***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: Study Design . A prospect i ve r and omized controlled trial . Objectives . To examine the effectiveness of combined manipulative treatment , stabilizing exercises , and physician consultation compared with physician consultation alone for chronic low back pain . Summary of Background Data . Strong evidence exists that manual therapy provides more effective short-term pain relief than does placebo treatment in the management of chronic low back pain . The evidence for long-term effect is lacking . Methods . Two hundred four chronic low back pain patients , whose Oswestry disability index was at least 16 % , were r and omly assigned to either a manipulative-treatment group or a consultation group . All were clinical ly examined , informed about their back pain , provided with an educational booklet , and were given specific instructions based on the clinical evaluation . The treatment included four sessions of manipulation and stabilizing exercises aim ing to correct the lumbopelvic rhythm . Question naires inquired about pain intensity , self-rated disability , mental depression , health-related quality of life , health care costs , and production costs . Results . At the baseline , the groups were comparable , except for the percentage of employees ( P = 0.01 ) . At the 5- and 12-month follow-ups , the manipulative-treatment group showed more significant reductions in pain intensity ( P < 0.001 ) and in self-rated disability ( P = 0.002 ) than the consultation group . However , we detected no significant difference between the groups in health-related quality of life or in costs . Conclusions . The manipulative treatment with stabilizing exercises was more effective in reducing pain intensity and disability than the physician consultation alone . The present study showed that short , specific treatment programs with proper patient information may alter the course of chronic low back pain 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 OBJECTIVE The purpose of this study was to evaluate the pain/pressure threshold of selected myofascial points in subjects with chronic mechanical back pain after a single manipulation or mobilization . DESIGN The study design was a r and omized control trial . SETTING Chiropractic College outpatient clinic . PARTICIPANTS Thirty subjects aged 18 - 50 yr ( mean age 31 yr , SD = 7 yr ) with chronic mechanical low back pain ( mean duration of pain 74 months , SD = 83 months ) were r and omized into two groups . One group received a manipulation and the other received a mobilization . OUTCOME MEASURE Pain/pressure threshold of selected myofascial points were measured before , immediately after , and 15 and 30 min postintervention . RESULTS Sixteen patients were allocated to the manipulation group and 14 to the mobilization group . Repeated measured analysis of variance for all locations failed to show clinical or statistical significance ( p > .287 ) . The overall effect between treatments and the interaction between treatment and time was not significant ( p > .268 ) . CONCLUSION The absence of significant changes may be attributed to the selection of myofascial points , the instrument sensitivity to small changes , the differences in baseline measures and the absence of effect from one intervention The purpose of this study was to assess the effects of two different treatment modalities on the rehabilitation process of chronic sacroiliac joint patients . The treatment modalities included spinal manipulative therapy given by a chiropractor and a program of back school therapy given by a physiotherapist . The rehabilitation process was assessed using clinical and biomechanical measures . It was found that back school therapy was a better treatment modality than the spinal manipulative therapy , according to the clinical measures of rehabilitation . Precisely the opposite result was found for the biomechanical measures Ninety-four patients with non-specific lumbar pain referred to hospital rheumatology and orthopaedic clinics participated in a double-blind controlled trial comparing mobilisation and manipulation with placebo physiotherapy . Results were assessed immediately after the tratment course , two months later , and at one year . Many patients showed improvement , but in contrast to a study on general-practitioner patients with nonspecific back pain no definite advantage could be associated with mobilisation and manipulation . The benefits of mobilisation and manipulation for low back pain are probably restricted to hastening recovery in patients likely rapidly to improve spontaneously . Hence patients whose severity and duration of symptoms warrant specialist referral are less likely to benefit from the technique Spinal trunk list is a common occurrence in clinical practice , but few conservative methods of spinal rehabilitation have been reported . This study is a non-r and omized clinical control trial of 63 consecutive retrospective subjects undergoing spinal rehabilitation and 23 prospect i ve volunteer controls . All subjects presented with lateral thoracic-cage-translation posture ( trunk list ) and chronic low back pain . Initial and follow-up numerical pain rating scales ( NRS ) and AP lumbar radiographs were obtained after a mean of 11.5 weeks of care ( average of 36 visits ) for the treatment group and after a mean of 37.5 weeks for the control group . The radiographs were digitized and analyzed for a horizontal displacement of T12 from the second sacral tubercle , verticality of the lumbar spine at the sacral base , and any dextro/levo angle at mid-lumbar spine . Treatment subjects received the Harrison mirror image postural correction methods , which included an opposite trunk-list exercise and a new method of opposite trunk-list traction . Control subjects did not receive spinal rehabilitation therapy , but rather self-managed their back pain . For the treatment group , there were statistically significant improvements ( approximately 50 % ) in all radiographic measurements and a decrease in pain intensity ( NRS : 3.0 to 0.8 ) . For the control group , no significant radiographic and NRS differences were found , except in trunk-list displacement of T12 to S1 , worsened by 2.4 mm . Mirror image ( opposite posture ) postural corrective exercises and a new method of trunk-list traction result ed in 50 % reduction in trunk list and were associated with nearly resolved pain intensity in this patient population . The findings warrant further study in the conservative treatment of chronic low back pain and spinal disorders OBJECTIVE To determine whether traditional bone- setting or continuous light exercise therapy could case back pain and improve function better than ordinary physiotherapy . DESIGN Observer-blinded , r and omized clinical trial with a 6-month follow-up . SETTING An outpatient institution for folk medicine research . PATIENTS Of 147 back pain patients recruited from local health centers and by newspaper announcements , 132 were found eligible ( non-retired-no contraindications to manipulation ) and entered . A final 114 ( one dropout ) with back pain for longer than 7 weeks were included in this intent to treat analysis . INTERVENTIONS Bone- setting , guidance for continuous light back movements or physiotherapy for up to ten 1-hour sessions during 6 weeks . MAIN OUTCOME MEASURES Spinal mobility and muscular performance . Back pain assessed by visual analog scales ( VAS ) . RESULTS The physical measures changed only modestly , from one tenth to half of st and ard deviation , while the VAS was halved . The thoracolumbar side-bending , the modified Schober , and the VAS were significantly better improved by bone- setting than by exercise but not better than by physiotherapy . CONCLUSION Neither bone- setting nor exercise differed significantly from physiotherapy , but bone- setting improved lateral and forward bending of the spine and back pain more than did exercise 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 ) OBJECTIVE This paper provides descriptive data on  chiropractors  , their practice , and their patients in North America in the past decade . METHOD Five sites in the United States and 1 in Canada were chosen , and a r and om sample of chiropractors was interviewed . In each practice , 10 patients were systematic ally selected on a single day . A total of 131 chiropractors and 1275 patients were interviewed . SUMMARY The results suggest that doctors of chiropractic have firmly established themselves within the health care system in the United States and Canada and are able to attract patients who come to them directly for treatment , for largely back-related conditions , and who are willing to pay for their care BACKGROUND The prescription of exercise as a conservative treatment for lumbar pain is frequent and seems effective for the chronic cases of nonspecific low back pain . However , there is no evidence favoring one type of exercise over another . Often , exercise programs are prescribed without adequate evaluation of the individual characteristics like posture , muscular force , and extensibility . Patients with totally different causes of low back pain will often be given the same type of exercises . OBJECTIVE Our objective was to compare the effectiveness of 2 home exercise programs in decreasing disability and pain related to subacute and chronic nonspecific low back pain . To do so we compared a specific ( individualized ) exercise program with a program of commonly prescribed exercises for low back pain . METHOD In a control group study , 20 patients with chronic or subacute nonspecific low back pain participated after giving their informed consent . All subjects were evaluated ( physical evaluation of lumbar and pelvic muscles [ 1 ] force and [ 2 ] extensibility , [ 3 ] trunk range of motion ) and then divided in 2 groups : 10 patients received specific exercises ( experimental group ) based on their evaluation , and 10 patients received a commonly prescribed exercise program for low back pain ( control group ) . Six weeks later a second physical evaluation was conducted . Pain ( visual analog pain scale ) and disability ( modified Oswestry ) question naires were also completed by each subject at both evaluations . DESIGN This was a r and omized experimental study . RESULTS Both groups had similar age , weight , and sex characteristics . The experimental group showed significant improvements for some components targeted by the program . The control group significantly had improvement of some physical characteristics not related to their initial deficits . Even if both groups showed some improvements in muscular force and extensibility , only the members of the group who received specific exercises significantly reduced their level of pain and disability . Both groups showed a similar rate of participation in the program . CONCLUSION The results of this study suggest that applying a specific physical evaluation and exercise prescription is an appropriate treatment for people having subacute or chronic nonspecific pain . Thus clinicians should prescribe exercise programs based on individual muscular deficits rather than most commonly prescribed exercise programs Reprinted with permission from the British Medical Journal 300:1431 - 1437.1990 . Objective - To compare chiropractic and hospital outpatient treatment for managing low back pain of mechanical origin . Design - R and omized controlled trial . Allocation to chiropractic or hospital management by minimization to establish groups for analysis of results according to initial referral clinic , length of current episode , history , and severity of back pain . Patients were followed up for up to two years . Setting - Chiropractic and hospital outpatient clinics in 11 centers . Patients - 741 patients aged 18 - 65 who had no contraindications to manipulation and who had not been treated within the past month . Interventions - Treatment at the discretion of the chiropractors , who used chiropractic manipulation in most patients , or of the hospital staff , who most commonly used Maitl and mobilization or manipulation , or both . Main outcome measures - Changes in the score on the Oswestry pain disability question naire and in the results of tests of straight leg raising and lumbar flexion . Results - Chiropractic treatment was more effective than hospital outpatient management , mainly for patients with chronic or severe back pain . A benefit of about 7 percent points on the Oswestry scale was seen at two years . The benefit of chiropractic treatment became more evident throughout the follow-up period . Secondary outcome measures also showed that chiropractic was more beneficial . Conclusions - For patients with low back pain in whom manipulation is not contraindicated , chiropractic almost certainly confers worthwhile , long-term benefit in comparison with hospital outpatient management . The benefit is seen mainly in those with chronic or severe pain . Introducing chiropractic into NHS practice should be considered . J Orthop Sports Phys Ther 1991;13(6):278 - 287 BACKGROUND CONTEXT Although many research ers and practitioners believe that patients ' positive expectations of their treatment favorably influence clinical outcomes , there is little scientific evidence to support this belief . PURPOSE To describe the level of patients ' initial confidence in the success of their assigned treatment , 
    Output:
    
As much or more evidence exists for the use of spinal manipulation to reduce symptoms and improve function in patients with chronic LBP as for use in acute and subacute LBP .
Use of exercise in conjunction with  manipulation  is likely to speed and improve outcomes as well as minimize episodic recurrence .
There was less evidence for the use of manipulation for patients with LBP and radiating leg pain , sciatica , or radiculopathy