***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: & NA ; • STUDY DESIGN : Controlled laboratory study . • BACKGROUND : Spinal manipulation ( SM ) can trigger a cascade of responses involving multiple systems , including the sympathetic nervous system and the endocrine system , specifically , the hypothalamic‐pituitary axis . However , no manual therapy study has investigated the neuroendocrine response to SM ( ie , sympathetic nervous system‐hypothalamic‐pituitary axis ) in the same trial . • OBJECTIVE : To determine short‐term changes in sympathetic nervous system activity , heart rate variability , and endocrine activity ( cortisol , testosterone , and testosterone‐cortisol [ T/C ] ratio ) following a thoracic SM . • METHODS : Twenty‐four healthy men aged between 18 and 45 years were r and omized into 2 groups :  thoracic SM ( n = 12 ) and sham ( n = 12 ) . Outcome measures were salivary cortisol ( micrograms per deciliter ) , salivary testosterone ( picograms per milliliter ) , T/C ratio , heart rate variability , and changes in oxyhemoglobin concentration of the right calf muscle ( micromoles per liter ) . Measurements were done before and at 5 minutes , 30 minutes , and approximately 6 hours after intervention . • RESULTS : A statistically significant group‐by‐time interaction was noted for T/C ratio ( P<.05 ) and salivary cortisol ( P<.01 ) concentrations . Significant between‐group differences were noted for salivary cortisol concentration at 5 minutes ( mean difference , 0.35 ; 95 % confidence interval : 0.12 , 0.6 ; interaction : P<.01 ) and for T/C ratio at 6 hours postintervention ( mean difference , ‐0.09 ; 95 % confidence interval : ‐0.16 , ‐0.04 ; P = .02 ) . However , SM did not differentially alter oxyhemoglobin , testosterone , or heart rate variability relative to responses in the sham group . • CONCLUSION : Thoracic SM result ed in an immediate decrease in salivary cortisol concentration and reduced T/C ratio 6 hours after intervention . A pattern of immediate sympathetic excitation was also observed in the SM group . • KEY WORDS : autonomic nervous system , cortisol , spinal manipulation , sympathetic nervous system , BACKGROUND Some normotensive patients can have a spike in resting systolic blood pressure ( SBP ) in response to acute neck pain . Applying the typical dosage of mobilization may potentially result in a sympatho-excitatory response , further increasing resting SBP . Therefore , there is a need to explore other dosage regimens that could result in a decrease in SBP . OBJECTIVES To compare the blood pressure ( BP ) and heart rate ( HR ) response of pain-free , normotensive adults when receiving unilateral posterior-to-anterior mobilization ( PA ) applied to the neck versus its corresponding placebo ( PA-P ) . STUDY DESIGN Double-Blind , R and omized Clinical Trial . METHODS 44 ( 18 females ) healthy , pain-free participants ( mean age , 23.8 ± 3.04 years ) were r and omly allocated to 1 of 2 groups . Group 1 received a PA-P in which light touch was applied to the right 6th cervical vertebra . Group 2 received a PA to the same location . BP and HR were measured prior to , during , and after the application of PA or PA-P. A mixed-effect model of repeated measure analysis was used for statistical analysis . RESULTS During-intervention , the PA group had a significant reduction in SBP , while the placebo group had an increase in SBP . The change in SBP during-intervention was significantly different between the PA and the placebo group ( p-value = 0.003 ) . There were no significant between-group differences found for HR and diastolic BP ( DBP ) . The overall group-by-time interaction was statistically significant for SBP ( p-value = 0.01 ) . CONCLUSIONS When compared to placebo , the dosage of applied PA result ed in a small , short-lived drop in SBP not exceeding the minimal detectable change . Trial registered at Germanctr.de ( DRKS00005095 ) Overwhelming evidence shows the quality of reporting of r and omised controlled trials ( RCTs ) is not optimal . Without transparent reporting , readers can not judge the reliability and validity of trial findings nor extract information for systematic review s. Recent method ological analyses indicate that inadequate reporting and design are associated with biased estimates of treatment effects . Such systematic error is seriously damaging to RCTs , which are considered the gold st and ard for evaluating interventions because of their ability to minimise or avoid bias . A group of scientists and editors developed the CONSORT ( Consoli date d St and ards of Reporting Trials ) statement to improve the quality of reporting of RCTs . It was first published in 1996 and up date d in 2001 . The statement consists of a checklist and flow diagram that authors can use for reporting an RCT . Many leading medical journals and major international editorial groups have endorsed the CONSORT statement . The statement facilitates critical appraisal and interpretation of RCTs . During the 2001 CONSORT revision , it became clear that explanation and elaboration of the principles underlying the CONSORT statement would help investigators and others to write or appraise trial reports . A CONSORT explanation and elaboration article was published in 2001 alongside the 2001 version of the CONSORT statement . After an expert meeting in January 2007 , the CONSORT statement has been further revised and is published as the CONSORT 2010 Statement . This up date improves the wording and clarity of the previous checklist and incorporates recommendations related to topics that have only recently received recognition , such as selective outcome reporting bias . This explanatory and elaboration document-intended to enhance the use , underst and ing , and dissemination of the CONSORT statement-has also been extensively revised . It presents the meaning and rationale for each new and up date d checklist item providing examples of good reporting and , where possible , references to relevant empirical studies . Several examples of flow diagrams are included . The CONSORT 2010 Statement , this revised explanatory and elaboration document , and the associated website ( www.consort-statement.org ) should be helpful re sources to improve reporting of r and omised trials Background This systematic review up date d and extended the " UK evidence report " by Bronfort et al. ( Chiropr Osteopath 18:3 , 2010 ) with respect to conditions/ interventions that received an ' inconclusive ’ or ' negative ’ evidence rating or were not covered in the report . Methods A literature search of more than 10 general medical and specialised data bases was conducted in August 2011 and up date d in March 2013 . Systematic review s , primary comparative studies and qualitative studies of patients with musculoskeletal or non-musculoskeletal conditions treated with manual therapy and reporting clinical outcomes were included . Study quality was assessed using st and ardised instruments , studies were summarised , and the results were compared against the evidence ratings of Bronfort . These were either confirmed , up date d , or new categories not assessed by Bronfort were added . Results 25,539 records were found ; 178 new and additional studies were identified , of which 72 were systematic review s , 96 were r and omised controlled trials , and 10 were non-r and omised primary studies . Most ' inconclusive ’ or ' moderate ’ evidence ratings of the UK evidence report were confirmed . Evidence ratings changed in a positive direction from inconclusive to moderate evidence ratings in only three cases ( manipulation/mobilisation [ with exercise ] for rotator cuff disorder ; spinal mobilisation for cervicogenic headache ; and mobilisation for miscellaneous headache ) . In addition , evidence was identified on a large number of non-musculoskeletal conditions not previously considered ; most of this evidence was rated as inconclusive . Conclusions Overall , there was limited high quality evidence for the effectiveness of manual therapy . Most review ed evidence was of low to moderate quality and inconsistent due to substantial method ological and clinical diversity . Areas requiring further research are highlighted Joint mobilisation to the T4 vertebra has been advocated as a treatment for T4 syndrome . To date no controlled studies have investigated the effects of thoracic spinal manual therapy ( SMT ) applied to T4 on sympathetic activity in the h and s. This study investigated whether a grade III postero-anterior rotatory joint mobilisation technique applied to the T4 vertebra at a frequency of 0.5 Hz had demonstrably greater effects than a vali date d placebo intervention on skin conductance ( SC ) in the h and s of healthy subjects . A power analysis calculation was performed and using a double blind , placebo-controlled , independent groups design , 36 healthy subjects ( 18 - 35 years ) were r and omly assigned to two groups ( placebo intervention or treatment intervention ) . A BioPac unit recorded continuous SC measures before , during and after each experimental intervention . An exit question naire was used to vali date the expectancy effects of the placebo intervention . Results demonstrated a significant difference between groups in SC in the right h and during the post-treatment rest period ( F = 4.888 , p = 0.034 ) ; with the treatment intervention being sympathoexcitatory in nature . A trend towards a significant difference between groups was also demonstrated in the left h and during the rest period ( F = 4.072 , p = 0.052 ) . This study provides preliminary evidence that joint mobilisation applied to the T4 vertebra at a frequency of 0.5 Hz can produce sympathoexcitatory effects in the h and . Further research is recommended in a patient population Blinding refers to the concealment of group allocation from one or more individuals involved in a clinical research study , most commonly a r and omized controlled trial ( RCT ) . Although r and omization minimizes differences between treatment groups at the outset of the trial , it does nothing to prevent differential treatment of the groups later in the trial or the differential assessment of outcomes , either of which may result in biased estimates of treatment effects . The optimal strategy to minimize the likelihood of differential treatment or assessment s of outcomes is to blind as many individuals as possible in a trial . R and omized controlled trials of surgical interventions are frequently more difficult to blind than RCTs of medications , which typically achieve blinding with placebos . However , imaginative techniques may make blinding more feasible in surgical trials than is commonly believed by many research ers . In this article we discuss the importance of blinding and provide practical suggestions to research ers who wish to incorporate blinding into their surgical studies Spinal manipulative therapy techniques are commonly employed by physiotherapists in the clinical setting for the management of neuromusculoskeletal pain and dysfunction , although their underlying mechanism is not fully understood . Mulligan 's sustained natural apophyseal glides ( SNAGs ) constitute one of these techniques . This preliminary investigation was undertaken to investigate the relationship between the application of cervical SNAGs to the C5/6 intervertebral joint ( with cervical right rotation ) and indirect measures of sympathetic nervous system ( SNS ) activity . Previous investigations have suggested that cervical manipulative therapy techniques , separate to cervical SNAGs , result in a sympatheoexcitatory effect and that this may be instrumental in producing an analgesic response . Sixteen asymptomatic subjects participated in a laboratory-based experiment . A single blind , r and omized , within subject , repeated measures study design which included control , placebo and treatment comparisons was used . Measures of skin conductance ( SC ) and skin temperature ( ST ) in the right and left upper limbs were used as indicators of SNS activity . The cervical SNAG technique produced a sympathoexcitatory response demonstrated by a significant increase in SC during application of the treatment intervention ( P<0.0005 ) and for a 2-min period after the intervention ( P=0.001 ) compared with control . There was also a significant increase in SC for the placebo condition , both during intervention ( P=0.015 ) and after intervention ( P=0.011 ) compared with control . There was a statistically significant difference in SC between placebo and treatment conditions for the 2-min period after the intervention had been applied ( P=0.01 ) . A trend did emerge for ST change , illustrating a decrease in ST for the treatment and placebo conditions compared with control , however this did not reach statistically significant levels . There were no apparent left/right upper limb differences for SC and ST for each condition . The results of this study suggest that cervical SNAG techniques , performed on naïve asymptomatic subjects , have a sympathoexcitatory effect as measured by changes in SC and ST . The importance of this sympathoexcitatory effect in relation to potential mechanisms for manipulation induced analgesia are discussed , and further areas of research proposed Background Neuromechanical responses to spinal manipulation therapy ( SMT ) have been shown to be modulated through the variation of SMT biomechanical parameters : peak force , time to peak force , and preload force . Although rate of force application was modulated by the variation of these parameters , the assumption that neuromuscular responses are modulated by the rate of force application remains to be confirmed . Therefore , the purpose of the present study was to evaluate the effect of a constant rate of force application in neuromechanical responses to SMT  in healthy adults . Methods  Four SMT force-time profiles  presenting different time to peak force and peak force , but with a constant rate of force application were applied on 25 healthy participants ’ T7 transverse processes .  Muscular responses were recorded through surface electromyography electrodes ( T6 and T8 levels ) , while vertebral displacements were assessed through pasted kinematic markers on T6 to T8 spinous processes . Effects of SMT force-time profiles on neuromechanical responses were assessed using repeated- measures ANOVAs . Results There was no main effect of SMT  force-time profile modulation on muscular responses ( ps > .05 ) except for the left T8 ( F ( 3 , 72 ) = 3.23 , p = .03 ) and left T6 ( F ( 3 
    Output:
    
Mobilizations ( oscillatory technique ) probably produce an immediate and short-term , bilateral increase in skin sympathetic nerve activity ( reflected by an increase in skin conductance ) regardless of the area treated ( moderate-certainty evidence ) .
It is uncertain whether the sympathetic arousal also explains an increase in respiratory rate ( very low-certainty evidence ) .
Our evaluation of the literature suggests that spinal sustained apophyseal glides ( SNAGs ) mobilization and HVLA manipulation of the spine may have no acute effect on the studied markers of ANS activity ( very low- to low-certainty evidence ) .
ConclusionS ome types of mobilizations probably produce an immediate and short-term , statistically significant increase in skin sympathetic nerve activity when compared to a sham procedure , whereas spinal SNAGs and spinal HVLA techniques may have no acute effect on the studied markers of ANS activity .
No region-specific results were noted .
Il y a des preuves de certitude modérée que les mobilisations ( avec une technique d’oscillation ) produisent une augmentation bilatérale , immédiate et à court terme de l’activité sympathique cutanée , indépendamment de la région mobilisée .
Conclusion Certaines techniques de mobilisation articulaire produisent probablement une augmentation ( statistiquement significative ) immédiate et à court terme de l’activité sympathique cutanée comparées à une procédure placebo .
Les manipulations spinales ( HVLA ) pourraient ne pas avoir d’effet immédiat sur l’activité autonome étudiée .
Nous n’avons pas remarqué d’effet spécifique en fonction de la zone du traitement .