***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: 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 BACKGROUND Shock-absorbing and biomechanic shoe orthoses are frequently used in the prevention and treatment of back and lower extremity problems . One review concludes that the former is clinical ly effective in relation to prevention , whereas the latter has been tested in only 1 r and omized clinical trial , concluding that stress fractures could be prevented . OBJECTIVES To investigate if biomechanic shoe orthoses can prevent problems in the back and lower extremities and if reducing the number of days off-duty because of back or lower extremity problems is possible . DESIGN Prospect i ve , r and omized , controlled intervention trial . STUDY SUBJECTS One female and 145 male military conscripts ( aged 18 to 24 years ) , representing 25 % of all new conscripts in a Danish regiment . METHOD Health data were collected by question naires at initiation of the study and 3 months later . Custom-made biomechanic shoe orthoses to be worn in military boots were provided to all in the study group during the 3-month intervention period . No intervention was provided for the control group . Differences between the 2 groups were tested with the chi-square test , and statistical significance was accepted at P < .05 . Risk ratio ( RR ) , risk difference ( ARR ) , numbers needed to prevent ( NNP ) , and cost per successfully prevented case were calculated . OUTCOME VARIABLES Outcome variables included self-reported back and /or lower extremity problems ; specific problems in the back or knees or shin splints , Achilles tendonitis , sprained ankle , or other problems in the lower extremity ; number of subjects with at least 1 day off-duty because of back or lower extremity problems and total number of days off-duty within the first 3 months of military service because of back or lower extremity problems . RESULTS Results were significantly better in an actual-use analysis in the intervention group for total number of subjects with back or lower extremity problems ( RR 0.7 , ARR 19 % , NNP 5 , cost 98 US dollars ) ; number of subjects with shin splints ( RR 0.2 , ARR 19 % , NNP 5 , cost 101 US dollars ) ; number of off-duty days because of back or lower extremity problems ( RR 0.6 , ARR < 1 % , NNP 200 , cost 3750 US dollars ) . In an intention-to-treat analysis , a significant difference was found for only number of subjects with shin splints ( RR 0.3 , ARR 18 % , NNP 6 cost 105 US dollars ) , whereas a worst-case analysis revealed no significant differences between the study groups . CONCLUSIONS This study shows that it may be possible to prevent certain musculoskeletal problems in the back or lower extremities among military conscripts by using custom-made biomechanic shoe orthoses . However , because care-seeking for lower extremity problems is rare , using this method of prevention in military conscripts would be too costly . We also noted that the choice of statistical approach determined the outcome OBJECTIVES This level II outcome study was conducted to examine the efficacy and toxicity of a diagnostic and treatment protocol using electrodermal screening ( EDS ) in allergy/sensitivity patients . METHODS Ninety-six patients with a diagnosis of allergy or sensitivity entered the study between 1994 and 1998 ; 90 participants completed the study . All participants followed the same protocol , and all interactions were with a single clinician at a single site . The Allergy Symptom Severity Index ( ASSI ) was developed to record symptomatic information .  EDS - conductance measurement 1/ ( - of specific acupuncture points was used as an objective endpoint ( indicator of outcome ) and for identification of antigens , according to Voll criteria . All measurements were taken before and after treatment , and EDS was carried out at all treatment sessions . Outcome criteria suggesting efficacy were reduction in ASSI score , reduction in number of items testing positive , and normalization of conductance measurements . A statistical analysis of the outcomes was performed using the student 's paired t-test . RESULTS There was a statistically significant change in pre- and post-treatment measurements of the ASSI . The conductance measurements normalized and the number of items testing positive decreased compared to pre-treatment testing . In addition to these parameters , 87.2 percent of subjects rated efficacy as good to excellent , and less than one-percent rated the outcome as poor . The outcome demonstrated longevity , meaning that people who had their post-treatment evaluation up to three years after primary treatment were still showing minimal ASSI scores , with no additional treatment . The treatment appeared to work equally well across age groups and gender . Forty-eight percent of participants had an aggravation of symptoms after treatment , lasting an average of 10 hours , with reactions described as mild to moderate . Average cost of the desensitization protocol ( all costs included ) was $ 822.16 . CONCLUSIONS This protocol demonstrated efficacy without serious toxicity and no long-term adverse effects . It is natural , non-invasive , and does not require long periods of avoidance of offending foods or environmental stimuli . The desensitization protocol is a low-cost , effective therapy for the treatment of patients suffering from symptoms of allergy/sensitivity disease Postoperative oral nutritional supplementation has been shown to be of clinical benefit . This study examined the clinical effects and cost of administration of oral supplements both before and after surgery BACKGROUND Re source -based relative value scales ( RBRVS ) have become a st and ard method for identifying costs and determining reimbursement for physician services . Development of RBRVS systems and methods are review ed , and the RBRVS concept of physician " work " is defined . OBJECTIVE Results of work and time inputs from chiropractic physicians are compared with those reported by osteopathic and medical specialties . Last , implication s for reimbursement of chiropractic fee services are discussed . METHODS Total work , intraservice work , and time inputs for clinical vignettes reported by chiropractic , osteopathic , and medical physicians are compared . Data for  chiropractic work and time reports were drawn from a national r and om sample of chiropractors conducted as part of a 1997 workers ' compensation chiropractic fee schedule development project . Medical and osteopathic inputs were drawn from RBRVS research conducted at Harvard University under a federal contract reported in 1990 . Both data sets used the same or similar clinical vignettes and similar methods . Comparisons of work and time inputs are made for clinical vignettes to assess whether work reported by chiropractors is of similar magnitude and variability as work reported by other specialties . RESULTS Chiropractic inputs for vignettes related to evaluation and management services are similar to those reported by medical specialists and osteopathic physicians . The range of variation between chiropractic work input and other specialties is of similar magnitude to that within other specialties . Chiropractors report greater work input for radiologic interpretation and lower work input for manipulation services . CONCLUSIONS Chiropractors seem to perform similar total " work " for evaluation and management services as other specialties . No basis exists for excluding chiropractors from using evaluation and management codes for reimbursement purpose s on grounds of dissimilar physician time or work estimates . Greater work input by chiropractors in radiology interpretation may be related to a greater importance placed on findings in care planning . Consistently higher reports for osteopathic work input on manipulation are likely attributable to differences in reference vignettes used in the respective population s. Research with a common reference vignette used for manipulation providers is recommended , as is development of a single generic approach to coding for manipulation services Purpose . To determine whether practice of the Transcendental Meditation ( TM ) technique can affect medical expenses . Design . The evaluation was a quasi experimental , longitudinal , cost-minimization study . Setting . Province of Quebec , Canada . Subjects . This study involved 1418 Quebec health insurance enrollees who practice d the TM technique compared with 1418 subjects who were r and omly selected from enrollees of the same age , sex , and region . TM subjects had chosen to begin the technique prior to learning about and choosing to enter the study . Measures . This 14-year , pre- and postintervention study retrospectively assessed government payments to physicians for treating the TM and comparison groups . Other medical expense data for individuals were unavailable . Data were inflation-adjusted . For each subject , least squares regression slopes were calculated to estimate pre- and postintervention annual rates of change in payments . We compared the groups ' means and 1 % , 5 % , and 10 % trimmed means ( robust estimators ) of the slopes . Results . Before starting meditation , the yearly rate of increase in payments between groups was not significantly different ( p > .17 ) . After commencing meditation , the TM group 's mean payments declined 1 % to 2 % annually . The comparison group 's payments increased up to 11 . 73 % annually over 6 years . There was a 13 . 78 % mean annual difference ( p = .0017 ) . Conclusions . The results suggest that the TM technique reduced payments to physicians between 5 % and 13 % annually relative to comparison subjects over 6 years . R and omized studies are recommended OBJECTIVES To measure the marginal costs of providing complementary medicine services ( mostly homoeopathy ) in outpatient clinics for patients with rheumatoid arthritis ( RA ) and to illustrate how parameters to which the cost of complementary medicine may be sensitive can be identified . DESIGN Retrospective , observational costing study . SETTING The outpatient clinic of the Royal London Homoeopathic Hospital . SUBJECTS R and om sample of 89 patients from the 427 ( RA ) patients attending outpatient clinics from April 1995 to March 1996 . MAIN OUTCOME MEASURES The marginal costs incurred by the hospital of treating 89 patients attending outpatient clinics and the relative contribution of the different re sources to the total costs . RESULTS The total costs of treating 89 patients were 7,124 Pounds of which 543 Pounds was assumed to be fixed and the remainder variable . The marginal costs of treating additional patients , starting from zero patients treated , are presented . Consultation time ( doctors and dietician ) contributed to 29 % of the total costs , non-conventional drugs contributed to 22 % of the total costs . CONCLUSIONS Underst and ing the marginal costs of providing complementary care to RA patients will inform the debate over whether these therapies are likely to be cost-effective . In addition , those who would like to explore the practicalities of establishing a service involving complementary medicine will gain an underst and ing of the likely provider costs . The cost of complementary medicine appears to be most sensitive to the time spent with the patient by the doctor Abstract Objective : To evaluate the cost effectiveness of physiotherapy , manual therapy , and care by a general practitioner for patients with neck pain . Design : Economic evaluation alongside a r and omised controlled trial . Setting : Primary care . Participants : 183 patients with neck pain for at least two weeks recruited by 42 general practitioners and r and omly allocated to  manual therapy ( n=60 , spinal mobilisation ) , physiotherapy ( n=59 , mainly exercise ) , or general practitioner care ( n=64 , counselling , education , and drugs ) . Main outcome measures : Clinical outcomes were perceived recovery , intensity of pain , functional disability , and quality of life . Direct and indirect costs were measured by means of cost diaries that were kept by patients for one year . Differences in mean costs between groups , cost effectiveness , and cost utility ratios were evaluated by applying non-parametric bootstrapping techniques . Results : The manual therapy group showed a faster improvement than the physiotherapy group and the general practitioner care group up to 26 weeks , but differences were negligible by follow up at 52 weeks . The total costs of manual therapy ( € 447 ; £ 273 ; $ 402 ) were around one third of the costs of physiotherapy ( € 1297 ) and general practitioner care ( € 1379 ) . These differences were significant : P<0.01 for manual therapy versus physiotherapy and manual therapy versus general practitioner care and P=0.55 for general practitioner care versus physiotherapy . The cost effectiveness ratios and the cost utility ratios showed that manual therapy was less costly and more effective than physiotherapy or general practitioner care . Conclusions : Manual therapy ( spinal mobilisation ) is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner . What is already known on this topic The cost of treating neck pain is considerable Many conservative interventions are available , such as prescription drugs , yet their cost effectiveness has not been evaluated No r and omised trials of conservative treatment for neck pain have so far included an economic evaluation What this study adds Manual therapy is more effective and less costly than physiotherapy or care by a general practitioner for treating neck pain Patients undergoing manual therapy  recovered more quickly than those 
    Output:
    
These exemplary studies indicate CAM therapies that may be considered cost-effective compared to usual care for various conditions : acupuncture for migraine , manual therapy for neck pain , spa therapy for Parkinson 's , self-administered stress management for cancer patients undergoing chemotherapy , pre- and post-operative oral nutritional supplementation for lower gastrointestinal tract surgery , biofeedback for patients with " functional " disorders ( eg , irritable bowel syndrome ) , and guided imagery , relaxation therapy , and potassium-rich diet for cardiac patients .