***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 
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    Input: 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 BACKGROUND Spinal pain is common and frequently disabling . Management guidelines have encouraged referral from primary care for spinal manipulation . However , the evidence base for these recommendations is weak . More pragmatic trials and economic evaluations have been recommended . OBJECTIVES Our aim was to assess the effectiveness and health care costs of a practice -based osteopathy clinic for subacute spinal pain . METHODS A pragmatic r and omized controlled trial was carried out in a primary care osteopathy clinic accepting referrals from 14 neighbouring practice s in North West Wales . A total of 201 patients with neck or back pain of 2 - 12 weeks duration were allocated at r and om between usual GP care and an additional three sessions of osteopathic spinal manipulation . The primary outcome measure was the Extended Aberdeen Spine Pain Scale ( EASPS ) . Secondary measures included SF-12 , EuroQol and Short-form McGill Pain Question naire . Health care costs were estimated from the records of referring GPs . RESULTS Outcomes improved more in the osteopathy group than the usual care group . At 2 months , this improvement was significantly greater in EASPS [ 95 % confidence interval ( CI ) 0.7 - 9.8 ] and SF-12 mental score ( 95 % CI 2.7 - 10.7 ) . At 6 months , this difference was no longer significant for EASPS ( 95 % CI -1.5 to 10.4 ) , but remained significant for SF-12 mental score ( 95 % CI 1.0 - 9.9 ) . Mean health care costs attributed to spinal pain were significantly greater by 65 UK pounds in the osteopathy group ( 95 % CI 32 - 155 UK pounds ) . Though osteopathy also cost 22 UK pounds more in mean total health care cost , this was not significant ( 95 % CI - 159 to 142 UK pounds ) . CONCLUSION A primary care osteopathy clinic improved short-term physical and longer term psychological outcomes , at little extra cost . Rigorous multicentre studies are now needed to assess the generalizability of this approach Study Design . A r and omized controlled clinical trial was conducted . Objective . To compare medication , needle acupuncture , and spinal manipulation for managing chronic ( > 13 weeks duration ) spinal pain because the value of medicinal and popular forms of alternative care for chronic spinal pain syndromes is uncertain . Summary of Background Data . Between February 1999 and October 2001 , 115 patients without contraindication for the three treatment regimens were enrolled at the public hospital ’s multidisciplinary spinal pain unit . Methods . One of three separate intervention protocol s was used : medication , needle acupuncture , or chiropractic spinal manipulation . Patients were assessed before treatment by a sports medical physician for exclusion criteria and by a research assistant using the Oswestry Back Pain Disability Index ( Oswestry ) , the Neck Disability Index ( NDI ) , the Short-Form-36 Health Survey question naire ( SF-36 ) , visual analog scales ( VAS ) of pain intensity and ranges of movement . These instruments were administered again at 2 , 5 , and 9 weeks after the beginning of treatment . Results . R and omization proved to be successful . The highest proportion of early ( asymptomatic status ) recovery was found for manipulation ( 27.3 % ) , followed by acupuncture ( 9.4 % ) and medication ( 5 % ) . Manipulation achieved the best overall results , with improvements of 50 % ( P = 0.01 ) on the Oswestry scale , 38 % ( P = 0.08 ) on the NDI , 47 % ( P < 0.001 ) on the SF-36 , and 50 % ( P < 0.01 ) on the VAS for back pain , 38 % ( P < 0.001 ) for lumbar st and ing flexion , 20 % ( P < 0.001 ) for lumbar sitting flexion , 25 % ( P = 0.1 ) for cervical sitting flexion , and 18 % ( P = 0.02 ) for cervical sitting extension . However , on the VAS for neck pain , acupuncture showed a better result than manipulation ( 50%vs 42 % ) . Conclusions . The consistency of the results provides , despite some discussed shortcomings of this study , evidence that in patients with chronic spinal pain , manipulation , if not contraindicated , results in greater short-term improvement than acupuncture or medication . However , the data do not strongly support the use of only manipulation , only acupuncture , or only nonsteroidal antiinflammatory drugs for the treatment of chronic spinal pain . The results from this exploratory study need confirmation from future larger studies CONTEXT A prior national survey documented the high prevalence and costs of  alternative medicine use in the United States in 1990 . OBJECTIVE To document trends in alternative medicine use in the United States between 1990 and 1997 . DESIGN Nationally representative r and om household telephone surveys using comparable key questions were conducted in 1991 and 1997 measuring utilization in 1990 and 1997 , respectively . PARTICIPANTS A total of 1539 adults in 1991 and 2055 in 1997 . MAIN OUTCOMES MEASURES Prevalence , estimated costs , and disclosure of alternative therapies to physicians . RESULTS Use of at least 1 of 16 alternative therapies during the previous year increased from 33.8 % in 1990 to 42.1 % in 1997 ( P < or = .001 ) . The therapies increasing the most included herbal medicine , massage , megavitamins , self-help groups , folk remedies , energy healing , and homeopathy . The probability of users visiting an alternative medicine practitioner increased from 36.3 % to 46.3 % ( P = .002 ) . In both surveys alternative therapies were used most frequently for chronic conditions , including back problems , anxiety , depression , and headaches . There was no significant change in disclosure rates between the 2 survey years ; 39.8 % of alternative therapies were disclosed to physicians in 1990 vs 38.5 % in 1997 . The percentage of users paying entirely out-of-pocket for services provided by alternative medicine practitioners did not change significantly between 1990 ( 64.0 % ) and 1997 ( 58.3 % ) ( P=.36 ) . Extrapolations to the US population suggest a 47.3 % increase in total visits to alternative medicine practitioners , from 427 million in 1990 to 629 million in 1997 , thereby exceeding total visits to all US primary care physicians . An estimated 15 million adults in 1997 took prescription medications concurrently with herbal remedies and /or high-dose vitamins ( 18.4 % of all prescription users ) . Estimated expenditures for alternative medicine professional services increased 45.2 % between 1990 and 1997 and were conservatively estimated at $ 21.2 billion in 1997 , with at least $ 12.2 billion paid out-of-pocket . This exceeds the 1997 out-of-pocket expenditures for all US hospitalizations . Total 1997 out-of-pocket expenditures relating to alternative therapies were conservatively estimated at $ 27.0 billion , which is comparable with the projected 1997 out-of-pocket expenditures for all US physician services . CONCLUSIONS  Alternative medicine use and expenditures increased substantially between 1990 and 1997 , attributable primarily to an increase in the proportion of the population seeking alternative therapies , rather than increased visits per patient Objective : We sought to compare total outpatient costs of 4 common treatments for low-back pain ( LBP ) at 18-months follow-up . Methods : Our work reports on findings from a r and omized controlled trial within a large medical group practice treating HMO patients . Patients ( n = 681 ) were assigned to 1 of 4 treatment groups , ie , medical care only ( MD ) , medical care with physical therapy ( MDPt ) , chiropractic care only ( DC ) , or chiropractic care with physical modalities ( DCPm ) . Total outpatient costs , excluding pharmaceuticals , were measured at 18 months . We did not perform a cost-effectiveness analysis because previously published findings showed no clinical ly meaningful difference in outcomes among the 4 treatment groups . Thirty-seven participants were lost to follow-up at 18 months , leaving a final sample size of n = 654 . Results : Adjusting for covariates , DC was 51.9 % more expensive than MD ( P < 0.001 ) , DCPm 3.2 % more expensive than DC ( P = 0.76 ) , and MDPt 105.8 % more expensive than MD ( P < 0.001 ) . The adjusted mean outpatient costs per treatment group were $ 369 for MD , $ 560 for DC , $ 579 for DCPm , and $ 760 for MDPt . Conclusions : This study is the first r and omized trial to show higher costs for chiropractic care without producing better clinical outcomes , but our findings are likely to understate the costs of medical care with or without physical therapy because of the absence of pharmaceutical data . Physical therapy provided in combination with medical care and physical modalities provided in combination with chiropractic care do not appear to be cost-effective strategies for treatment of LBP ; they produce higher costs without clinical ly significant improvements in outcome OBJECTIVE This study reports pain and disability outcomes up to 4 years for chiropractic and medical patients with low back pain ( LBP ) and assesses the influence of doctor type and pain duration on clinical outcomes . DESIGN Prospect i ve , longitudinal , nonr and omized , practice -based , observational study . SETTING Fifty-one chiropractic and 14 general practice community clinics . SUBJECTS A total of 2870 acute and chronic ambulatory patients with LBP of mechanical origin . METHODS Sixty chiropractic ( DC ) and 111 general practice ( MD ) physicians participated . Primary outcomes were pain , using a 100-point visual analogue scale ( VAS ) , and functional disability , using the Revised Oswestry Disability Question naire . These were measured at baseline and 8 time points . Regression analysis compared acute and chronic DC and MD patients after correcting for baseline differences in the 4 cohorts . RESULTS Most improvement was seen by 3 months and sustained for 1 year ; exacerbation was seen thereafter . Acute patients demonstrated greater relief at all time points . A clinical ly important advantage for chiropractic patients was seen in chronic patients in the short-term ( > 10 VAS points ) , and both acute and chronic chiropractic patients experienced somewhat greater relief up to 1 year ( P<.000 ) . The advantage for DC care was prominent for chronic patients with leg pain below the knee ( P<.001 ) . More than 50 % of chronic patients had over 50 days of pain in the third year . CONCLUSION Study findings were consistent with systematic review s of the efficacy of spinal manipulation for pain and disability in acute and chronic LBP . Patient choice and interdisciplinary referral should be prime considerations by physicians , policymakers , and third-party payers in identifying health services for patients with LBP OBJECTIVES To compare the effect of manual therapy in addition to the stay-active concept versus the stay-active concept only in low back pain patients . STUDY DESIGN A r and omized , controlled trial during 10 weeks . METHODS One hundred sixty out patients with acute or subacute low back pain were recruited from a geographically defined area . They were r and omly allocated to a reference group treated with the stay-active concept and , in some cases , muscle stretching and an experimental group receiving manual therapy and , in some cases , steroid injections in addition to the stay-active concept .  Pain and disability rating index were used as outcome measures . RESULTS At baseline , the experimental group had somewhat more 
    Output:
    
Acute and chronic chiropractic patients experienced better outcomes in pain , functional disability , and patient satisfaction ( P < .01 ) ; clinical ly important differences in pain and disability improvement were found for chronic patients only .
Chiropractic care appeared relatively cost-effective for the treatment of chronic LBP .
Chiropractic and medical care performed comparably for acute patients .
Practice -based clinical outcomes were consistent with systematic review s of spinal manipulation efficacy : manipulation-based therapy is at least as good as and , in some cases , better than other therapeusis .