***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 Low back pain ( LBP ) , with high incidence and prevalence rate , is one of the most common reasons to consult the health system and is responsible for a significant amount of sick leave , leading to high health and social costs . The objective of the study is to assess the cost-effectiveness and cost-utility analysis of a multidisciplinary biopsychosocial educational group intervention ( MBEGI ) of non-specific sub-acute LBP in comparison with the usual care in the working population recruited in primary healthcare centres . Methods / design The study design is a cost-effectiveness and cost-utility analysis of a MBEGI in comparison with the usual care of non-specific sub-acute LBP . Measures on effectiveness and costs of both interventions will be obtained from a cluster r and omised controlled clinical trial carried out in 38 Catalan primary health care centres , enrolling 932 patients between 18 and 65 years old with a diagnosis of non-specific sub-acute LBP . Effectiveness measures are : pharmaceutical treatments , work sick leave ( % and duration in days ) , Rol and Morris disability , McGill pain intensity , Fear Avoidance Beliefs ( FAB ) and Golberg Question naires . Utility measures will be calculated from the SF-12 . The analysis will be performed from a social perspective . The temporal horizon is at 3 months ( change to chronic LBP ) and 12 months ( evaluate the outcomes at long term ) . Assessment of outcomes will be blinded and will follow the intention-to-treat principle . Discussion We hope to demonstrate the cost-effectiveness and cost-utility of MBEGI , see an improvement in the patients ' quality of life , achieve a reduction in the duration of episodes and the chronicity of non-specific low back pain , and be able to report a decrease in the social costs . If the intervention is cost-effectiveness and cost-utility , it could be applied to Primary Health Care Centres . Trial registration IS RCT N : IS RCT Abstract Objective To compare the effects of a minimal intervention strategy aim ed at assessment and modification of psychosocial prognostic factors and usual care for treatment of (sub)acute low back pain in general practice . Design Cluster r and omised clinical trial . Setting 60 general practitioners in 41 general practice s. Participants 314 patients with non-specific low back pain of less than 12 weeks ' duration , recruited by their general practitioner . Interventions In the minimal intervention strategy group the general practitioner explored the presence of psychosocial prognostic factors , discussed these factors , set specific goals for reactivation , and provided an educational booklet . The consultation took about 20 minutes . Usual care was not st and ardised . Main outcome measures Functional disability ( Rol and -Morris disability question naire ) , perceived recovery , and sick leave because of low back pain assessed at baseline and after 6 , 13 , 26 , and 52 weeks . Results The dropout rate was 8 % in the minimal intervention strategy group and 9 % in the usual care group . Multilevel analyses showed no significant differences between the groups on any outcome measure during 12 months of follow-up in the whole group or in relevant subgroups ( patients with high scores on psychosocial measures at baseline or a history of frequent or prolonged low back pain ) . Conclusion This study provides no evidence that ( Dutch ) general practitioners should adopt our new treatment strategy aim ed at psychosocial prognostic factors in patients with (sub)acute low back pain . Further research should examine why our new strategy was not more effective than usual care Objectives To evaluate the risk of bias tool , introduced by the Cochrane Collaboration for assessing the internal validity of r and omised trials , for inter-rater agreement , concurrent validity compared with the Jadad scale and Schulz approach to allocation concealment , and the relation between risk of bias and effect estimates . Design Cross sectional study . Study sample 163 trials in children . Main outcome measures Inter-rater agreement between review ers assessing trials using the risk of bias tool ( weighted κ ) , time to apply the risk of bias tool compared with other approaches to quality assessment ( paired t test ) , degree of correlation for overall risk compared with overall quality scores ( Kendall ’s τ statistic ) , and magnitude of effect estimates for studies classified as being at high , unclear , or low risk of bias ( metaregression ) . Results Inter-rater agreement on individual domains of the risk of bias tool ranged from slight ( κ=0.13 ) to substantial ( κ=0.74 ) . The mean time to complete the risk of bias tool was significantly longer than for the Jadad scale and Schulz approach , individually or combined ( 8.8 minutes ( SD 2.2 ) per study v 2.0 ( SD 0.8 ) , P<0.001 ) . There was low correlation between risk of bias overall compared with the Jadad scores ( P=0.395 ) and Schulz approach ( P=0.064 ) . Effect sizes differed between studies assessed as being at high or unclear risk of bias ( 0.52 ) compared with those at low risk ( 0.23 ) . Conclusions Inter-rater agreement varied across domains of the risk of bias tool . Generally , agreement was poorer for those items that required more judgment . There was low correlation between assessment s of overall risk of bias and two common approaches to quality assessment : the Jadad scale and Schulz approach to allocation concealment . Overall risk of bias as assessed by the risk of bias tool differentiated effect estimates , with more conservative estimates for studies at low risk The results of a multicentered r and omised clinical trial are reported of bed rest and of a physiotherapy and education programme for patients who presented in family practice with an acute episode of low back pain . No beneficial effect of either treatment was observed on several clinical outcome measures , including straight leg raising , lumbar flexion , activities of daily living , and pain . In fact the results favoured early mobilisation over bed rest and suggested that the physiotherapy and education programme was doing more harm than good . Moreover , additional analyses , which focused on clinical ly interesting patient subgroups , discovered no subset of patients who benefited from either of the treatments under study . Having failed to identify any clinical ly important benefits , or other explanations for these negative results , we can only conclude that family doctors have little reason to prescribe either bed rest or isometric exercises to patients who suffer from low back pain Forty patients with acute mechanical low-back pain were treated in a double-blind manner with either Rado-Salil ® or placebo for 14 days . Statistically significant improvements in spontaneous pain , muscular contracture and in both the patient 's and physician 's opinions occurred by day 3 . These improvements persisted at day 14 and , in addition , there were statistically significant improvements in the finger – floor distance and the degree of lumbar extension . Treatment with Rado-Salil ® also allowed significant reduction in the use of oral analgesics . Only a few localized transient side-effects , requiring no specific treatment , were observed OBJECTIVES Verbally administered numerical rating scales ( NRSs ) from 0 to 10 are often used to measure pain , but they have not been vali date d in the emergency department ( ED ) setting . The authors wished to assess the comparability of the NRS and  visual analog scale ( VAS )  as measures of acute pain , and to identify the minimum clinical ly significant difference in pain that could be detected on the NRS . METHODS This was a prospect i ve cohort study of a convenience sample of adults presenting with acute pain to an urban ED . Patients  verbally rated pain intensity as an integer from 0 to 10 ( 0 = no pain , 10 = worst possible pain ) , and marked a 10-cm horizontal VAS bounded by these descriptors .  VAS and NRS data were obtained at presentation , 30 minutes later , and 60 minutes later . At 30 and 60 minutes , patients were asked whether their pain was " much less , " " a little less , " " about the same , " " a little more , " or " much more . " Differences between consecutive pairs of measurements on the VAS and NRS obtained at 30-minute intervals were calculated for each of the five categories of pain descriptor . The association between VAS and NRS scores was expressed as a correlation coefficient . The VAS scores were regressed on the NRS scores in order to assess the equivalence of the measures . The mean changes associated with descriptors " a little less " or " a little more " were combined to define the minimum clinical ly significant difference in pain measured on the VAS and NRS . RESULTS Of 108 patients entered , 103 provided data at 30 minutes and 86 at 60 minutes . NRS scores were strongly correlated to VAS scores at all time periods ( r = 0.94 , 95 % CI = 0.93 to 0.95 ) . The slope of the regression line was 1.01 ( 95 % CI = 0.97 to 1.06 ) and the y-intercept was -0.34 ( 95 % CI = -0.67 to -0.01 ) . The minimum clinical ly significant difference in pain was 1.3 ( 95 % CI = 1.0 to 1.5 ) on the NRS and 1.4 ( 95 % CI = 1.1 to 1.7 ) on the VAS . CONCLUSIONS The findings suggest that the verbally administered NRS can be substituted for the VAS in acute pain measurement OBJECTIVE To evaluate of the efficacy and safety of 8 hours of continuous , low-level heatwrap therapy administered during sleep . DESIGN Prospect i ve , r and omized , parallel , single-blind ( investigator ) , placebo-controlled , multicenter clinical trial . SETTING Two community-based research facilities . PARTICIPANTS Seventy-six patients , aged 18 to 55 years , with acute , nonspecific low back pain . INTERVENTIONS Subjects were stratified by baseline pain intensity and gender and r and omized to one of the following treatments : evaluation of efficacy ( heatwrap , n=33 ; oral placebo , n=34 ) or blinding ( unheated wrap , n=5 ; oral ibuprofen , n=4 ) . All treatments were administered for 3 consecutive nights with 2 days of follow-up . MAIN OUTCOME MEASURES Primary : morning pain relief ( hour 0 ) on days 2 through 4 ( 0 - 5-point verbal response scale ) . Secondary : mean daytime pain relief score ( days 2 - 4 , hours 0 - 8 ) , mean extended pain relief score ( day 4 , hour 0 ; day 5 , hour 0 ) , muscle stiffness , lateral trunk flexibility , and disability ( Rol and -Morris Disability Question naire ) . RESULTS Heatwrap therapy was significantly better than placebo at hour 0 on days 2 through 4 for mean pain relief ( P=.00005 ) ; at hours 0 through 8 on days 2 through 4 for pain relief ( P<.001 ) ; at hour 0 on day 4 and at hour 0 on day 5 for mean pain relief ( P<.001 ) ; on day 4 in reduction of morning muscle stiffness ( P<.001 ) ; for increased lateral trunk flexibility on day 4 ( P<.002 ) ; and for decreased low back disability on day 4 ( P=.005 ) . Adverse events were mild and infrequent . CONCLUSIONS Overnight use of heatwrap therapy provided effective pain relief throughout the next day , reduced muscle stiffness and disability , and improved trunk flexibility . Positive effects were sustained more than 48 hours after treatments were completed Background . The management of common low back pain has two principal objectives : to relieve acute pain and to attempt prevention of transition to chronicity . Several studies have shown the ineffectiveness of prolonged periods of bed rest . Objective . To compare 4 days of bed rest with continued normal daily activity in acute low back pain , taking into account the type of work ( physical or sedentary labor ) . Methods . This open , comparative multicenter study enrolled 281 ambulatory patients , ages 18 to 65 years , with low back pain ( onset < 72 hours ) . The subjects did not have pain radiating below the buttocks and did not have work-related injuries . They were r and omized into two treatment groups : one instructed to continue normal activity ( insofar as the pain allowed ) , and the other prescribed 4 days of bed rest . After inclusion , patients were seen at three visits : on day 6 or 7 , after 1 month , and after 3 months . Results . On day 6 or 7 , pain intensity was similar for both groups , as was the overall judgment of the treatment by patients and physicians . At 1 and 3 months , the groups again had equivalent intensity of back pain , functional disability , and vertebral stiffness . A higher proportion of patients in the bed rest group than in the normal activity group had an initial sick leave ( 86%vs 52%;P < 0.0001 ) . This difference was greater for the patients whose work was sedentary . Conclusions . For patients with acute low back pain , normal activity is at least equivalent to bed rest . The findings of this study indicate that prescriptions for bed rest , and thus for sick leaves , should be limited when the physical dem and s of the job are similar to those for daily life activities OBJECTIVE To evaluate the short-term effect of physical exercise and a cognitive intervention in low back pain . DESIGN R and omized controlled trial . SUBJECTS Ninety-three patients sick-listed for 8 - 12 weeks for sub-acute low back pain were r and omized to an exercise regime ( n = 30 ) , a cognitive intervention ( n = 34 ) or a control group ( n = 29 ) . METHODS Primary outcome measures were pain , disability , sick-listing and satisfaction with care . Secondary outcome measures were self-efficacy for pain and for function , fear-avoidance beliefs , emotional distress , generic health status and life satisfaction . RESULTS Eighteen percent of subjects dropped out . Drop-out was most frequent in the exercise group . At 18 weeks after inclusion fear-avoidance beliefs were reduced in both intervention groups . The cognitive group demonstrated significant improvement in disability , self-efficacy for pain , emotional distress , general health and life satisfaction . Patients in the exercise group were significantly more satisfied with the treatment , and patients following the exercise protocol reduced pain significantly . No effect 
    Output:
    
PERSPECTIVE There is limited evidence that nonsteroidal anti-inflammatory drugs , heat wrap , and rubefacients provide immediate pain relief for acute back pain and that bed rest and advice are both ineffective .