***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: Evidence -based practice involves the use of evidence from systematic review s and r and omised controlled trials , but the extent of this evidence in physiotherapy has not previously been surveyed . The aim of this survey is to describe the quantity and quality of r and omised controlled trials and the quantity of systematic review s relevant to physiotherapy . The Physiotherapy Evidence Data base ( PEDro ) was search ed . The quality of trials was assessed with the PEDro scale . The search identified a total of 2,376 r and omised controlled trials and 332 systematic review s. The first trial was published in 1955 and the first review was published in 1982 . Since that time , the number of trials and review s has grown exponentially . The mean PEDro quality score has increased from 2.8 in trials published between 1955 and 1959 to 5.0 for trials published between 1995 and 1999 . There is a substantial body of evidence about the effects of physiotherapy . However , there remains scope for improvements in the quality of the conduct and reporting of clinical trials & NA ;  Pain intensity is frequently measured on an 11‐point pain intensity numerical rating scale ( PI‐NRS ) , where 0=no pain and 10=worst possible pain . However , it is difficult to interpret the clinical importance of changes from baseline on this scale ( such as a 1‐ or 2‐point change ) . To date , there are no data driven estimates for clinical ly important differences in pain intensity scales used for chronic pain studies . We have estimated a clinical ly important difference on this scale by relating it to global assessment s of change in multiple studies of chronic pain . Data on 2724 subjects from 10 recently completed placebo‐controlled clinical trials of pregabalin in diabetic neuropathy , postherpetic neuralgia , chronic low back pain , fibromyalgia , and osteoarthritis were used . The studies had similar design s and measurement instruments , including the PI‐NRS , collected in a daily diary , and the st and ard seven‐point patient global impression of change ( PGIC ) , collected at the endpoint . The changes in the PI‐NRS from baseline to the endpoint were compared to the PGIC for each subject . Categories of ‘ much improved ’ and ‘ very much improved ’ were used as determinants of a clinical ly important difference and the relationship to the PI‐NRS was explored using graphs , box plots , and sensitivity/specificity analyses . A consistent relationship between the change in PI‐NRS and the PGIC was demonstrated regardless of study , disease type , age , sex , study result , or treatment group . On average , a reduction of approximately two points or a reduction of approximately 30 % in the PI‐NRS represented a clinical ly important difference . The relationship between percent change and the PGIC was also consistent regardless of baseline pain , while higher baseline scores required larger raw changes to represent a clinical ly important difference . The application of these results to future studies may provide a st and ard definition of clinical ly important improvement in clinical trials of chronic pain therapies . Use of a st and ard outcome across chronic pain studies would greatly enhance the comparability , validity , and clinical applicability of these studies Study Design . A follow‐up study of a cohort of 444 patients aged 16 to 59 years who consulted with their general practitioners(GPs ) in 1987‐1988 for an incident episode of back pain . Objectives . To determine the proportion of patients with back pain in whom chronic back problems develop after a follow‐up of 7 years , to compare health outcomes and labor force participation of patients with and without chronic back problems and to identify determinants of chronicity . Summary of Background Data . The incidence and prevalence of back pain are very high . A large proportion of the costs related to medical consumption , absence from work , and disability are probably caused by chronic back problems . It is unknown what proportion of back problems become chronic , especially after a long follow‐up period , and which factors can predict chronicity . Methods . Data on the course of the symptoms and medical consumption from the period between 1987‐1988 and 1991 were gathered retrospectively . Data on several health outcomes , including LFP , and data on some work characteristics were collected prospect ively in 1991 . A more extensive data set on health outcomes including psychologic status and working situation was collected in 1994 . Results . Chronic back problems developed in 28 % of the patients . These patients reported more pain , higher levels of medical re source consumption , worse health outcomes , and lower labor force participation . Episodes of back pain before 1987‐1988 , severe pain in 1991 , and disability score in 1991 were positively associated with chronicity in 1994 , difficulties with job performance in 1991 , and frequent stooping in the subgroup of patients who held a paying job in the follow‐up period . Conclusions . Even after a follow‐up of 7 years , the proportion of people with chronic back problems was high . The consequences for quality of life , labor force participation , and consumption of medical re sources are clear . Further research is necessary to examine determinants and ways to prevent chronicity Properly conducted r and omised trials can aid clinical decision-making by providing unbiased estimates of the average size of treatment effects . This paper , the first of two , discusses how readers of clinical trials can extract simple estimates of treatment effect size from trial reports when trial outcomes are measured on a continuous scale . When making decisions about therapy for individual patients , these estimates can be modified on the basis of patient characteristics . Modified estimates of treatment effect size can be used to determine if the effect of treatment is likely to be large enough to be " clinical ly worthwhile " . This approach optimises clinical decision-making by combining unbiased estimates of the size of treatment effect from clinical trials with clinical intuition and patient preferences Most systematic review s rely substantially on the assessment of the method ological quality of the individual trials . The aim of this study was to obtain consensus among experts about a set of generic core items for quality assessment of r and omized clinical trials ( RCTs ) . The invited participants were experts in the field of quality assessment of RCTs . The initial item pool contained all items from existing criteria lists . Subsequently , we reduced the number of items by using the Delphi consensus technique . Each Delphi round comprised a question naire , an analysis , and a feedback report . The feedback report included staff team decisions made on the basis of the analysis and their justification . A total of 33 international experts agreed to participate , of whom 21 completed all question naires . The initial item pool of 206 items was reduced to 9 items in three Delphi rounds . The final criteria list ( the Delphi list ) was satisfactory to all participants . It is a starting point on the way to a minimum reference st and ard for RCTs on many different research topics . This list is not intended to replace , but rather to be used alongside , existing criteria lists The effectiveness of spinal manipulation carried out by a non-medical qualified osteopath was compared with that of short-wave diathermy ( SWD ) and a placebo ( detuned SWD ) in 109 patients with low back pain . More than half the subjects in each of the 3 treatment groups benefited immediately from therapy . Significant improvements were observed in the 3 groups at the end of 2 weeks ' treatment , and these were still apparent at 12 weeks . The outcome of treatment was unrelated to the initial severity or duration of pain or to the trend of pain towards deterioration or improvement . It is , therefore , unlikely that the results simply reflect the natural history of low back pain . Benefits obtained with osteopathy and SWD in this study may have been achieved through a placebo effect OBJECTIVES To study the relative efficacy of three different treatment for chronic low back pain ( CLBP ) . Two preplanned comparisons were made : ( a ) Spinal manipulative therapy ( SMT ) combined with trunk strengthening exercises ( TSE ) vs. SMT combined with trunk stretching exercises , and ( b ) SMT combined with TSE vs. nonsteroidal anti-inflammatory drug ( NSAID ) therapy combined with TSE . STUDY DESIGN Interdisciplinary , prospect i ve , observer-blinded , r and omized clinical trial with a 1-yr follow-up period . The trial evaluated therapies in combination only and was not design ed to test the individual treatment components . SETTING Primary contact , college out-patient clinic . PATIENTS In total , 174 patients aged 20 - 60 yr were admitted to the study . MAIN OUTCOME MEASURES Patient-rated low back pain , disability , and functional health status at 5 and 11 wk . INTERVENTIONS Five weeks of SMT or NSAID therapy in combination with supervised trunk exercise , followed by and additional 6 wk of supervised exercise alone . RESULTS Individual group comparisons after 5 and 11 wk of intervention on all three main outcome measures did not reveal any clear clinical ly important or statistically significant differences . There seemed to be a sustained reduction in medication use at the 1-yr follow-up . in the SMT/TSE group . Continuance of exercise during the follow-up year , regardless of type , was associated with a better outcome . CONCLUSION Each of the three therapeutic regimens was associated with similar and clinical ly important improvement over time that was considered superior to the expected natural history of long-st and ing CLBP . For the management of CLBP , trunk exercise in combination with SMT or NSAID therapy seemed to be beneficial and worthwhile . The magnitude of nonspecific therapeutic ( placebo ) effects , cost-effectiveness and relative risks of side effects associated with these types of therapy need to be addressed in future studies Study Design A r and omized trial was conducted on a representative sample of patients with untreated low back pain lasting 7 weeks or longer , or having more than 6 episodes in 12 months . Objectives To contrast the effectiveness of manipulation , a manipulation mimic , and a back education program . Method ologic criticisms of earlier studies were addressed . Summary of Background Data Published meta-anal-yses suggest clinical benefit from manipulation for acute patients . Data are inconclusive for patients having symptoms for longer than 1 month . Methods A total of 1267 consecutive patients were screened . Block r and omization was used to assign 209 qualifying patients to treatment groups . Self-reported pain and activity tolerance served as primary outcome measures . Patients were assessed at enrollment , after 2 weeks of treatment , and again after 2 weeks without treatment . Multiple teams conducted recruitment , r and omization , assessment , treatment , and data analysis independently without sharing information . Treatments were carefully described , monitored , and balanced for physician attention and physical contact effects . Results A total of 81.3 % of subjects completed the study . Confounding factors and missing data were identified in approximately 20 % of those completing the final follow-up . Analysis of the remaining data was carried out . A strong time effect under treatment was observed . Greater improvement was noted in pain and activity tolerance in the manipulation group . Immediate benefit from pain relief continued to accrue after manipulation , even for the last encounter at the end of the 2-week treatment interval . Conclusion Time is a strong ally of the low back pain patient . In human terms , however , there appears to be clinical value to treatment according to a defined plan using manipulation even in low back pain exceeding 7 weeks ' duration OBJECTIVE To study the efficacy of manual therapy and physiotherapy in subgroups of patients with persistent back and neck complaints . The second objective was to determine the correlation between three important outcome measures used in this trial . DESIGN R and omized clinical trial ( subgroup analysis ) . SETTING Primary health care in the Netherl and s. PATIENTS Two hundred fifty-six patients with nonspecific back and neck complaints of at least 6 wk duration who had not received physiotherapy or manual therapy in the past 2 yr . INTERVENTIONS At the discretion of the manual therapists , physiotherapists and general practitioners . Physiotherapy consisted of exercises , massage and physical therapy ( heat , electrotherapy , ultrasound , shortwave diathermy ) . Manual therapy consisted of manipulation and mobilization of the spine . Treatment by the general practitioner consisted of drugs ( e.g. , analgesics ) , advice about posture , home exercises and (bed)rest . Placebo treatment consisted of detuned shortwave diathermy ( 10 min ) and detuned ultrasound ( 10 min ) . MAIN OUTCOME MEASURES Changes in severity of the main complaint and limitation of physical functioning measured on 10-point scales by a blinded research assistant and global perceived effect measured on a 6-point scale by the patients . RESULTS Improvement in the main complaint was larger with manual therapy ( 4.3 ) than with physiotherapy ( 2.5 ) for patients with chronic conditions ( duration complaint of 1 yr or longer ) . Also , improvement in the main complaint was larger with manual therapy ( 5.5 ) than with physiotherapy ( 4.0 ) for patients younger than 40 yr ( both were measured after 12-mo follow-up ) . Labeling of patients by the treating manual therapists as " suitable " or " not suitable " for treatment with manual therapy did not predict differences in outcomes . Generally , there was a moderate to strong correlation between the three outcome measures , although a considerable number of patients gave a relatively low score for perceived benefit , while the research assistant gave a high improvement score for the main complaint and physical functioning . CONCLUSIONS The subgroup analysis suggests better results of manual therapy compared to physiotherapy in chronic patients ( duration of present complaints of 1 yr or longer ) and in patients younger than 40 yr old ) . Differences for other subgroups were less clear . The explorative findings of these subgroup analyses have to be investigated in future research OBJECTIVE To compare needle acupuncture , medication ( tenoxicam with ranitidine ) , and spinal manipulation for managing chronic ( > 13 weeks duration ) spinal pain syndromes . DESIGN Prospect i ve , r and omized , independently assessed preintervention and postintervention clinical pilot trial . SETTING Specialized spinal pain syndrome out-patient unit at Townsville General Hospital , Queensl and , Australia . SUBJECTS Seventy-seven patients ( without contraindication to manipulation 
    Output:
    
It is concluded that spinal manipulation does not produce clinical ly worthwhile decreases in pain compared with sham treatment , and does not produce clinical ly worthwhile reductions in disability compared with NSAIDs for patients with chronic low back pain .
It is not clear whether spinal manipulation is more effective than NSAIDs in reducing pain of patients with chronic low back pain