention in the treatment of  chronic pain .  The lack of a satisfying placebo method has made it impossible to show whether needling is an important part of the method or whether the improvement felt by the patient is due to the therapeutic setting and psychological phenomena . Also , the effectiveness of acupuncture has not been demonstrated sufficiently . We treated 52 sportsmen with rotator cuff tendinitis in a r and omised single-blind clinical trial using a new placebo-needle as control . Patients were treated for 4 weeks . The primary endpoint of the trial was the change in the modified Constant-Murley-score from the baseline . Assessment of the treatment outcome was made by experienced orthopaedists not informed of the treatment allocation . Acupuncture with penetration of the skin was shown to be more effective 
    Output:
    