***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: Background Chronic back pain is a major public health problem and the primary reason patients seek massage treatment . Despite the growing use of massage for chronic low back pain , there have been few studies of its effectiveness . This trial will be the first evaluation of the effectiveness of relaxation massage for chronic back pain and the first large trial of a focused structural form of massage for this condition . Methods and Design A total of 399 participants ( 133 in each of three arms ) between the ages of 20 and 65 years of age who have low back pain lasting at least 3 months will be recruited from an integrated health care delivery system . They will be r and omized to one of two types of massage ( " focused structural massage " or " relaxation massage " ) , or continued usual medical care . Ten massage treatments will be provided over 10 weeks . The primary outcomes , st and ard measures of dysfunction and bothersomeness of low back pain , will be assessed at baseline and after 10 , 26 , and 52 weeks by telephone interviewers masked to treatment assignment . General health status , satisfaction with back care , days of back-related disability , perceived stress , and use and costs of healthcare services for back pain will also be measured . Outcomes across assigned treatment groups will be compared using generalized estimating equations , accounting for participant correlation and adjusted for baseline value , age , and sex . For both primary outcome measures , this trial will have at least 85 % power to detect the presence of a minimal clinical ly significant difference among the three treatment groups and 91 % power for pairwise comparisons . Secondary analyses will compare the proportions of participants in each group that improve by a clinical ly meaningful amount . Conclusion Results of this trial will help clarify the value of two types of massage therapy for chronic low back pain . Trial registration Clinical Trials.gov NCT 00371384 Objective : This article examines the effectiveness of manual therapy with specific adjuvant exercise for treating  chronic low back pain and disability .  Methods : A single blind , r and omized , controlled trial was employed . Patients were prescribed an exercise program that was tailored to treat their musculoskeletal dysfunctions or given a nonspecific program of general stretching and aerobic conditioning . In addition , patients received manual therapy or sham manual therapy . Participants were seen for 6 weekly sessions and were asked to perform their exercise program twice daily . Results : Seventy-two out of 100 patients completed the study . Multivariate tests conducted for measures of pain and disability revealed a significant group by time interaction ( P = 0.04 and P = 0.05 , respectively ) , indicating differential change in these measures pretreatment to posttreatment as a function of the treatment received . When controlling for pretreatment scores , patients receiving manual therapy with specific adjuvant exercise reported significant reductions in pain . No change in perceived disability was observed , with the exception that patients receiving sham manual therapy with specific adjuvant exercise reported significantly greater disability at posttreatment . Discussion : Manual therapy with specific adjuvant exercise appears to be beneficial in treating  chronic low back pain .  Despite changes in pain , perceived function did not improve . It is possible that impacting chronic low back pain alone does not address psychosocial or other factors that may contribute to disability . Further studies are needed to examine the long-term effects of these interventions and to address what adjuncts are beneficial in improving function in this population Non-specific low back pain ( NLBP ) is an increasing health problem for athletes . This r and omized controlled trial was design ed to investigate the effects of Chinese massage combined with herbal ointment for NLBP . 110 athletes with NLBP were r and omly assigned to experimental group with Chinese massage combined with herbal ointment or control group with simple massage therapy . The primary outcome was pain by Chinese Short Form McGill Pain Question naire ( C-SFMPQ ) . The secondary outcome was local muscle stiffness by Myotonometer . After 4 weeks , the experimental group experienced significant improvements in C-SFMPQ and in local muscle stiffness compared with control group ( between-group difference in mean change from baseline , −1.24 points , P = 0.005 in sensory scores ; −3.14 points , P < 0.001 in affective scores ; −4.39 points , P < 0.001 in total scores ; −0.64 points , P = 0.002 in VAS ; −1.04 points , P = 0.005 in local muscle stiffness during relaxation state ) . The difference remained at one month followup , but it was only significant in affective scores ( −2.83 points , P < 0.001 ) at three months followup . No adverse events were observed . These findings suggest that Chinese massage combined with herbal ointment may be a beneficial complementary and alternative therapy for athletes with NLBP Objective To determine the effectiveness of lessons in the Alex and er technique , massage therapy , and advice from a doctor to take exercise ( exercise prescription ) along with nurse delivered behavioural counselling for patients with chronic or recurrent back pain . Design Factorial r and omised trial . Setting 64 general practice s in Engl and . Participants 579 patients with chronic or recurrent low back pain ; 144 were r and omised to normal care , 147 to massage , 144 to six Alex and er technique lessons , and 144 to 24 Alex and er technique lessons ;  half of each of these groups were r and omised to exercise prescription . Interventions Normal care ( control ) , six sessions of massage , six or 24 lessons on the Alex and er technique , and prescription for exercise from a doctor with nurse delivered behavioural counselling . Main outcome measures Rol and Morris disability score ( number of activities impaired by pain ) and number of days in pain . Results Exercise and lessons in the Alex and er technique , but not massage , remained effective at one year ( compared with control Rol and disability score 8.1 : massage −0.58 , 95 % confidence interval −1.94 to 0.77 , six lessons −1.40 , −2.77 to −0.03 , 24 lessons −3.4 , −4.76 to −2.03 , and exercise −1.29 , −2.25 to −0.34 ) . Exercise after six lessons achieved 72 % of the effect of 24 lessons alone ( Rol and disability score −2.98 and −4.14 , respectively ) . Number of days with back pain in the past four weeks was lower after lessons ( compared with control median 21 days : 24 lessons −18 , six lessons −10 , massage −7 ) and quality of life improved significantly . No significant harms were reported . Conclusions One to one lessons in the Alex and er technique from registered teachers have long term benefits for patients with chronic back pain . Six lessons followed by exercise prescription were nearly as effective as 24 lessons . Trial registration National Research Register N0028108728 . How does the Alex and er Technique work ? What are the authors findings about the clinical and cost effectiveness of the treatment ? Watch this video to find out ( 12 mins ) . Three treatments for non-specific lumbar pain -- balneotherapy , underwater traction bath , and underwater massage -- were assessed in a r and omised prospect i ve controlled trial in 158 out patients . Each group was treated for four weeks and patients were review ed at the end of this period and at 12 months after entry to the trial . The prescription of analgesics and the pain score were significantly reduced in all three treated groups , but there was no difference between the three groups . No significant change occurred in spinal motion and the straight leg raising test . After one year only the analgesic consumption was significantly lower than in the control group Objective An economic evaluation of therapeutic massage , exercise , and lessons in the Alex and er technique for treating persistent back pain . Design Cost consequences study and cost effectiveness analysis at 12 month follow-up of a factorial r and omised controlled trial . Participants 579 patients with chronic or recurrent low back pain recruited from primary care . Interventions Normal care ( control ) , massage , and six or 24 lessons in the Alex and er technique . Half of each group were r and omised to a prescription for exercise from a doctor plus behavioural counselling from a nurse . Main outcome measures Costs to the NHS and to participants . Comparison of costs with Rol and -Morris disability score ( number of activities impaired by pain ) , days in pain , and quality adjusted life years ( QALYs ) . Comparison of NHS costs with QALY gain , using incremental cost effectiveness ratios and cost effectiveness acceptability curves . Results Intervention costs ranged from £ 30 for exercise prescription to £ 596 for 24 lessons in Alex and er technique plus exercise . Cost of health services ranged from £ 50 for 24 lessons in Alex and er technique to £ 124 for exercise . Incremental cost effectiveness analysis of single therapies showed that exercise offered best value ( £ 61 per point on disability score , £ 9 per additional pain-free day , £ 2847 per QALY gain ) . For two-stage therapy , six lessons in Alex and er technique combined with exercise was the best value ( additional £ 64 per point on disability score , £ 43 per additional pain-free day , £ 5332 per QALY gain ) . Conclusions An exercise prescription and six lessons in Alex and er technique alone were both more than 85 % likely to be cost effective at values above £ 20 000 per QALY , but the Alex and er technique performed better than exercise on the full range of outcomes . A combination of six lessons in Alex and er technique lessons followed by exercise was the most effective and cost effective option . How does the Alex and er Technique work ? What are the authors findings about the clinical and cost effectiveness of the treatment ? Watch this video to find out ( 12 mins ) . Background and Purpose — The Safe Implementation of Thrombolysis in Stroke-MOnitoring STudy ( SITS-MOST ) unadjusted results demonstrated that intravenous alteplase is well tolerated and that the effects were comparable with those seen in r and omized , controlled trials ( RCTs ) when used in routine clinical practice within 3 hours of ischemic stroke onset . We aim ed to identify outcome predictors and adjust the outcomes of the SITS-MOST to the baseline characteristics of RCTs . Methods — The study population was SITS-MOST ( n=6483 ) and pooled RCTs ( n=464 ) patients treated with intravenous alteplase within 3 hours of stroke onset . Multivariable , backward stepwise regression analyses ( until P≤0.10 ) were performed to identify the outcome predictors for SITS-MOST . Variables appearing either in the final multivariable model or differing ( P<0.10 ) between SITS-MOST and RCTs were included in the prediction model for the adjustment of outcomes . Main outcome measures were symptomatic intracerebral hemorrhage , defined as National Institutes of Health Stroke Scale deterioration ≥1 within 7 days with any hemorrhage ( RCT definition ) , mortality , and independency as defined by modified Rankin Score of 0 to 2 at 3 months . Results — The adjusted proportion of symptomatic intracerebral hemorrhage for SITS-MOST was 8.5 % ( 95 % CI , 7.9 to 9.0 ) versus 8.6 % ( 6.3 to 11.6 ) for pooled RCTs ; mortality was 15.5 % ( 14.7 to 16.2 ) versus 17.3 % ( 14.1 to 21.1 ) ; and independency was 50.4 % ( 49.6 to 51.2 ) versus 50.1 % ( 44.5 to 54.7 ) , respectively . In the multivariable analysis , older age , high blood glucose , high National Institutes of Health Stroke Scale score , and current infa rct ion on imaging scans were related to poor outcome in all parameters . Systolic blood pressure , atrial fibrillation , and weight were additional predictors of symptomatic intracerebral hemorrhage . Current smokers had a lower rate of symptomatic intracerebral hemorrhage . Disability before current stroke ( modified Rankin Score 2 to 5 ) , diastolic blood pressure , antiplatelet other than aspirin , congestive heart failure , patients treated in new centers , and male sex were related to high mortality at 3 months . Conclusions — The adjusted outcomes from SITS-MOST were almost identical to those in relevant RCTs and reinforce the conclusion drawn previously in the unadjusted analysis . We identified several important outcome predictors to better identify patients suitable for thrombolysis OBJECTIVE --To compare the effectiveness of manipulative therapy , physiotherapy , treatment by the general practitioner , and placebo therapy in patients with persistent non-specific back and neck complaints . DESIGN --R and omised clinical trial . SETTING -- Primary health care in the Netherl and s. PATIENTS --256 patients with non-specific back and neck complaints of at least six weeks ' duration who had not received physiotherapy or manipulative therapy in the past two years . INTERVENTIONS --At the discretion of the manipulative therapists , physiotherapists , and general practitioners . Physiotherapy consisted of exercises , massage , and physical therapy ( heat , electrotherapy , ultrasound , shortwave diathermy ) . Manipulative therapy consisted of manipulation and mobilisation of the spine . Treatment by general practitioners consisted of drugs ( for example , analgesics ) , advice about posture , home exercises , and (bed)rest . Placebo treatment consisted of detuned shortwave diathermy ( 10 minutes ) and detuned ultrasound ( 10 minutes ) . 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 --Many patients 
    Output:
    
We have very little confidence that massage is an effective treatment for LBP .
Acute , sub-acute and chronic LBP had improvements in pain outcomes with massage only in the short-term follow-up .
Functional improvement was observed in participants with sub-acute and chronic LBP when compared with inactive controls , but only for the short-term follow-up .
There were only minor adverse effects with massage