***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: Abstract Objective To estimate the effect of adding exercise classes , spinal manipulation delivered in NHS or private premises , or manipulation followed by exercise to “ best care ” in general practice for patients consulting with back pain . Fig 1 Progress of the UK BEAM trial Design Pragmatic r and omised trial with factorial design . Setting 181 general practice s in Medical Research Council General Practice Research Framework ; 63 community setting s around 14 centres across the United Kingdom . Participants 1334 patients consulting their general practice s about low back pain . Main outcome measures Scores on the Rol and Morris disability question naire at three and 12 months , adjusted for centre and baseline scores . Results All groups improved over time . Exercise  improved mean disability question naire scores at three months by 1.4 ( 95 % confidence interval 0.6 to 2.1 ) more than “ best care . ” For manipulation the additional improvement was 1.6 ( 0.8 to 2.3 ) at three months and 1.0 ( 0.2 to 1.8 ) at 12 months . For manipulation followed by exercise the additional improvement was 1.9 ( 1.2 to 2.6 ) at three months and 1.3 ( 0.5 to 2.1 ) at 12 months . No significant differences in outcome occurred between manipulation in NHS premises and in private premises . No serious adverse events occurred . Conclusions Relative to “ best care ” in general practice , manipulation followed by exercise achieved a moderate benefit at three months and a small benefit at 12 months ; spinal manipulation achieved a small to moderate benefit at three months and a small benefit at 12 months ; and exercise achieved a small benefit at three months but not 12 months BACKGROUND Spinal pain is common and frequently disabling . Management guidelines have encouraged referral from primary care for spinal manipulation . However , the evidence base for these recommendations is weak . More pragmatic trials and economic evaluations have been recommended . OBJECTIVES Our aim was to assess the effectiveness and health care costs of a practice -based osteopathy clinic for subacute spinal pain . METHODS A pragmatic r and omized controlled trial was carried out in a primary care osteopathy clinic accepting referrals from 14 neighbouring practice s in North West Wales . A total of 201 patients with neck or back pain of 2 - 12 weeks duration were allocated at r and om between usual GP care and an additional three sessions of osteopathic spinal manipulation . The primary outcome measure was the Extended Aberdeen Spine Pain Scale ( EASPS ) . Secondary measures included SF-12 , EuroQol and Short-form McGill Pain Question naire . Health care costs were estimated from the records of referring GPs . RESULTS Outcomes improved more in the osteopathy group than the usual care group . At 2 months , this improvement was significantly greater in EASPS [ 95 % confidence interval ( CI ) 0.7 - 9.8 ] and SF-12 mental score ( 95 % CI 2.7 - 10.7 ) . At 6 months , this difference was no longer significant for EASPS ( 95 % CI -1.5 to 10.4 ) , but remained significant for SF-12 mental score ( 95 % CI 1.0 - 9.9 ) . Mean health care costs attributed to spinal pain were significantly greater by 65 UK pounds in the osteopathy group ( 95 % CI 32 - 155 UK pounds ) . Though osteopathy also cost 22 UK pounds more in mean total health care cost , this was not significant ( 95 % CI - 159 to 142 UK pounds ) . CONCLUSION A primary care osteopathy clinic improved short-term physical and longer term psychological outcomes , at little extra cost . Rigorous multicentre studies are now needed to assess the generalizability of this approach A national telephone survey was conducted in 1998 using r and om-digit dialing and the first Osteopathic Survey of Healthcare in America ( OSTEOSURV-I ) instrument to determine patients ' satisfaction with their healthcare , as well as their perceptions of osteopathic medicine . Of the 1106 respondents , 243 ( 22.0 % ) had received medical care from an osteopathic physician , and another 307 ( 27.8 % ) cl aim ed to be aware of osteopathic physicians . Patients of osteopathic physicians reported the highest levels of satisfaction in 8 of the 11 elements studied when compared with patients of allopathic physicians , chiropractors , and nonphysician clinicians other than chiropractors . Respondents perceived osteopathic manipulative treatment ( OMT ) to be beneficial for musculoskeletal disorders ( P < .001 ) . In addition , respondents perceived that healthcare services provided by osteopathic physicians were similar to those provided by allopathic physicians ( P < .001 ) , but not to those provided by chiropractors ( P = .01 ) . A total of 97.9 % of current patients of osteopathic physicians agreed with the statement that osteopathic physicians practice d in their local community , compared with 80.6 % of former patients of osteopathic physicians and 67.8 % of patients who had never visited osteopathic physicians ( P < .001 ) . In general , the most favorable perceptions of osteopathic medicine were reported by current patients of osteopathic physicians , followed by former patients of such physicians . The least favorable perceptions came from patients who had never been patients of osteopathic physicians . The perception that OMT should be covered by health insurance was significantly associated with the use of osteopathic physicians ( odds ratio , 3.2 ; 95 % confidence interval , 1.5 to 6.7 , among patients who had ever been to an osteopathic physician ) . The results of our survey suggest that greater access to osteopathic services , including OMT , is desirable and that promotional efforts aim ed at encouraging the use of osteopathic medical services among the general population are warranted Abstract This single-blind r and omised clinical trial compared osteopathic manipulative treatment with chemonucleolysis ( used as a control of known efficacy ) for symptomatic lumbar disc herniation . Forty patients with sciatica due to this diagnosis ( confirmed by imaging ) were treated either by chemonucleolysis or manipulation . Outcomes ( leg pain , back pain and self-reported disability ) were measured at 2 weeks , 6 weeks and 12 months . The mean values for all outcomes improved in both groups . By 12 months , there was no statistically significant difference in outcome between the treatments , but manipulation produced a statistically significant greater improvement for back pain and disability in the first few weeks . A similar number from both groups required additional orthopaedic intervention ; there were no serious complications . Crude cost analysis suggested an overall financial advantage from manipulation . Because osteopathic manipulation produced a 12-month outcome that was equivalent to chemonucleolysis , it can be considered as an option for the treatment of  symptomatic lumbar disc herniation  , at least in the absence of clear indications for surgery . Further study into the value of manipulation at a more acute stage is warranted Abstract Objective To assess the cost effectiveness of adding spinal manipulation , exercise classes , or manipulation followed by exercise ( “ combined treatment ” ) to “ best care ” in general practice for patients consulting with low back pain . Design Stochastic cost utility analysis alongside pragmatic r and omised trial with factorial design . Setting 181 general practice s and 63 community setting s for physical treatments around 14 centres across the United Kingdom . Participants 1287 ( 96 % ) of 1334 trial participants . Main outcome measures Healthcare costs , quality adjusted life years ( QALYs ) , and cost per QALY over 12 months . Results Over one year , mean treatment costs relative to “ best care ” were £ 195 ( $ 360 ; € 279 ; 95 % credibility interval £ 85 to £ 308 ) for manipulation , £ 140 ( £ 3 to £ 278 ) for exercise , and £ 125 ( £ 21 to £ 228 ) for combined treatment . All three active treatments increased participants ' average QALYs compared with best care alone . Each extra QALY that combined treatment yielded relative to best care cost £ 3800 ; in economic terms it had an “ incremental cost effectiveness ratio ” of £ 3800 . Manipulation alone had a ratio of £ 8700 relative to combined treatment . If the NHS was prepared to pay at least £ 10 000 for each extra QALY ( lower than previous recommendations in the United Kingdom ) , manipulation alone would probably be the best strategy . If manipulation was not available , exercise would have an incremental cost effectiveness ratio of £ 8300 relative to best care . Conclusions Spinal manipulation is a cost effective addition to “ best care ” for back pain in general practice . Manipulation alone probably gives better value for money than manipulation followed by exercise Back pain is a common illness and chiropractors provide a large proportion of back pain care in the United States . This is the first study to systematic ally compare  chiropractic patients with those who saw other providers for back pain . The authors analyzed data from the R AND Health Insurance Experiment , a community-based study of the use of health services . Insurance cl aims forms were examined for all visits specified by the patient as occurring for back pain . Visits were grouped into episodes using decision rules and clinical judgment . The primary provider of back pain care was defined as the provider who delivered most of the services . Sociodemographic and health status and attitudes variables of patients were examined for association with the choice of chiropractor . Multivariate logistic regression models were constructed to calculate adjusted odds ratios for independent predictors . There were 1020 episodes of back pain care made by 686 different persons and encompassing 8825 visits . Results indicated that chiropractors were the primary provider for 40 % of episodes , and retained as primary provider a greater percentage of their patients ( 92 % ) who had a second episode of back pain care than did medical doctors . Health insurance experiment site , white race , male sex , and high school education were independent predictors of choosing a chiropractor . Conclusions suggested that chiropractors were the choice of one third of all patients who sought back pain care , and provided care for 40 % of all episodes of care . Geographic site , education , gender , and income were independent patient factors predicting chiropractic use Fifty-four subjects volunteered to participate in a controlled study contrasting spinal manipulation with spinal mobilization without the rotational forces and leverage required to move facet joints . All suffered from regional low-back pain for less than 1 month , were ages 18–40 , had never previously undergone any form of spinal manipulation , and denied a prior episode of backache within the previous 6 months . R and omization was stratified at outset into those who suffered for less than 2 weeks and those whose discomfort had persisted for 2–4 weeks . Outcome was monitored by a question naire assessing functional impairment . A treatment effect of manipulation was demonstrated only in the strata with more prolonged illness at entry . In the first week following manipulation , these patients improved to a greater degree ( P=.009 , t test ) and more rapidly ( P < .025 , Wilcoxon rank-sum test ) 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 Previous studies have shown that dysmenorrhea produces low-back pain and an electromyographic ( EMG ) pattern typical of trauma-induced low-back pain . To determine the effects of high-velocity low-amplitude osteopathic manipulative treatment ( OMT ) on this type of low-back pain , 12 dysmenorrheic subjects were assigned to a group receiving OMT or to a group not receiving OMT ( or both ) . Eight subjects participated in both groups , the other four being equally distributed between groups . Osteopathic manipulative treatment significantly decreased EMG activity during extension of the lumbar spinae erector muscles and abolished the spontaneous EMG activity . These EMG changes coincided with the patient 's report of alleviated low-back pain and menstrual cramping .  Osteopathic manipulative treatment did not change the creatinine kinase , lactate dehydrogenase or lactate-dehydrogenase isoenzyme activity , or myoglobin concentration A r and omized clinical trial of rotational manipulation was conducted on 95 patients with low back pain selected for ( 1 ) the absence of any contraindications for vertebral manipulation , ( 2 ) the absence of any psychosocial problems that might affect the outcome of treatment , ( 3 ) the absence of any previous experience with manipulative therapy , and ( 4 ) the presence of palpatory cues indicating that manipulation might be successful . Patients were r and omly assigned to one of two groups : an experimental group receiving manipulation therapy and a control group receiving soft-tissue massage . Comparison of the two groups indicated that ( 1 ) patients who received manipulative treatment were much more likely to report immediate relief after the first treatment , and ( 2 ) at discharge , there was no significant difference between the two groups because both showed substantial improvement In a multicentre trial 456 selected patients with low back pain were r and omly allocated to one of four treatments-manipulation , definitive physiotherapy , corset , or analgesic tablets . Patients were reassessed clinical ly after three weeks ' treatment and again after a further three weeks . Question naires were used to find out 
    Output:
    
There were significant pain reductions with OMT regardless of whether trials were performed in the United Kingdom or the United States .
Significant pain reductions were also observed during short- , intermediate- , and long-term follow-up .
Conclusion OMT significantly  reduces low back pain .
The level of pain reduction is greater than expected from placebo effects alone and persists for at least three months .