***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: OBJECTIVE To establish the short-term effects of lumbar posteroanterior mobilization in patients with low-back pain , compared with a control intervention . DESIGN Self-controlled cross-over design . MAIN OUTCOME MEASURES The force-displacement characteristics of the spine in response to the application of a posteroanterior force , lumbar flexion , and extension range of movement ; pain during flexion , extension , and on worst movement ; pain on posteroanterior loading ; and overall pain relief . PATIENTS Twenty-six patients with nonspecific low-back pain who experienced pain on flexion or extension and whose pain settled quickly after provocation , from a physiotherapy clinic and university campus . METHODS Patients received posteroanterior mobilization and a control intervention in an order that was r and omly allocated . The magnitude of force in treatment dose was selected by the treating physiotherapist . An observer who was blinded to the order of interventions performed all measurements . Outcome measures were recorded before and after each intervention , and change scores were calculated to quantify the effect of the intervention . RESULTS No significant differences were found between the mobilization and control interventions in relation to posteroanterior response or range of movement . The score for pain on worst movement showed significantly greater improvement for the mobilization than for the control procedure . CONCLUSIONS Lumbar posteroanterior mobilization was not observed to produce any objective ly measurable change in the mechanical behavior of the lumbar spine of patients with low-back pain . Improvement in some pain variables was observed in comparison with a control procedure , but this may be due to a placebo effect 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 OBJECTIVES The purpose of this study was to compare the outcomes of patients with low back pain who had a matched , unmatched , or were indifferent with their pretreatment expectation/preference to the manual therapy thrust or nonthrust intervention .  A secondary purpose was to explore baseline patient characteristics affiliated with a preference of manual therapy treatment type ( thrust or nonthrust manipulation ) . METHODS The study is a secondary analysis of a prospect i ve r and omized controlled trial that enrolled 149 patients with low back pain , from 16 distinct outpatient physical therapy practice s within the United States . Patient 's pretreatment expectations were identified before r and omization . The intervention included manual therapy ( thrust or nonthrust manipulation ) with a st and ardized exercise program , which was carried out for 2 treatment sessions . Six outcomes captured the constructs of ( a ) disability , ( b ) pain perception , ( c ) care intensity , ( d ) fear avoidance behaviors , and ( e ) perception of extent of recovery . Descriptive statistics , analysis of variance ( and Tukey , a post hoc test ) , Fisher exact test , and a multivariate logistic regression analysis were used for analysis . RESULTS There were no statistical differences in any of the 6 dedicated outcomes measures between the matched , unmatched , and no preference groups . Therapist-determined patient " irritability " was associated with patient preference of nonthrust treatment , and higher body mass index was associated with patient preference of thrust treatment . CONCLUSIONS This study shows that patients demonstrated no statistical difference in disability or pain outcome measures when matched , unmatched , or indifferent to the intervention 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 The purpose of this study was to investigate the comparative effectiveness of early use of thrust ( TM ) and non-thrust manipulation ( NTM ) in sample of patients with mechanical low back pain ( LBP ) . The r and omized controlled trial included patients with mechanically reproducible LBP , ≥ age 18-years who were r and omized into two treatment groups . The main outcome measures were the Oswestry Disability Index ( ODI ) and a Numeric Pain Rating Scale ( NPRS ) , with secondary measures of Rate of Recovery , total visits and days in care , and the work subscale of the Fears Avoidance Beliefs Question naire work subscale ( FABQ-w ) . A two-way mixed model MANCOVA was used to compare ODI and pain , at baseline , after visit 2 , and at discharge and total visits , days in care , and rate of recovery ( while controlling for patient expectations and clinical equipoise ) . A total of 149 subjects completed the trial and received care over an average of 35 days . There were no significant differences between TM and NTM at the second visit follow-up or at discharge with any of the outcomes categories . Personal equipoise was significantly associated with ODI and pain . The findings suggest that there is no difference between early use of TM or NTM , and secondarily , that personal equipoise affects study outcome . Within-groups changes were significant for both groups Background : Non-specific chronic low back pain disorders have been proven resistant to change , and there is still a lack of clear evidence for one specific treatment intervention being superior to another . Methods : This r and omized controlled trial aim ed to investigate the efficacy of a behavioural approach to management , classification-based cognitive functional therapy , compared with traditional manual therapy and exercise . Linear mixed models were used to estimate the group differences in treatment effects . Primary outcomes at 12-month follow-up were Oswestry Disability Index and pain intensity , measured with numeric rating scale .  Inclusion criteria were as follows : age between 18 and 65 years , diagnosed with non-specific chronic low back pain for > 3 months , localized pain from T12 to gluteal folds , provoked with postures , movement and activities . Oswestry Disability Index had to be > 14 % and pain intensity last 14 days > 2/10 . A total of 121 patients were r and omized to either classification-based cognitive functional therapy group n = 62 ) or manual therapy and exercise group ( n > = 59 ) . Results : The classification-based cognitive functional therapy group displayed significantly superior outcomes to the manual therapy and exercise group , both statistically ( p < 0.001 ) and clinical ly . For Oswestry Disability Index , the classification-based cognitive functional therapy group improved by 13.7 points , and the manual therapy and exercise group by 5.5 points . For pain intensity , the classification-based cognitive functional therapy improved by 3.2 points , and the manual therapy and exercise group by 1.5 points . Conclusions : The classification-based cognitive functional therapy produced superior outcomes for non-specific chronic low back pain compared with traditional manual therapy and exercise 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 In a r and omized clinical trial to assess the effectiveness of different strategies for treating low-back pain in a managed-care setting , 681 adult patients presenting with low-back pain were r and omized to four treatment groups : medical care with and without physical therapy ; and chiropractic care with and without physical modalities . Follow-up information was obtained by question naires at two and six weeks , six , 12 and 18 months and by a telephone interview at four weeks . One outcome measurement at each follow-up is the patient ’s self-report on the perception of low-back pain improvement from the previous survey , recorded as ‘ A lot better , ’ ‘ A little better , ’ ‘ About the same ’ and ‘ Worse . ’ Since the patient ’s perception of improvement may be influenced by past experience , the outcome is analysed using a transition ( first-order Markov ) model . Although one could collapse categories to the point that logistic regression analysis with repeated measurements could be used , here we allow for multiple 
    Output:
    
There is moderate- quality evidence that manipulation and mobilization are likely to reduce pain and improve function for patients with chronic low back pain ;  manipulation appears to produce a larger effect than mobilization .
Both therapies appear safe .