***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: Integrative medicine ( IM ) refers to the combination of conventional and “ complementary ” medical services ( e.g. , chiropractic , acupuncture , massage , mindfulness training ) . More than half of all medical schools in the United States and Canada have programs in IM , and more than 30 academic health centers currently deliver multidisciplinary IM care . What remains unclear , however , is the ideal delivery model ( or models ) whereby individuals can responsibly access IM care safely , effectively , and reproducibly in a coordinated and cost-effective way . Current models of IM across existing clinical centers vary tremendously in their organizational setting s , principal clinical focus , and services provided ; practitioner team composition and training ; incorporation of research activities and educational programs ; and administrative organization ( e.g. , reporting structure , use of medical records , scope of clinical practice ) and financial strategies ( i.e. , specific business plans and models for sustainability ) . In this article , the authors address these important strategic issues by sharing lessons learned from the design and implementation of an IM  facility within an academic teaching hospital , the Brigham and Women ’s Hospital at Harvard Medical School ; and review alternative options based on information about IM centers across the United States . The authors conclude that there is currently no consensus as to how integrative care models should be optimally organized , implemented , replicated , assessed , and funded . The time may be right for prospect i ve research in “ best practice s ” across emerging models of IM care nationally in an effort to st and ardize , refine , and replicate them in preparation for rigorous cost-effectiveness evaluations 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 Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more Background Low back pain ( LBP ) is a prevalent condition and a socioeconomic problem in many countries . Due to its recurrent nature , the prevention of further episodes ( secondary prevention ) , seems logical . Furthermore , when the condition is persistent , the minimization of symptoms and prevention of deterioration ( tertiary prevention ) , is equally important . Research has largely focused on treatment methods for symptomatic episodes , and little is known about preventive treatment strategies . Methods / Design This study protocol describes a r and omized controlled clinical trial in a multicenter setting investigating the effect and cost-effectiveness of preventive manual care ( chiropractic maintenance care ) in a population of patients with recurrent or persistent LBP.Four hundred consecutive study subjects with recurrent or persistent LBP will be recruited from chiropractic clinics in Sweden . The primary outcome is the number of days with bothersome pain over 12 months . Secondary measures are self-rated health ( EQ-5D ) , function ( the Rol and Morris Disability Question naire ) , psychological profile ( the Multidimensional Pain Inventory ) , pain intensity ( the Numeric Rating Scale ) , and work absence . The primary utility measure of the study is quality -adjusted life years and will be calculated using the EQ-5D question naire . Direct medical costs as well as indirect costs will be considered . Subjects are r and omly allocated into two treatment arms : 1 ) Symptom-guided treatment ( patient controlled ) , receiving care when patients feel a need . 2 ) Preventive treatment ( clinician controlled ) , receiving care on a regular basis . Eligibility screening takes place in two phases : first , when assessing the primary inclusion /exclusion criteria , and then to only include fast responders , i.e. , subjects who respond well to initial treatment . Data are collected at baseline and at follow-up as well as weekly , using SMS text messages . Discussion This study investigates a manual strategy ( chiropractic maintenance care ) for recurrent and persistent LBP and aims to answer questions regarding the effect and cost-effectiveness of this preventive approach . Strict inclusion criteria should ensure a suitable target group and the use of frequent data collection should provide an accurate outcome measurement . The study utilizes normal clinical procedures , which should aid the transferability of the results .Trial registration Clinical trials.gov ; NCT01539863 , February 22 , 2012 . The first patient was r and omized into the study on April 13th 2012 OBJECTIVE The purpose of the study was to compare the effects of thrust manipulation ( TM ) and non-TM ( NTM ) on a sample of older subjects with low back pain . METHODS This is a secondary data analysis of a r and omized control trial . Forty-nine subjects aged 55 to 88 years participated in the trial , who received either a TM or NTM on at least 2 occasions during the course of care , and were extracted from the larger data set . The treatment program included a st and ardized home exercise program for the first 2 sessions , which could be modified by the therapist after those 2 sessions . Numeric pain rating scale and Oswestry Disability Index ( ODI ) were the outcomes for this study . RESULTS Multivariate analysis revealed no significant between-group differences for treatment group ( P=.99 ) without group × time interaction ( P=.90 ) . Significant within-group changes were observed for both groups for ODI and numeric pain rating scale ( P<.001 ) ; the average self-report of recovery was 78.0 % ( SD , 19.8 % ) . Age stratification of the older subset revealed between-group differences in ODI change scores for the oldest subjects ( > 70 years ) compared with 60 to 69 years ( P=.02 ) . CONCLUSIONS This study showed that outcomes for both TM and NTM improved in older adults with low back pain OBJECTIVE The purpose of this pilot clinical trial was to assess the feasibility of recruiting older adults with lumbar spinal stenosis ( LSS ) into a clinical trial that used different dosages of flexion-distraction manipulation . METHODS This r and omized controlled trial used a 4-group design . Three groups consisted of chiropractic flexion-distraction manipulation applied at different dosages ( 8 , 12 , or 18 treatments ) . The fourth group was given 8 treatments of placebo care .  Feasibility measures included recruitment goals , adherence to various treatment schedules , credibility of the placebo treatment , and rates of adverse events . The primary outcome measure was the Swiss Spinal Stenosis Question naire , a vali date d self-report of LSS symptom severity and physical function . RESULTS The recruitment and adherence goals of the study were met with a total of 60 subjects r and omized ( n = 15 per group ) and most subjects attending at least 75 % of their scheduled visits . No adverse events were reported by any of the subjects in the trial . Our placebo treatment did not appear to be credible ; most subjects correctly guessed that they were receiving a placebo treatment . Between-group effect size estimates were small , indicating larger sample s are needed for future studies . CONCLUSION This pilot study showed that it is feasible to recruit patients with LSS and that most subjects will adhere to a 6-week treatment schedule . The information gained from this trial will be useful to inform the design of larger trials Introduction : Chronic lower back pain ( CLBP ) is problematic in older veterans .  Spinal manipulative therapy ( SMT ) is commonly utilized for CLBP in older adults , yet there are few r and omized placebo-controlled trials evaluating SMT . Methods : The purpose of the study was to compare the effectiveness of SMT to a sham intervention on pain ( Visual Analogue Scale , SF-36 pain subscale ) , disability ( Oswestry Disability Index ) , and physical function ( SF-36 subscale , Timed Up and Go ) by performing a r and omized placebo-controlled trial at 2 Veteran Affairs Clinics . Results : Older veterans ( ≥ 65 years of age ) who were naive to chiropractic were recruited . A total of 136 were included in the study with 69 being r and omly assigned to SMT and 67 to sham intervention . Patients were treated 2 times per week for 4 weeks assessing outcomes at baseline , 5 , and 12 weeks postbaseline . Both groups demonstrated significant decrease in pain and disability at 5 and 12 weeks . At 12 weeks , there was no significant difference in pain and a statistically significant decline in disability scores in the SMT group when compared to the sham intervention group . There were no significant differences in adverse events between the groups . Conclusions : The SMT did not result in greater improvement in pain when compared to our sham intervention ; however , SMT did demonstrate a slightly greater improvement in disability at 12 weeks . The fact that patients in both groups showed improvements suggests the presence of a nonspecific therapeutic effect OBJECTIVE Chiropractic care is used by many older patients for low back pain ( LBP ) , but there are no published results of r and omized trials examining spinal manipulation ( SM ) for older adults . The purpose of this study was to compare the effects of 2 biomechanically distinct forms of SM and minimal conservative medical care ( MCMC ) for participants at least 55 years old with subacute or chronic nonradicular LBP . METHODS R and omized controlled trial . The primary outcome variable was low back-related disability assessed with the 24-item Rol and Morris Disability question naire at 3 , 6 , 12 , and 24 weeks . Participants were r and omly allocated to 6 weeks of care including 12 visits of either high-velocity , low-amplitude (HVLA)-SM , low-velocity , variable-amplitude (LVVA)-SM , or 3 visits of MCMC . RESULTS Two hundred forty participants ( 105 women and 135 men ) ages 63.1 + /- 6.7 years without significant comorbidities .  Adjusted mean Rol and Morris Disability change scores ( 95 % confidence intervals ) from baseline to the end of active care were 2.9 ( 2.2 , 3.6 ) and 2.7 ( 2.0 , 3.3 ) in the LVVA-SM and HVLA-SM groups , respectively , and 1.6 ( 0.5 , 2.8 ) in the MCMC group . There were no significant differences between LVVA-SM and HVLA-SM at any of the end points . The LVVA-SM group had significant improvements in mean functional status ranging from 1.3 to 2.2 points over the MCMC group . There were no serious adverse events associated with any of the interventions . CONCLUSIONS Biomechanically distinct forms of SM did not lead to different outcomes in older LBP patients and both SM procedures were associated with small yet clinical ly important changes in functional status by the end of treatment for this relatively healthy older population . Participants who received either form of SM had improvements on average in functional status ranging from 1 to 2.2 over those who received MCMC . From an evidence -based care perspective , patient preference and clinical experience should drive how clinicians and patients make the SM procedure decision for this patient population BACKGROUND We design ed this observational cohort study to assess the association between patient-centered communication in primary care visits and subsequent health and medical care utilization . METHODS We selected 39 family physicians at r and om , and 315 of their patients participated . Office visits were audiotaped and scored for patient-centered communication . In addition , patients were asked for their perceptions of the patient-centeredness of the visit . The outcomes were : ( 1 ) patients ' health , assessed by a visual analogue scale on symptom discomfort and concern ; ( 2 ) self-report of health , using the Medical Outcomes Study Short Form-36 ; and ( 3 ) medical care utilization variables of diagnostic tests , referrals , and visits to the family physician , assessed by chart review . The 2 measures of patient-centeredness were correlated with the outcomes of visits , adjusting for the clustering of patients by physician and controlling for confounding variables . RESULTS Patient-centered communication was correlated with the patients ' perceptions of finding common ground . In addition , positive perceptions ( both the total score and the subscore on finding common ground ) were associated with better recovery from their discomfort and concern , better emotional health 2 months later , and fewer diagnostic tests and referrals . CONCLUSIONS Patient-centered communication influences patients ' health through perceptions that their visit was patient centered , and especially through perceptions that common ground was achieved with the physician . Patient-centered practice improved health status and increased the efficiency of care by reducing diagnostic tests and referrals OBJECTIVE The objective of the 
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As a result , statements regarding the safety of manipulation were strengthened and additional statements were added recommending that DCs advise patients on exercise and that manipulation and mobilization contribute to general positive outcomes beyond pain reduction only .
Conclusions : This document provides a summary of evidence ‐informed best practice s for doctors of chiropractic for the evaluation , management , and manual treatment of older adult patients