***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: OBJECTIVES To compare outcomes in perception of pain and disability for a group of patients suffering with chronic low-back pain ( CLBP ) when managed in a hospital by either a regional pain clinic or a chiropractor .  DESIGN The study was a pragmatic , r and omized , controlled trial . SETTING The trial was performed at a National Health Service ( NHS ) hospital outpatient clinic ( pain clinic ) in the United Kingdom . SUBJECTS AND INTERVENTIONS Patients with CLBP ( i.e. , symptom duration of > 12 weeks ) referred to a regional pain clinic ( outpatient hospital clinic ) were assessed and r and omized to either chiropractic or pain-clinic management for a period of 8 weeks . The study was pragmatic , allowing for normal treatment protocol s to be used . Treatment was administered in an NHS hospital setting . OUTCOME MEASURES The Rol and -Morris Disability Question naire ( RMDQ ) and Numerical Rating Scale were used to assess changes in perceived disability and pain . Mean values at weeks 0 , 2 , 4 , 6 , and 8 were calculated . The mean differences between week 0 and week 8 were compared across the two treatment groups using Student 's t-tests . Ninety-five percent ( 95 % ) confidence intervals ( CIs ) for the differences between groups were calculated . RESULTS R and omization placed 12 patients in the pain clinic and 18 in the chiropractic group , of which 11 and 16 , respectively , completed the trial . At 8 weeks , the mean improvement in RMDQ was 5.5 points greater for the chiropractic group ( decrease in disability by 5.9 ) than for the pain-clinic group ( 0.36 ) ( 95 % CI 2.0 points to 9.0 points ; p = 0.004 ) . Reduction in mean pain intensity at week 8 was 1.8 points greater for the chiropractic group than for the pain-clinic group ( p = 0.023 ) . CONCLUSIONS This study suggests that chiropractic management administered in an NHS setting may be effective for reducing levels of disability and perceived pain during the period of treatment for a sub population of patients with CLBP 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 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 Our earlier findings suggest that patients with musculoskeletal complaints have lower numbers and percentages of natural killer ( NK ) cells than asymptomatic subjects . This study examines patient lymphocyte profiles , as a secondary outcome measure , in a trial of manipulative therapies to treat chronic low back pain ( LBP ) of mechanical origin . DESIGN The patients were compared in a r and omized controlled trial . Baseline measures were collected at the initial visit ; all patients were scheduled for 11 treatments in 14 days . Treatment consisted of either a high-force , high-velocity , low-amplitude manipulation procedure ; a low-force , high-velocity , low-amplitude procedure or a series of educational lectures on lower back pain . Posttreatment measures were collected at the final treatment session ; follow-up measures were obtained 2 wk later . SETTING The study was conducted at a chiropractic teaching clinic in the suburban Chicago area . PARTICIPANTS Individuals over 18 were eligible if they were new patients or repeat patients with a 6 month 's hiatus , if the chief complaint was LBP of greater than 50 days ' duration , if pain was elicited with palpation over one or more of the facet joints from the spinal levels between L1 and S1 and including the sacroiliac joints , and if there was absence of pain referral or if pain referral was only scleratogenous in nature . Criteria for excluding patients included hard neurologic signs , systemic disease potentially affecting the musculoskeletal system , contraindication to spinal manipulation such as osteoporosis , fracture or other bony pathology , or treatment with medication intended to relieve symptoms associated with their LBP . Eligibility was determined by a staff diagnostic team independent of the attending physician . Three hundred sixty-seven of 1,275 consecutive new patients met the eligibility criteria . Of these , 209 participated . These results are for 201 patients from whom flow cytometric data were obtained . OUTCOME MEASURES Both absolute numbers and percentages of B-lymphocytes , T-lymphocytes , T-Helper ( TH ) , T-Suppressor ( TS ) and NK lymphocytes were determined . Blood sample s were collected at the same time that the primary outcome measures were obtained . Cells were stained with two-color monoclonal antibodies directed against specific cell surface antigens , and each lymphocyte sub population was quantified directly from lysed whole blood with a Coulter Epics Profile II flow cytometer . RESULTS Thirty-five patients dropped out before the follow-up visit and technical problems result ed in the loss of data from 17 more and the exclusion of some sub population data . In all , 148 cases were analyzed for B cells , 146 for TH , TS and NK cells and 138 for cells that carried both the NK and TS marker . A one-way analysis of variance revealed no significant differences in the lymphocyte profiles at baseline among the three groups . All sub population baseline values were within reported reference ranges for normal adult population s. However , the percentage of NK cells ( 9.1 % ) was below the published minimum critical value . A repeated measures analysis of variance was used to determine whether treatment effects changed over time , that is , treatment-time interaction . The cell types for which the interaction tests were at or near statistical significance were : TH cells ( p = .0208 ) , total T cell percent ( p = .0928 ) and absolute total T cells ( p = .0908 ) . Interaction tests for differences in either percent or absolute counts of B cells , TS cells , or NK cells were not statistically significant . CONCLUSIONS This is the first report of lymphocyte profiles in patients with diagnosed chronic LBP . Our finding of a lower percentage of NK cells in these patients confirms our earlier finding that patients with musculoskeletal problems have a lower percentage of NK cells than do asymptomatic subjects . However , manipulative therapy was not shown to have a clinical ly significant effect on either the absolute Abstract The inability to predict outcome in patients with low back/neck pain leads to inappropriate or unnecessary treatment . The aims of the study were to identify prognostic factors for disability at 1‐year follow‐up in patients with back pain visiting primary care , and to compare the effect of these in two treatment strategies – chiropractic and physiotherapy . Data were taken from a r and omised trial on patients with back/neck pain visiting the general practitioner , in which patients were allocated to chiropractic and physiotherapy as primary management .  Three hundred and twenty‐three patients , aged 18–60 years , who had no contraindications to manipulation and who had not been treated within the previous month were included in the study . Multiple regression analysis was used to identify prognostic factors . Dependent variables were mean Oswestry score and mean change in Oswestry score at 12‐month follow‐up . The multiple regression analysis revealed five significant ( P<0.001–0.01 ) prognostic factors ; duration of current episode , Oswestry score at entry , expectations of treatment , number of localisations , and well‐being . Besides , the regression coefficients for the significant factors were compared between the two treatment strategies . No significant difference in effect or regression coefficients for the prognostic factors were seen between the two treatment strategies . Twelve per cent of the patients had poor prognostic factors ( duration ≥1 month , more than one localisation , low expectations of treatment and low well‐being ) at entry . These patients had a mean Oswestry score above 20 % at 1‐year follow‐up . Clinical decision models for the management of patients with back pain visiting primary care that consider prognostic factors need to be implemented and prospect ively evaluated Background Reporting numbers needed to treat ( NNT ) improves interpretability of trial results . It is unusual that continuous outcomes are converted to numbers of individual responders to treatment ( i.e. , those who reach a particular threshold of change ) ; and deteriorations prevented are only rarely considered . We consider how numbers needed to treat can be derived from continuous outcomes ; illustrated with a worked example showing the methods and challenges . Methods We used data from the UK BEAM trial ( n = 1 , 334 ) of physical treatments for back pain ; originally reported as showing , at best , small to moderate benefits . Participants were r and omised to receive ' best care ' in general practice , the  comparator treatment  ,  or one of three manual and /or exercise treatments : ' best care ' plus manipulation , exercise , or manipulation followed by exercise . We used established consensus thresholds for improvement in Rol and -Morris disability question naire scores at three and twelve months to derive NNTs for improvements and for benefits ( improvements gained+deteriorations prevented ) . Results At three months , NNT estimates ranged from 5.1 ( 95 % CI 3.4 to 10.7 ) to 9.0 ( 5.0 to 45.5 ) for exercise , 5.0 ( 3.4 to 9.8 ) to 5.4 ( 3.8 to 9.9 ) for manipulation , and 3.3 ( 2.5 to 4.9 ) to 4.8 ( 3.5 to 7.8 ) for manipulation followed by exercise . Corresponding between-group mean differences in the Rol and -Morris disability question naire were 1.6 ( 0.8 to 2.3 ) , 1.4 ( 0.6 to 2.1 ) , and 1.9 ( 1.2 to 2.6 ) points . Conclusion In contrast to small mean differences originally reported , NNTs were small and could be attract 
    Output:
    
There is varying quality of evidence ( ranging from low to high ) that SMT has a statistically significant short-term effect on pain relief and functional status when added to another intervention .
There is very low quality evidence that SMT is not statistically significantly more effective than inert interventions or sham SMT for short-term pain relief or functional status .
Data were particularly sparse for recovery , return-to-work , quality of life , and costs of care .
No serious complications were observed with SMT .
High quality evidence suggests that there is no clinical ly relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain .