The Responsiveness and Minimal Important Change of the Western Ontario Shoulder Instability Index and Oxford Shoulder Instability Score Does acupuncture used in nulliparous women reduce time from prelabour rupture of membranes at term to active phase of labour? A randomised controlled trial. Online training course on critical appraisal for nurses: adaptation and assessment Evaluating the teaching of evidence-based medicine. Efficiency of Neuromuscular Electrical Stimulation and Transcutaneous Nerve Stimulation on Hemiplegic Shoulder Pain: A Randomized Controlled Trial. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, patient self-report section: reliability, validity, and responsiveness. Impact of a medical journal club on house-staff reading habits, knowledge, and critical appraisal skills. A randomized control trial. Evidence-based consumer health information: developing teaching in critical appraisal skills. Teaching critical appraisal during critical care fellowship training: A foundation for evidence-based critical care medicine Critical appraisal and positive outcome bias in case reports published in Brazilian dental journals. Teaching of evidence-based medicine to medical students in Mexico: a randomized controlled trial Affecting residents' literature reading attitudes, behaviors, and knowledge through a journal club intervention. The effects of emotion regulation strategies on the pain experience: a structured laboratory investigation Development and Psychometric Evaluation of the Flexilevel Scale of Shoulder Function Clinical study comparing acupuncture, physiotherapy, injection and oral anti-inflammatory therapy in shoulder-cuff lesions. Patient-Reported and Objectively Measured Function Before and After Reverse Shoulder Arthroplasty Systematic Review of Arthroscopic Versus Open Repair for Recurrent Anterior Shoulder Dislocations How do systematic reviews incorporate risk of bias assessments into the synthesis of evidence? A methodological study Critical appraisal skills training for health care professionals: a randomized controlled trial [ISRCTN46272378] Effectiveness of instruction in critical appraisal (evidence-based medicine) skills: a critical appraisal. Evaluation of an education and activation programme to prevent chronic shoulder complaints: design of an RCT [ISRCTN71777817] The Effect of Ouhyul Herbal Acupuncture Point Injections on Shoulder Pain after Stroke Prefrontal TDCS attenuates medial prefrontal connectivity upon being criticized in individuals scoring high on perceived criticism
• STUDY DESIGN : Prospect i ve cohort study . • BACKGROUND : Patient‐reported outcome measurements ( PROMs ) are widely used to evaluate functional limitations . Considering PROMs for shoulder instability , information is lacking with regard to what constitutes a relevant change from baseline scores . • OBJECTIVES : To evaluate the responsiveness of the Western Ontario Shoulder Instability Index ( WOSI ) and the  Oxford Shoulder Instability Score ( OSIS ) and estimate their minimal important change ( MIC ) . • METHODS : One hundred five consecutive patients with shoulder instability completed 5 PROMs at baseline and at 6‐month follow‐up . The PROMs included the  WOSI and OSIS , the Simple Shoulder Test , the Oxford Shoulder Score , and the Disabilities of the Arm , Shoulder and H and assessment .  Patients also rated their functional change on an anchor question at follow‐up . Responsiveness was evaluated by testing 9 hypotheses regarding predefined correlations between the changes in PROM scores , by calculating the area under the receiver operating characteristic curve and by calculating the st and ardized response mean and effect size statistics . The MIC was determined by identifying the optimal cutoff on the receiver operating characteristic curve . • RESULTS : Seven out of 9 hypotheses ( 78 % ) were confirmed ; as expected , a high correlation ( 0.77 ) was found between change scores of the WOSI and OSIS , whereas the correlations of the change scores of the WOSI and OSIS with those of general shoulder PROMs were slightly lower ( 0.61‐0.75 ) . The area under the curve was 0.83 ( 95 % confidence interval : 0.75 , 0.91 ) for the OSIS and 0.82 ( 95 % confidence interval : 0.74 , 0.90 ) for the WOSI . The MIC was about 6 points for the OSIS and about 14 points for the WOSI . • CONCLUSION : Both the WOSI and OSIS are able to measure change in shoulder function in patients with shoulder instability . The estimated MIC is 6 points for the OSIS ( on a scale from 0 to 48 ) and 14 points for the WOSI ( on a scale from 0 to 100 ) . •KEY WORDS : clinimetrics , functional outcome measures , outcome assessment , BACKGROUND To assess if acupuncture influences the onset of labour and the need for induction after prelabour rupture of membranes ( PROM ) in nulliparous women . Further , to investigate a possible effect of acupuncture on the woman 's wellbeing . METHODS In a r and omised controlled trial ( RCT ) , 106 nulliparous women with PROM were allocated to an acupuncture group ( AG ) or a control group ( CG ) . The outcome measures were time from PROM to onset of active phase of labour , and rate of inductions if labour was absent after 2 days . The women 's self-reported wellbeing was registered on a Visual Analogue Scale ( VAS ) . RESULTS There was no statistically significant difference between the 2 groups regarding time from PROM to active phase ( median times in AG versus CG : 15 versus 20.5 h , p=0.34 ) . Additionally , there was no difference between the 2 groups in the need for induction . We found no significant differences in self-reported wellbeing , but the women receiving acupuncture considered their treatment to be more positive than the controls ( p=0.003 ) . No adverse effects were reported . CONCLUSIONS Acupuncture treatment used in nulliparas after PROM showed no significant effect in reducing time to active labour or in reducing rate of inductions . There was no change in wellbeing as a result of acupuncture , but it was considered positive to receive this kind of treatment while waiting for labour to begin Background Research is an essential activity for improving quality and efficiency in healthcare . The objective of this study was to train nurses from the public Basque Health Service ( Osakidetza ) in critical appraisal , promoting continuous training and the use of research in clinical practice . Methods This was a prospect i ve pre-post test study . The InfoCritique course on critical appraisal was translated and adapted . A sample of 50 nurses and 3 tutors was recruited . Educational strategies and assessment instruments were established for the course . A course website was created that contained contact details of the teaching team and coordinator , as well as a course h and book and videos introducing the course . Assessment comprised the administration of question naires before and after the course , in order to explore the main intervention outcomes : knowledge acquired and self-learning readiness . Satisfaction was also measured at the end of the course . Results Of the 50 health professionals recruited , 3 did not complete the course for personal or work-related reasons . The mean score on the pre-course knowledge question naire was 70.5 out of 100 , with a st and ard deviation of 11.96 . In general , participants ’ performance on the knowledge question naire improved after the course , as reflected in the notable increase of the mean score , to 86.6 , with a st and ard deviation of 10.00 . Further , analyses confirmed statistically significant differences between pre- and post-course results ( p < 0.001 ) . With regard to self-learning readiness , after the course , participants reported a greater readiness and ability for self-directed learning . Lastly , in terms of level of satisfaction with the course , the mean score was 7 out of 10 . Conclusions Participants significantly improved their knowledge score and self-directed learning readiness after the educational intervention , and they were overall satisfied with the course . For the health system and nursing professionals , this type of course has the potential to provide method ological tools for research , promote a research culture , and encourage critical thinking for evidence -based decision making AN INCREASING NUMBER OF MEDICAL SCHOOLS AND residency programs are instituting curricula for teaching the principles and practice of evidence based medicine ( EBM ) . For example , 95 % of US internal medicine residency programs have journal clubs and 37 % of US and Canadian internal medicine residencies have time dedicated for EBM . Curricula based on EBM are increasingly popular in residency programs in other specialties , including family medicine , pediatrics , obstetrics/ gynecology , and surgery . Despite the widespread teaching of EBM , however , most of what is known about the outcomes of evidence -based curricula relies on observational data . Although evaluation of the quality of research evidence is a core competency of EBM , the quantity and quality of the evidence for effectively teaching EBM are poor . Ironically , if one were to develop guidelines for how to teach EBM based on these results , they would be based on the lowest level of evidence . There are several reasons why the quality of the evidence for teaching EBM is so weak . Many of these problems are related to the limitations in educational research in general . First , quantitative research methods may be inadequate to capture the complexity of an educational system . Second , students and residents change frequently , making it difficult to retain a consistent sample . Third , the time allotted for a given intervention may be brief in the context of the overall medical curriculum . Fourth , educational institutions may be hesitant to pay students as research participants or to allocate them to unproved educational interventions . Fifth , because most educational interventions are unique to specific institutions , assessment of their effectiveness is usually limited by small sample sizes . Furthermore , even if such interventions could be instituted across multiple institutions , the problems of st and ardization and cointervention would be particularly challenging . Sixth , perhaps because they are simplest to measure , the most frequently reported outcomes are subjective variables such as satisfaction or self-reported changes in attitudes or knowledge , rather than more important assessment s of objective ly measured clinical skills or improved patient outcomes . Finally , granting agencies do not give priority to educational investigations , making it difficult to undertake definitive multicenter studies . Educators who have struggled to evaluate educational interventions will find these issues all too familiar . With the increasing prevalence of EBM teaching , however , high quality evidence is more important than ever . Assessment of EBM teaching has also presented some unique problems . For instance , we originally defined evidence -based practice in terms of 4 basic competencies : ( 1 ) recognition of a patient problem and construction of a structured clinical question ; ( 2 ) ability to efficiently and effectively search the medical literature to retrieve the best available evidence to answer the clinical question ; ( 3 ) critical appraisal of the evidence ; and ( 4 ) integration of the evidence with all aspects of individual patient decision making to determine the best clinical care for the patient . Although these 4 skills were the most commonly reported curricular objectives in 99 internal medicine residencies that teach EBM , almost all the research on EBM education has focused exclusively on the third item : teaching critical appraisal skills . Examining this literature may yield useful insights into the difficulties of EBM educational research . Since critical appraisal skills involve the ability to differentiate strong from weak research methods , one might expect that this research would be of relatively high quality . In fact , most of these studies are method ologically weak . Using broad criteria to identify any reports of a graduate ( residency ) EBM curricula , Green identified 18 reports published between 1980 and 1997 . Of these , 72 % used a traditional journal club format to teach critical appraisal skills . Only 7 of the 18 studies evaluated the effectiveness of their intervention . Five of these 7 studies compared intervention with control ( only 1 with r and omized design ) ; only 2 of 7 studies used any blinding . Of these 5 controlled studies , 2 used a vali date d outcome measure to evaluate  critical appraisal skills .  Measurement of behavioral change relied on self-report in all 5 studies , and none examined patient outcomes . Most reports did not evaluate their OBJECTIVE To compare the efficacy of neuromuscular electrical stimulation ( NMES ) and transcutaneous nerve stimulation ( TENS ) on  hemiplegic shoulder pain ( HSP ) . DESIGN This is a prospect i ve r and omized controlled trial . SETTING A rehabilitation hospital . PARTICIPANTS Participants ( N=90 ) were r and omized into  NMES  ( n=36 ) , TENS ( n=36 ) , or control groups ( n=18 ) . INTERVENTIONS NMES ( 15Hz , pulse width 200μs ) was applied to supraspinatus and deltoids ( medial and posterior parts ) , whereas TENS ( 100Hz , pulse width 100μs ) was used on the same areas . The surface electrodes were placed near the motor points of the supraspinatus and medial or posterior bundle of deltoids . The 4-week treatment consisted of 20 sessions , each session composed of 1 hour of stimulation per day . Routine rehabilitation program without any stimulation was administered to the control and the NMES/TENS groups . Numerical rating scale ( NRS ) , active/passive range of motion ( AROM/PROM ) of shoulder , upper extremity Fugl-Meyer Assessment ( FMA ) , modified Ashworth scale ( MAS ) , Barthel Index ( BI ) , and stroke-specific quality of life scale ( SSQOLS ) were assessed in a blinded manner at baseline , 2 , 4 , and 8 weeks after treatment , respectively . MAIN OUTCOME MEASURES The primary endpoint was the improvement from baseline in NRS for HSP at 4 weeks . RESULTS NRS scores in NMES , TENS , and control groups had decreased by 2.03 , 1.44 , and 0.61 points , respectively after 4 weeks of treatment , with statistically significant differences among the 3 groups ( P<.001 ) . The efficacy of the NMES group was significantly better than that of the TENS group ( P=.043 ) . Moreover , the efficacy of NMES and TENS groups was superior to that of the control group ( P<.001 , P=.044 , respectively ) . The differences in the therapeutic efficacy on shoulder AROM/PROM , FMA , MAS , BI , and SSQOLS scores were not significant among the 3 groups . CONCLUSIONS TENS and NMES  can effectively improve HSP , the efficacy of NMES being distinctly superior to that of TENS in maintaining long-term analgesia . However , NMES was not more efficacious than the TENS or control group in improving the shoulder joint mobility , upper limb function , spasticity , the ability of daily life activity , and stroke-specific quality of life in HSP patients The purpose of this study was to examine the psychometric properties of the American Shoulder and Elbow Surgeons St and ardized Shoulder Assessment Form ( ASES ) , patient self-report section . Patients with shoulder dysfunction ( n = 63 ) completed the ASES , The University of Pennsylvania Shoulder Score , and the  Short Form-36  during the initial evaluation , 24 to 72 hours after the initial visit , and after 3 to 4 weeks of physical therapy . The test-retest reliability ( intraclass correlation coefficient[1-way r and om-effects ] , 0.84 ; 95 % CI lower limit , 0.75 ) and internal consistency ( Cronbach alpha , 0.86 ) values were acceptable . The st and ard error of the measure was 6.7 ASES points ( 90 % CI , 11.0 ) . Construct and discriminant validity was demonstrated . Responsiveness was demonstrated with a st and ardized response mean of 1.5 and an effect size of 1.4 . The minimal detectable change was 9.7 ASES points ( 90 % CI , 16 ) , and the minimal clinical ly important difference was 6.4 ASES points . The results indicate that the ASES is a reliable , valid , and responsive outcome tool The journal club is an established teaching modality in many house-staff training programs . To determine if a journal club improves house-staff reading habits , knowledge of epidemiology and biostatistics , and critical appraisal skills , we r and omized 44 medical interns to receive either a journal club or a control seminar series .  A test instrument developed by the Delphi method was administered before and after the interventions ( mean , five journal club sessions ) . By self-report , 86 % of the house staff in the journal club group improved their reading habits vs 0 % in the control group . Knowledge scores increased more in the journal club group than in the control group , and a trend was found toward more knowledge gained as more sessions were attended . Ability to appraise critically a test article increased slightly in each group , but there was no significant difference between the groups . We conclude that a journal club is a powerful motivator of critical house-staff reading behavior and can help teach epidemiology and biostatistics to physicians-in-training OBJECTIVE To help people who give health information to the public develop the skills they need to make sense of evidence about effectiveness . DESIGN Educational approach , preceded by careful planning with representatives of possible participants . SETTING AND STUDY OF PARTICIPANTS : Staff in consumer health information services and members of maternity self-help groups in the UK in summer 1995 . INTERVENTIONS Pairs of half-day workshops introducing participants to r and omised controlled trials and systematic review s and to their critical appraisal . The workshops were run participatively and had at their centre a critical appraisal session in small groups . MAIN OUTCOME MEASURES Attendance at workshops , satisfaction and enjoyment of workshops ; comments at a follow-on event . RESULTS Four pairs of workshops were held ( three for consumer health information services , one for maternity self-help groups ) , 54 people attended a pair of workshops and a further 34 attended individual workshops . The workshops were enjoyed and found to be a good use of time . CONCLUSIONS It is feasible to introduce critical appraisal skills to people whose primary role is to give health information to the public . There is a need for comparative evaluation of different approaches Objective To determine whether  fellowship training in critical care medicine with critical appraisal exercises improves the ability and confidence of fellows to evaluate the medical literature .  Design Prospect i ve , interventional pilot study . Setting Multidisciplinary critical care medicine training program at a large university hospital . InterventionFellows were given three didactic sessions covering study design , analysis , and critical appraisal techniques . During the course of the year , each fellow was required to review one article from the literature and present a critique of this article to the group and faculty ( Journal Club ) . Fellows were guided in the preparation of this presentation by one of the critical care medicine faculty . Finally , a written analysis and critique of the article was performed by each fellow . Measurements and Main Results A test was given to each fellow at the beginning and end of the academic year . This test consisted of two pairs of articles on therapy for acute lung injury . For the pretest , each fellow was assigned , at r and om , one pair of articles . Fellows were given 1 hr to review both articles and to fill out a six-point test to assess their ability and confidence to appraise each article . At the end of the year , each fellow was tested on the opposite pair , the tests were grade d in a blinded fashion and the results of each test were compared . Six fellows completed both pre- and posttests . These paired results were analyzed separately , whereas results for another six fellows were conducted as an unpaired analysis . Mean scores increased both for the paired analysis ( 4.1 ± 0.7 vs. 5.1 ± 0.5;p = .015 ) and for the unpaired analysis ( 4.3 ± 0.6 vs. 5.0 ± 0.5;p = .012 ) . Self-reported confidence in critical appraisal also increased ( 2.5 ± 0.5 vs. 3.9 ± 0.7;p = .004 and 2.6 ± 0.5 vs. 3.9 ± 0.6;p < .001 , respectively ) . Conclusion Critical appraisal exercises used in the training of critical care medicine fellows appear to improve both ability and confidence to appraise relevant medical literature The aim of this study was to carry out a critical appraisal to detect the occurrence of publication bias , specifically positive- outcome bias , in Brazilian dental journals . A convenience sample of twenty-eight dental journals published in Brazil between 1994 and 2003 was selected ( 564 issues containing 5,453 articles ) . Each article was classified according to method ological design ; 1,064 were classified as case reports . A simple r and om sample of 435 articles comprised the final study sample and was su bmi tted to a critical appraisal by previously trained raters . Although a great part of case reports achieve proper structural aspects , most authors did not consider important aspects that could help the decision making process , such as discussion of alternative approaches , limitation of the performed procedures , lack of long-term clinical follow-up , possible variations in treatment outcome , and failure to discuss limitations of study design . In addition , unanimous reports of successful outcomes of clinical interventions strongly suggest that publication of case reports was influenced by positive outcome bias , which may influence readers ' clinical decision making process Background Evidence -Based Medicine ( EBM ) is an important competency for the healthcare professional . Experimental evidence of EBM educational interventions from rigorous research studies is limited . The main objective of this study was to assess EBM learning ( knowledge , attitudes and self-reported skills ) in undergraduate medical students with a r and omized controlled trial . Methods The educational intervention was a  one-semester EBM course in the 5th year of a public medical school in Mexico . The study design was an experimental parallel group r and omized controlled trial for the main outcome measures in the 5th year class ( M5 EBM vs. M5 non-EBM groups ) , and quasi-experimental with static-groups comparisons for the 4th year ( M4 , not yet exposed ) and 6th year ( M6 , exposed 6 months to a year earlier ) groups . EBM attitudes , knowledge and self-reported skills were measured using Taylor ’s question naire and a summative exam which comprised of a 100-item multiple-choice question ( MCQ ) test . Results 289 Medical students were assessed : M5 EBM=48 , M5 non-EBM=47 , M4=87 , and M6=107 . There was a higher reported use of the Cochrane Library and secondary journals in the intervention group ( M5 vs. M5 non-EBM ) . Critical appraisal skills and attitude scores were higher in the intervention group ( M5 ) and in the group of students exposed to EBM instruction during the previous year ( M6 ) . The knowledge level was higher after the intervention in the M5 EBM group compared to the M5 non-EBM group ( p<0.001 , Cohen 's d=0.88 with Taylor 's instrument and 3.54 with the 100-item MCQ test ) . M6 Students that received the intervention in the previous year had a knowledge score higher than the M4 and M5 non-EBM groups , but lower than the M5 EBM group . Conclusions Formal medical student training in EBM produced higher scores in attitudes , knowledge and self-reported critical appraisal skills compared with a r and omized control group . Data from the concurrent groups add validity evidence to the study , but rigorous follow-up needs to be done to document retention of EBM abilities OBJECTIVE To investigate whether a limited teaching intervention , based on principles of adult education , could change residents ' literature reading attitudes , behaviors , and knowledge . DESIGN The educational intervention supplemented an ongoing bimonthly journal club . The effects on residents were studied prospect ively before and four months following the intervention . SETTING A community hospital internal medicine training program . PARTICIPANTS All 14 residents : six in the first year , and four each in the second and third years of training . INTERVENTION A one-hour seminar incorporating principles of adult education , including the use of multiple teaching modalities . The content was based on the critical literature reading guidelines published by the McMaster group . Reinforcement of learning objectives was achieved by learner participation , written assignments , active feedback , and follow-up in subsequent journal clubs . RESULTS Residents improved their performances on objective testing of critical appraisal knowledge by 60 % ( p = 0.02 ) . They reported improved ability to appraise original research articles critically ( p = 0.01 ) and reported spending more useful time reading . Unaffected were the total time spent reading journals , the reasons for reading them , and the perceived value of journals in " keeping up " with advances in medical knowledge . CONCLUSION Journal clubs are important to residents , and their effectiveness in teaching critical appraisal and promoting reading of the literature may be augmented by applying principles of adult education Abstract Although emotion regulation modulates the pain experience , inconsistencies have been identified regarding the impact of specific regulation strategies on pain . Our goal was to examine the effects of emotion suppression and cognitive re appraisal on automatic ( ie , nonverbal ) and cognitively mediated ( ie , verbal ) pain expressions . Non clinical participants were r and omized into either a suppression ( n = 58 ) , re appraisal ( n = 51 ) , or monitoring control ( n = 42 ) condition . Upon arrival to the laboratory , participants completed the Emotion Regulation Question naire , to quantify self-reported suppression and re appraisal tendencies . Subsequently , they completed a thermal pain threshold and tolerance task . They were then provided with instructions to use , depending on their experimental condition , suppression , re appraisal , or monitoring strategies . Afterward , they were exposed to experimentally induced pain .  Self-report measures of pain , anxiety , and tension were administered , and facial expressions , heart rate , and galvanic skin response were recorded . The Facial Action Coding System was used to quantify general and pain-related facial activity ( ie , we defined facial actions that occurred during at least 5 % of pain stimulation periods as “ pain-related actions ” ) . Re appraisal and suppression induction led to reductions in nonverbal and verbal indices of pain . Moreover , self-reported tendencies to use suppression and re appraisal ( as measured by the Emotion Regulation Question naire ) did not interact with experimental condition in the determination of participants ' responses . Results suggest that consciously applying emotion regulation strategies during a painful task can moderate both cognitively mediated ( eg , verbal ) and automatic ( eg , facial activity ) expressions of pain Background . Existing measures of self‐reported shoulder function fail to measure effectively the full range of shoulder functioning . The classic approach for improving the reliability of a scale is adding items , but a scale with a substantial number of items imposes a large response burden on participants . A more efficient approach is to use modern psychometric methods to construct an adaptive scale in which patients respond only to items that are targeted at their level of shoulder function . Objectives . We developed a Flexilevel Scale of Shoulder Function ( FLEX‐SF ) . This scale includes three testlets that target low , medium , and high shoulder function . Scores on the testlets were equated to a common mathematical metric . Design and Subjects . We developed an initial pool of 68 items . This pool was administered to 400 patients , and responses were calibrated using a rating scale model . Subsets of items were identified for an easy , medium difficulty , and hard testlet . Properties of the scale were evaluated in a 3‐month longitudinal study of 200 shoulder patients . Results . The FLEX‐SF exhibited high reliability at both the scale level ( intraclass correlation coefficient [ 3,1 ] = 0.90 ) and specific trait levels . The validity of the FLEX‐SF was supported by its internal and external responsiveness ( Guyatt responsiveness index = 1.12 ) and the pattern of its associations with other health status measures . Conclusions . The FLEX‐SF can be used as a primary endpoint in clinical trials even when there are relatively few people in each treatment group . The scale also has excellent properties for use in clinical setting s tracking individual changes over time 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 Background and Purpose : Documenting functional outcomes after  reverse shoulder arthroplasty ( RSA )  is critical to advancing patient care . The interplay been self-reported and objective ly measured outcome measures has not been widely described . The utilization of wearable devices to document upper extremity limb activity is a new approach for objective ly measuring outcomes . Therefore , the purpose of this study was to evaluate changes in pain , and self-reported function and objective ly measured limb activity after RSA . We also assessed the influence of pain on self-reported function and objective ly measured limb activity to determine the impact of pain on outcomes after RSA . Material s : This study implemented a prospect i ve , repeated- measures design . Fourteen patients undergoing RSA underwent testing before surgery , and 2 and 12 months after surgery . Patient-reported instruments included pain , Disabilities of Arm , Shoulder and h and s ( DASH ) , and physical component summary ( PCS ) of the 36-Item Short Form Health Survey . Objective limb activity ( mean activity value , m/s2/min epoch ; inactive time , % ; low activity , % ; and high activity , % ) was captured with triaxial accelerometers worn on the upper and lower arm . A repeated- measures ANOVA tested for differences across time . The Spearman rank-order correlation was calculated to evaluate the influence of pain on DASH , PCS scores , and mean limb activity . Results : Patient-reported measures improved after surgery ( pain , P < .01 ; DASH , P < .01 ; PCS , P = .01 ) . No change in limb activity was found at 1 year compared with preoperative values for mean ( forearm , P = 1.00 ; arm , P = .36 ) , inactivity ( forearm , P = .33 ; arm , P = .22 ) , low ( forearm , P = .77 ; arm , P = .11 ) or high ( forearm , P = 1.00 ; arm , P = .20 ) activity . There was a relationship between pain and DASH scores 1 year after surgery ( P = .04 ) but not before surgery ( P = .16 ) , or 2 months after surgery ( P = .30 ) . There was no relationship between pain and PCS scores at any time point ( preoperative , P = .97 ; 2 months , P = .21 ; 1 year , P = .08 ) nor pain and limb activity ( forearm : preoperative , P = .36 ; 2 months , P = .67 ; 1 year , P = .16 ; arm : preoperative , P = .97 ; 2 months , P = .59 ; 1 year , P = .51 ) . Conclusions : RSA reduced pain and enhanced patient-perceived function . Objective ly measured upper extremity limb activity is not different 1 year after surgery compared with preoperative levels . Level of Evidence : III Context : It remains unknown if arthroscopic repair of recurrent anterior shoulder instability is as effective as open repair . Objective : The purpose of this study is to analyze the literature to provide clinical recommendations regarding the most appropriate therapeutic intervention for recurrent anterior shoulder instability . Study Design : Systematic review of level I and II studies . Data Sources : PubMed , EMBASE , the Cochrane Data base of Systematic Review s , and secondary references from 1967 to March 2010 were appraised for studies that met the inclusion criteria . Study Selection : Inclusion criteria were English- language level I or level II trials involving the treatment of recurrent anterior shoulder instability . Exclusion criteria included non-English- language studies ; level III , IV , or V studies ; and trials examining treatment of first-time shoulder dislocation , posterior shoulder dislocation , or diagnoses other than recurrent anterior shoulder dislocations . Data Extraction : Included studies underwent quality appraisal independently by each author identifying strengths , weaknesses , and biases . Results : Four r and omized controlled trials compared the use of arthroscopic and open repair for recurrent anterior shoulder dislocations .  These studies show no statistically significant difference between the 2 operative approaches . No long-term follow-up data describing the effects of either surgical approach are available at this time . Each investigation had weaknesses in study design that decreased the validity of its findings . Conclusions : While limited , the available evidence from r and omized controlled trials does not show a statistically significant difference in redislocation rates , return to activity , and functional outcomes between the arthroscopic and open repair groups . Range of motion is marginally better following arthroscopic treatment when compared with open repair . Recommendations on the optimal surgical intervention can not be provided Background Systematic review s ( SRs ) are expected to critically appraise included studies and privilege those at lowest risk of bias ( RoB ) in the synthesis . This study examines if and how critical appraisal s inform the synthesis and interpretation of evidence in SRs . Methods All SRs published in March – May 2012 in 14 high-ranked medical journals and a sample from the Cochrane library were systematic ally assessed by two review ers to determine if and how : critical appraisal was conducted ; RoB was summarised at study , domain and review levels ; and RoB appraisal s informed the synthesis process . Results Of the 59 SRs studied , all except six ( 90 % ) conducted a critical appraisal of the included studies , with most using or adapting existing tools . Almost half of the SRs reported critical appraisal in a manner that did not allow readers to determine which studies included in a review were most robust . RoB assessment s were not incorporated into synthesis in one-third ( 20 ) of the SRs , with their consideration more likely when review s focused on r and omised controlled trials . Common methods for incorporating critical appraisal s into the synthesis process were sensitivity analysis , narrative discussion and exclusion of studies at high RoB. Nearly half of the review s which investigated multiple outcomes and carried out study -level RoB summaries did not consider the potential for RoB to vary across outcomes . Conclusions The conclusions of the SRs , published in major journals , are frequently uninformed by the critical appraisal process , even when conducted . This may be particularly problematic for SRs of public health topics that often draw on diverse study design Introduction Critical appraisal skills are believed to play a central role in an evidence -based approach to health practice . The aim of this study was to evaluate the effectiveness and costs of a critical appraisal skills educational intervention aim ed at health care professionals . Methods This prospect i ve controlled trial r and omized 145 self-selected general practitioners , hospital physicians , professions allied to medicine , and healthcare managers/administrators from the South West of Engl and to a half-day critical appraisal skills training workshop  ( based on the model of problem-based small group learning ) or waiting list control . The following outcomes were assessed at 6-months follow up : knowledge of the principles necessary for appraising evidence ; attitudes towards the use of evidence about healthcare ; evidence seeking behaviour ; perceived confidence in appraising evidence ; and ability to critically appraise a systematic review article . Results At follow up overall knowledge score [ mean difference : 2.6 ( 95 % CI : 0.6 to 4.6 ) ] and ability to appraise the results of a systematic review [ mean difference : 1.2 ( 95 % CI : 0.01 to 2.4 ) ] were higher in the critical skills training group compared to control . No statistical significant differences in overall attitude towards evidence , evidence seeking behaviour , perceived confidence , and other areas of critical appraisal skills ability ( methodology or generalizability ) were observed between groups . Taking into account the workshop provision costs and costs of participants time and expenses of participants , the average cost of providing the critical appraisal workshops was approximately £ 250 per person . Conclusions The findings of this study challenge the policy of funding ' one-off ' educational interventions aim ed at enhancing the evidence -based practice of health care professionals . Future evaluations of evidence -based practice interventions need to take in account this trial 's negative findings and method ological difficulties OBJECTIVE To examine the evidence that the teaching of critical appraisal ( evidence -based medicine ) skills to undergraduate medical students or residents will result in significant gains in knowledge and increased use of the literature in clinical decision-making . DATA SOURCES Articles published from 1966 to 1995 , retrieved through a MEDLINE search supplemented by manual search es ; review of bibliographies maintained by individuals involved in teaching critical appraisal skills ; and a previous method ological review . STUDY SELECTION Articles were selected if the study involved some form of control group , although strict r and omization was not required , and a measure of performance followed the intervention . Articles were excluded if they simply reported the process of teaching critical appraisal skills or used some form of " happiness index . " DATA SYNTHESIS There were 10 studies of the impact of teaching critical appraisal skills  , 6 involving medical students and 4 involving residents . Results from 3 of the studies were nearly uninterpretable and thus were excluded ; the remaining 7 were method ologically acceptable . Analysis showed that interventions implemented in undergraduate programs result ed in significant gains in knowledge , as assessed by a written test ( mean gain 17.0 % ; st and ard deviation [ SD ] 4.0 % ) . Conversely , studies at the residency level consistently showed a small change in knowledge ( mean gain 1.3 % ; SD 1.7 % ) . Two studies that examined residents ' use of the literature were unable to demonstrate any positive changes . CONCLUSIONS Studies of the effect of teaching critical appraisal skills on gains in knowledge at the undergraduate level showed consistent improvement . By contrast , changes in knowledge at the residency level were small . Several suggestions from the educational literature are offered to increase effectiveness of critical appraisal interventions Background About half of all newly presented episodes of shoulder complaints ( SC ) in general practice are reported to last for at least six months . Early interventions aim ed at the psychological and social determinants of SC are not common in general practice , although such interventions might prevent the development of chronic SC.The Education and Activation Programme ( EAP ) consists of an educational part and a time-contingent activation part . The aim of the EAP is to provide patients with the proper cognitions by means of education , and to stimulate adequate behaviour through advice on activities of daily living . Design The article describes the design of a r and omised clinical trial ( RCT ) to evaluate the effectiveness and cost-effectiveness of an EAP in addition to usual care , compared to usual care only , in the prevention of chronic SC after six months . It also describes the analysis of the cost and effect balance .  Patients suffering from SC for less than three months are recruited in general practice and through open recruitment . A trained general practitioner or a trained therapist administers the EAP . Primary outcome measures are patient-perceived recovery , measured by self- assessment on a seven-point scale , and functional limitations in activities of daily living . Question naires are used to study baseline measures , prognostic measures , process measures and outcome measures . Discussion The inclusion of patients in the study lasted until December 31st 2003 . Data collection is to end in June 2004 An effective and safe remedy for shoulder pain is needed as shoulder pain is a common complication of stroke and restricts recovery of patients . This study was carried out to evaluate the effect of Ouhyul herbal acupuncture point injection ( O-API ) on shoulder pain in patients with stroke . Twenty-four participants with shoulder pain after stroke were recruited and r and omized to the O-API and control groups . Treatment was conducted for 2 weeks three times per week . We evaluated the effects of treatment with a numerical rating scale ( NRS ) , painless passive range of motion ( PROM ) of external shoulder rotation , and the Fugl-Meyer Motor Assessment ( FMMA ) at baseline , each week , and 1 week after the final treatment . All measures were similar between the O-API and control groups at baseline . The O-API group showed significant improvement on the NRS compared with that in the control group after 2 weeks of treatment , and the treatment effect was maintained until the follow-up period . PROM decreased significantly in both groups , but the reduction was maintained only in the O-API group . No significant difference was observed on the FMMA between the two groups . O-API result ed in significant improvement in shoulder pain after stroke , and its effect was maintained after termination of treatment without any severe side effects The mechanisms by which transcranial direct current stimulation ( tDCS ) influences emotional processing - and whether this is related to individual vulnerability for psychopathology - are still poorly understood . The present study aim ed to investigate if one prefrontal tDCS session modulates mood and neural functional connectivity after being exposed to negative information differently in individuals low or high in perceived criticism ( PC ) , which has been related to vulnerability for psychiatric illness . In a r and omized cross-over design , one session of MRI-compatible prefrontal tDCS ( neuronavigated placement of the anodal electrode at the left dorsolateral prefrontal cortex and the cathodal electrode at the right supraorbital region ; vs. sham ) was administered to healthy females , prior to listening to self-referential criticism . PC-dependent ( low vs. high PC ) changes in mood and resting-state functional connectivity patterns following tDCS and after hearing criticism were explored . After being criticized all females ( low and high PC ) felt angrier and more depressed , both in the active tDCS or sham tDCS condition . However , in contrast to low PC females , in high PC females prefrontal tDCS reduced connectivity between the left dorsal anterior cingulate cortex and the right dorsomedial prefrontal cortex following criticism . Despite having no differential effects on self-reported mood , prefrontal tDCS reduces medial prefrontal neural connectivity after being criticized in high PC females compared to low PC females . Depending on individual vulnerability for psychopathology , a single tDCS session differentially affects neural processing of negative emotional information , especially in brain regions involved in monitoring , experiencing and appraising/evaluating emotional material
The SPADI is the most frequently evaluated PROM and its measurement properties seem adequate apart from a lack of information regarding its measurement error and content validity .
Dutch users could use either the SDQ or the SST .
In Tamil , Slovene , Spanish and the Danish language s , the evaluated PROMs were not yet of acceptable validity .
None of these PROMs showed strong positive evidence for all measurement properties .
Objective To critically appraise and compare the measurement properties of self-administered patient-reported outcome measures ( PROMs ) focussing on the shoulder , assessing “ activity limitations . ”