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Home Mutual Funds Best Equity Income Mutual Funds 2019 Fund For Rising Interest Rates Best Ranked Mutual Funds What Are The Bonds To Invest In Bond Equity Income
Investing in Mutual Funds Is Easy. Putting together a portfolio of stocks and bonds can be difficult, if not impossible, for the average investor. For example, the time and knowledge required to research and analyze a dozen or more stocks can be too challenging for most people. That's not to mention all the trades needed to build the portfolio, plus the ongoing research and analysis required to maintain the portfolio. But when it comes to investing in mutual funds, investors can get started investing with just one mutual fund.
While it can be confusing, the answers to the following three questions will help you navigate the mutual fund waters—from how they work to how to add them to your investment portfolio. What Is a Mutual Fund? For all intents and purposes, mutual funds serve as an alternative for investors who can't afford an individually managed account. Mutual funds are formed when investors with smaller amounts of capital, pool their money together and then hire a portfolio manager to run the consolidated pool's portfolio—subsequently buying different stocks, bonds, or other securities in a manner consistent with the fund's prospectus. Each investor then receives their respective piece of the pie while sharing the expenses, which show up in something called the mutual fund expense ratio.
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Other Types of Mutual Funds: Index Funds. Today, not all funds are managed by a financial manager. Index funds use a computer program to buy all of the stock in a particular index, such as the Russell 3000 or the S&P 500, regardless of how they're performing. They don't have to do research or try to time the movement in the market to buy or sell at the "right" time. Index fund fees, therefore, are generally much lower than the fees for managed funds, and, therefore, the return on investment is higher.
All Mutual Funds Have High Capital Gains Distributions. If all mutual funds sell holdings and pass the capital gains on to investors as a taxable event, then we have a found a winner for the list of disadvantages of the mutual funds list. Oh well, not all mutual funds make annual capital gains distributions. Index mutual funds and tax-efficient mutual funds do not make these distributions every year. Yes, if they have the gains, they must distribute the gains to shareholders. However, many mutual funds (including index mutual funds and tax-efficient mutual funds) are low-turnover funds and do not make capital gains distributions on an annual basis.
Thanks to computers and the Internet, investing in mutual funds has never been easier. That said, there are many important considerations an investor should take into account before adding shares of a mutual fund to their portfolio. Mutual funds come in a multitude of varieties, including those that focus on different asset classes, those that seek to mimic an index (also known as index funds), and those that focus on dividend stocks. The list covers everything from geographic mandates to those that specialize in investing in securities that fall within a certain market capitalization.


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Milwaukee's Irish History with Carl Baehr
Milwaukee historian Carl Baehr joins the show to discuss the Cream City's Emerald Isle connections.
Milwaukee's history is commonly associated with German immigrants, but Irish immigrants played a creating the Cream City.
Historian Carl Baehr, author of Urban Milwaukee's City Streets column, joins the podcast to discuss his latest book, From the Emerald Isle to the Cream City, and what inspires him to dig into the city's history. For aspiring historians, Baehr also shares how his research process works.
We discuss major events in Milwaukee's history, including the Newhall House fire (more on that soon), sinking of the Lady Elgin and 1892 Historic Third Ward fire, and how they impacted Milwaukee's Irish history.
Download the Episode – Subscribe on iPhone/iTunes – Subscribe on Google Play – Subscribe on Spotify – Subscribe on Pocket Casts – Subscribe on Stitcher – RSS Feed
Carl's underrated restaurant pick? The Swingin' Door Exchange in the Mackie Building.
Music – Light Corporate by Masteck Media – https://soundcloud.com/masteck_media. Creative Commons Attribution-ShareAlike 3.0 Unported
City Beat
Jane's Walk MilwaukeeApr 19th, 2019 by Jeramey Jannene
Common Council Candidate Justin BielinskiApr 15th, 2019 by Jeramey Jannene
Milwaukee's Less Than Glamorous HistoryApr 5th, 2019 by Jeramey Jannene

subset: commoncrawl


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The aim of the current study was to evaluate the literature examining the impact of osteopathic care for spinal complaints. The bibliographic databases Medline (Pubmed), Web of Science, Embase, and PEDro were searched. In addition, a number of grey literature sources were searched. Only randomized controlled trials conducted in high-income Western countries were considered. Two authors independently screened the titles and abstracts. Primary outcomes included 'pain' and 'functional status', while secondary outcomes included 'medication use' and 'health status'. It was examined if differences existed related to the treatment protocol and geography (European vs. US studies). Study quality was assessed using the risk of bias tool of the Cochrane Back Review Group. Nineteen studies were included and qualitatively synthesized. Nine studies were from the US, followed by Germany with seven studies. The majority of studies (n = 13) focused on low back pain. In general, mixed findings related to the impact of osteopathic care on primary and secondary outcomes were observed. For the primary outcomes, a clear distinction between US and European studies was found, in favor of the latter ones. Studies were characterized by substantial methodological differences in sample sizes, number of treatments, control groups, and follow-up. In conclusion, there is some evidence suggesting that osteopathic care may be effective for people suffering from spinal complaints. Further studies with larger study samples and assessment of long-term impact are required to further increase the evidence-based knowledge of the potential of osteopathic care for individuals suffering from spinal complaints.
Citation: Verhaeghe N, Schepers J, van Dun P, Annemans L (2018) Osteopathic care for spinal complaints: A systematic literature review. PLoS ONE 13(11): e0206284. https://doi.org/10.1371/journal.pone.0206284
Editor: Qinhong Zhang, Stanford University School of Medicine, UNITED STATES
Received: October 31, 2017; Accepted: October 10, 2018; Published: November 2, 2018
Copyright: © 2018 Verhaeghe et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper.
Funding: The study was funded by an unrestricted grant from the GNRPO, the umbrella organization of the Belgian Professional Associations for Osteopaths.
Competing interests: Patrick van Dun is an osteopath.
Spinal complaints including low back pain (LBP) and neck pain are common conditions. The epidemiology of these conditions is well studied. For LBP, lifetime prevalence of non-specific LBP is estimated to be about 84%, with the prevalence of chronic LBP about 23% [1]. Neck pain annual prevalence rates are estimated to range between 15% and 50% [2]. Spinal complaints are thus a frequent health problem and they are associated with considerable medical, social and economic consequences such as the need for medical care, limitations in activities, absence from work, and disability [3–6]. It is estimated that in less than 15% of LBP cases, a specific cause can be identified [7]. As a consequence, the origin of LBP and neck pain is often unknown meaning that it is not possible to identify a specific cause of the pain and as a consequence the complaints are considered 'non-specific' [8]. Guidelines on the treatment of spinal complaints include a variety of approaches such as exercise, cognitive behavioral therapy, multidisciplinary treatment, and spinal manipulation [9–11].
Manual therapy/medicine including osteopathy is a common treatment option for musculoskeletal complaints including LBP and neck pain, and its use has worldwide increased in the past decades [12]. Osteopathy was founded at the end of the 19th century in the United States (US) and introduced in Europe at the beginning of the 20th century. International differences in osteopathic healthcare regulation influence its scope of practice, which may explain some of the differences between US and European and Australasian osteopathic healthcare provision [12, 13]. Osteopathy can be defined as a primary contact and patient-centered healthcare discipline, that emphasizes the interrelationship of structure and function of the body, facilitates the body's innate ability to heal itself, and supports a whole-person approach to all aspects of health and healthy development, principally by the practice of manual treatment [14]. The findings of previous literature reviews [15–18] assessing the impact of osteopathic care for spinal complaints suggested clinically relevant effects for LBP and neck pain on reducing pain and improving functional status. In all reviews, it was concluded that the findings of the studies must be cautiously interpreted due to methodological considerations such as small sample sizes, lack of long-term follow-up, and differences in comparison groups. The aim of the current literature review was to evaluate published randomized controlled trials examining the effectiveness of care administered by osteopathic practitioners for improving pain and functional status in patients with spinal complaints as compared to control treatments. Conversely to the previous reviews focusing on a specific spinal area such as LBP [15, 17, 18] or neck pain [16], the current review focused on spinal complaints including back pain, LBP, neck pain, and pelvic girdle pain. In addition, conversely to the reviews by Franke et al. [16] and Orrock and Myers [18], no restrictions were made concerning the chronicity of the complaint. Finally, conversely to previous reviews, an analysis distinguishing between different osteopathic treatment protocols is considered.
Materials and methods
The study followed the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)' (S1 Table) [19]. A comprehensive literature review was conducted searching the peer-reviewed bibliographic databases Medline (Pubmed), Web of Science (Core Collection), Embase, and PEDro. For each database, a search algorithm was developed adapted to the specific requirements or features of the database using a combination of the terms 'low back pain' [MeSH], 'back pain' [MeSH], 'neck pain' [MeSH], 'pelvic pain' [MeSH], 'pelvic girdle pain' [MeSH], 'spine' [MeSH], 'manipulation, osteopathic' [MeSH], 'manipulation, spinal' [MeSH], 'osteopathic medicine' [MeSH], 'comparative effectiveness research' [MeSH], 'pragmatic clinical trial' [MeSH], 'osteopathy', 'osteopathic', 'manipulative', 'manipulation', 'spinal', 'effectiveness', and 'efficacy'. The databases were searched referring to the years 1995 (01/01) until 2018 (31/05). In addition, previous published literature reviews [15–18, 20] were searched to identify studies missed by our search. In the review by Franke et al. [15], a number of studies derived from the grey literature source www.osteopathic-research.com were also included. To be as comprehensive as possible, we also searched this website to identify additional records. In addition, the grey literature sources 'OAIster' (https://www.oclc.org/en/oaister.html) and 'OpenGrey' (http://www.opengrey.eu/) were searched using terms such as 'low back', 'neck', 'spine', 'osteopathy', 'osteopathic', 'trial', 'effectiveness'. The initial search yielded 1,346 records. After excluding the duplicates (n = 499), 847 records remained for further evaluation (Fig 1).
Eligibility criteria were defined using the PICOS (Population, Intervention, Comparator, Outcome, and Study design) strategy [21]. An overview of the eligibility criteria is listed in Table 1.
The titles and/or abstracts were independently screened on the inclusion and exclusion criteria by two authors (NV and JS). Variations in authors' opinion were resolved through discussion and consensus involving the other authors (LA and PvD).
Data analysis
The effect of osteopathic care on the primary outcomes 'pain' and 'functional status' was assessed considering four levels of effectiveness including (from poorest to best): (1) the outcome is found to be numerically or significantly worse from baseline to endpoint within the osteopathic care group or is found to be worse than in the comparison group, (2) there is no significant between-group difference, but the outcome is found to be numerically improved in the osteopathic care group compared to baseline, (3) there is no significant between-group difference, but the outcome is found to be significantly improved in the osteopathic care group compared to baseline, and (4) there is a significant difference between the osteopathic care group and the comparison group. Inspiration for choosing this classification was derived from a systematic review and meta-analysis of quality of care in for-profit and not-for-profit nursing homes [22]. It was examined if differences in level of effectiveness were found according to the treatment protocol. A distinction was made between 'custom tailored' (the determination of the treatment was left at the clinical judgement of the osteopathic practitioner), 'semi-standardized' (where the osteopathic practitioner could choose from a set of predefined manual techniques, or it included a single or a set of standardized manual technique(s) always to be offered along with free choice of manual techniques left at the clinical judgment of the practitioner), and 'standardized' (where the treatment protocol included a detailed description of manual techniques to be applied) treatment protocols. It was also examined if differences in impact of osteopathic care on pain and functional status existed between studies conducted in Europe vs. those conducted in the US. The secondary outcomes included the effect of osteopathic care on 'medication use' since this is an often used treatment option [23] and on 'health status' since spinal problems have a considerable impact on health-related quality of life [24, 25].
Assessment of risk of bias
The assessment of risk of bias was undertaken by one researcher (NV). In case of any doubt, this was resolved through discussion and consensus involving another author (PvD). The risk of bias in individual studies was assessed using a checklist of 12 criteria as recommended by the Cochrane Back and Neck Group [26]. For each study, the risk of bias criteria were scored 'yes' (criterion met), 'no' (criterion not met) or 'unsure'. The latter score was used in case information on the criterion was missing or not clear. A study was rated as having a 'low risk of bias' when at least six criteria were met. Contrary, a study was rated as having a 'high risk of bias' when fewer than six of the 12 criteria were met.
Study selection process
Seven hundred and sixty-nine records were excluded on title and abstract screening. So, 78 records remained of which the full-text was evaluated. Fifty-nine records (reasons: outcome, n = 31; intervention, n = 24; study design, n = 2; geography, n = 2) were excluded after the full-text evaluation resulting in 19 records included (Fig 1).
Study characteristics
Nine studies were conducted in the US [27–35], and seven in Germany [36–42]. Studies originating from the UK [43, 44] and Italy [45] made up the remaining studies (Table 2). In the majority of studies (n = 13), osteopathic care was aimed at people suffering from LBP (Table 2). The studies differed considerably related to the study populations based on age-groups, duration of the spinal complaints, or target groups such as 'obese females' [45], 'women post-partum' [36, 40] or 'diabetes mellitus patients' [32]. The number of treatment sessions varied from a single session [35] to ten sessions [45] (Table 2). In 13 studies [28, 31–34, 36–38, 40–44], a follow-up period was considered ranging from two weeks [42] to nine months [43, 44] (Table 2). The number of study participants receiving osteopathic care ranged from ten [45] to 353 [44] (Table 3). The osteopathic treatment protocol could be labelled as 'standardized' in one study [30], 'semi-standardized' in nine studies [28, 29, 31–33, 35, 43–45], and 'custom tailored' in nine studies [27, 34, 36–42] (Table 2). A wide variety of comparators across studies was observed (Table 3).
Primary outcome–pain
The impact of osteopathic care on pain was assessed in 17 studies (Table 4) applying different measurement instruments including the VAS [27, 28, 30–34, 39, 40, 45], the NRS [35, 37, 38, 41], the PRS [35], and the NPAD [37]. From a treatment protocol point of view, a 'custom tailored' protocol was applied in nine studies. Seven showed significant between-group differences in favor of the osteopathic care group compared to controls: Peters & Van der Linde [39] (between-group difference VAS: 4.7, p<0.0005), Heinze [38] (NRS: 2.5, p<0.001), Recknagel & Roß [40] (VAS: 4.6, p<0.001), Schwerla et al. [2008] [41] (NRS: average pain 1.7, p = 0.017), Schwerla et al. [2015] [42] (VAS: 4.8, p<0.001), Engemann & Hofmeier [37] (NPAD/NRS: 2.5, p<0.001), Belz et al. [36] (VAS: 3.8, p<0.0005) and Licciardone et al. [2003] [34] (osteopathic treatment vs. no intervention VAS: no exact figures reported). In those applying a '(semi-)standardized' protocol, osteopathic care was found to be effective compared to controls in five of eight studies (Table 4): Cruser et al. [28] (between-group difference: VAS: 1.5, p = 0.026), Vismara et al. [45] (VAS: 1.6, p<0.05), Licciardone et al. [2013a] [32] (1.7, p = 0.04), Licciardone et al. [2013b] [33] (0.9, p = 0.002), and Licciardone et al. [2016] [31] (0.8, p = 0.002). In all European studies (n = 8), significant differences in pain improvement in individuals receiving osteopathic care compared to controls were observed. In seven of these studies, a 'custom tailored' protocol was used (Table 4). In the US studies applying such a protocol (n = 2), the findings were less homogeneous. In Andersson et al. [27], an only non-significant pain improvement, measured using the VAS, of 3.2±2.3 points (p = 0.19) from baseline to treatment end was observed in the osteopathic care group. In Licciardone et al. [34], back pain significantly improved in those receiving osteopathic care compared to those receiving no intervention (p = 0.02), but not compared to participants receiving sham manipulation (p = 0.95). Overall, the most promising results in the US studies, i.e. merely significant differences between the osteopathic care group and the comparison groups were identified in only four of nine studies including Cruser et al. [28] (between-group difference: VAS: 1.5, p = 0.026), Licciardone et al. [2013a] [32] (1.7, p = 0.04), Licciardone et al. [2013b] [33] (0.9, p = 0.002), and Licciardone et al. [2016] [31] (0.8, p = 0.002) (Table 4).
Primary outcome–functional status
The impact of osteopathic care on functional status was examined in 15 studies (Table 5) applying different measurement tools including the RMDQ [27–31, 34, 38, 44–46], the ODI [42, 43, 45], the OPQ [27, 40], the QBPDS [39], and the PGQ [36]. In none of three studies focusing on the neck area [35, 37, 41], the impact of osteopathic care on functional status was assessed. In seven of eight European studies, osteopathic care was found to significantly improve functional status compared to controls: Peters & Van der Linde [39] (between-group difference QBPDS: 19.5, p<0.0005), Heinze [38] (RMDQ: 5.5, p<0.001), Recknagel & Roß [40] (OPQ: 1.8, p<0.001), Schwerla et al. [42] (ODI: 10.6, p<0.001), Belz et al. [36](PGQ: 13.9, p<0.0005), UK BEAM Trial Team [44] (RMDQ: OT + best care vs. best care: 1.01, p = 0.05; OT + best care + exercise vs. best care: 1.30, p = 0.001), and Vismara et al. [45] RMDQ: 4.14, p<0.05; ODI: 5.68, p<0.05). In the study by Chown et al. [43], improvements in functional status were observed in individuals receiving osteopathic care (mean -5.0, 95%CI: -1.6, -8.4, p<0.01), as well as in those receiving physiotherapy (mean -4.1, 95%CI: -1.4, -6.9, p<0.01). In all five European studies applying a 'custom tailored' treatment protocol, significant between-group differences in favor of osteopathic care were found, while this was not the case in the US studies applying such a protocol (Table 5). Overall in the US studies, osteopathic care was found to significantly improve functional status in only one study [29]. In that study, functional status significantly improved in patients receiving osteopathic care compared to those receiving usual obstetrical care (between-group difference measured by the RMDQ 2.25, p<0.001), but not compared to patients receiving placebo ultrasound therapy (0.21, p>0.999) (Table 5). In one US study [30], functional status at the end of treatment even deteriorated in the osteopathic care group (Table 5).
Secondary outcome–medication use
Information on the impact of osteopathic care on medication use was examined in four studies [27, 28, 33, 34] (Table 3). In the study by Cruser et al. [28], information on medication use was obtained from records, while in the study by Licciardone et al. [2013b] [33], this information was collected from patients or from community-based clinicians. In the two other studies [27, 34], no detailed information how data on medication use was collected was provided. In Andersson et al. [27], significant differences in prescription practices between the osteopathic care group and a control group receiving standard allopathic care were observed for anti-inflammatory drugs (24.3% vs. 54.3%, p<0.001), and muscle relaxants (6.3% vs. 25.1%, p<0.001). Licciardone et al. [34] identified no significant differences in back-specific medication use between the osteopathic care group and a control group receiving sham manipulation. In another study by Licciardone et al. [33], a significant difference in the use of prescription drugs for LBP was found between the study population receiving osteopathic care and those receiving sham manipulation (13.0% vs. 20.0%, p = 0.048). Finally, Cruser et al. [28] identified no significant differences in medication prescribing practices between patients in osteopathic care and those receiving usual care for LBP.
Secondary outcome–health status
The impact of osteopathic care on health status was evaluated in six studies [33, 34, 37, 41, 43, 44]. Licciardone et al. [2003] [34] found significantly better scores for physical functioning and mental health (measured by the SF-36) one month after treatment in the osteopathic care group compared to the no intervention group. Compared to sham manipulation, significant between-group differences were only identified for physical functioning, but not for mental health. In another study by Licciardone et al. [2013b] [33], no significant effects on health status (measured by the SF-36) were observed (mean [IQR] OT vs. sham OT: 72 [52–87] vs. 72 [57–87], p = 0.87). In the UK BEAM trial [44] the effect of osteopathic care in addition to 'best care' on health-related quality of life was measured by the SF-36. A significant between-group difference (osteopathic care + best care vs. best care) was found for the physical component score at the end of a three-month treatment period (between group difference: 2.52 [95%CI: 1.30, 3.74], p<0.001) and after nine months of follow-up (1.68 [95%CI: 0.18, 3.19], p<0.05). For mental health, this was only observed at the end of the treatment phase (2.88 [95%CI: 1.36, 4.40], p<0.001). In Chown et al. [43], health-related quality of life (measured by the EQ-5D) significantly improved in individuals receiving osteopathic care (mean difference at 6 weeks: 0.11 [95%CI: 0.02, 0.19], p<0.05) as well as in the physiotherapy group (mean difference at 6 weeks: 0.10 [95%CI: 0.01, 0.18], p<0.05). In Schwerla et al. [41], a significant difference in bodily pain (measured by the SF-36) was identified in the study population receiving osteopathic care and in those receiving sham ultrasound (between-group difference: 14.6 [95%CI: 2.58, 26.60], p = 0.019). Finally, in the study by Engemann & Hofmeier [37], a significant-between group difference was observed between the osteopathic care group and the no intervention group for the physical component (between-group difference: 8.7, p = 0.012) and mental component score (7.5, p = 0.05).
Risk of bias
All 19 studies had a low risk of bias, meaning that at least six of the criteria were met (Table 6). In none of the studies blinding of patients, care provider or outcome assessor occurred or it was unclear. Important to note is that in three studies [29, 38, 42] the study groups differed to some extent at baseline. In Schwerla et al. [42], pain intensity at baseline (measured by the Oswestry Disability Index) was significantly different between the osteopathic care group and the controls (16.8±6.7 vs. 22.1±7.2; p = 0.001). In the study by Heinze [38], a significant between-group difference in Numerical Rating Scale score was observed (intervention vs. control: 6.5 vs. 5.9; p = 0.04). In Hensel et al. [29], subscale pain scores (measured by the Quadruple Visual Analog Scale) for 'pain now' and 'pain best' significantly differed between the three study groups (osteopathic care, ultrasound placebo, and usual care). In the latter study, a linear mixed model suitable for repeated measures was applied and models were adjusted for baseline values to address differences in baseline pain and disability. In the studies by Schwerla et al. [42] and Heinze [38] no information if the authors did control for the differences at baseline was reported.
The current literature review was to some extent different from previous reviews assessing the effectiveness of osteopathic care for spinal complaints. Previous reviews were aimed at a specific spinal area such as non-specific LBP [15, 17, 18] or chronic non-specific neck pain [16]. Conversely, for the current review, randomized controlled trials examining the effect of osteopathic care for spinal complaints independently from their location and from the pain duration were considered. Giving consideration to an 'authentic' osteopathic intervention and thus considering the 'real-world' osteopathic practice, only studies in which the treating osteopathic practitioner had a free choice of determining the treatment based on the clinical judgement were eligible for inclusion in the reviews by Franke et al. [15, 16]. For the current review, we defined studies applying such an approach as being 'custom tailored'. Though recognizing this pragmatic approach representing 'real-world' osteopathic practice, we also included studies applying a 'standardized' or 'semi-standardized' protocol in order to assess possible differences in effectiveness between the different treatment protocols. For the outcome 'pain', significant between-group differences were observed in eight of nine studies applying a 'custom tailored' approach, while these figures were seven of seven studies for those applying a 'semi-standardized' protocol. For functional status, significant between-group differences were identified in five of seven studies and three of seven studies applying a 'custom tailored' and 'semi-standardized' protocol, respectively. In the one study with a 'standardized' osteopathic intervention, a non-significant between group difference was observed.
In general, the results showed mixed findings related to the impact of osteopathic care for spinal complaints on the primary outcomes 'pain' and 'functional status'. In some studies, osteopathic care was found to be effective compared to control groups. In other studies, significant improvements in pain and functional status were observed in the osteopathic care groups, but no significant between-group differences were identified. Finally, in some studies neither significant within-group or between-group effects were found. For pain, significant between-group differences in favor of osteopathic care were observed in all European studies, while for functional status this was the case in all but one study. The findings from the US studies of the impact of osteopathic care on pain and functional status were less homogeneous. For 'functional status', differences in treatment protocols may probably explain the variation in effects of osteopathic care between European and US studies. Five of eight European studies evaluating functional status applied a 'custom tailored' protocol, all showing osteopathic care to be effective. Contrary, in the two US studies with such a protocol, osteopathic care resulted in a non-significant improvement in functional status. For the outcome measure 'pain', the association with treatment protocol was less clear. Thus, it appears that other elements than the treatment protocol are likely to explain the differences in impact of osteopathic care for spinal complaints between European and US studies. A possible explanation is the, largely for historical reasons, different evolution of osteopathy in Europe vs. the US, creating two professionals streams with two different scopes of practice. Osteopathy in Europe thus developed within a more limited scope of practice, concentrating more on manual techniques [13]. Mixed findings were also found for the secondary outcomes of interest 'medication use' and 'health status'.
The results related to the outcomes 'pain' and 'functional status' were evaluated taking into account four levels of effectiveness. We are aware that presenting the findings in such a way is rather unusual. This approach enabled us to compare the findings based on different variables such as study protocol (custom tailored, semi-standardized, and standardized) and geography (European vs. US studies). In addition, this method appeared to be appropriate as the current study consisted of a qualitative evidence synthesis. This type of literature is now acknowledged as a necessary and valuable type of information to answer health service research questions [47]. The studies were characterized by a number of clinical and methodological differences including different treatment protocols, differences in treatment strategies in the comparison groups (e.g. no intervention, sham manipulation, exercise, physiotherapy), differences in treatment duration, absence of follow-up in some studies, different target populations (e.g. pregnant women, obese females, women post-partum, diabetes patients), and differences in sample sizes. Such differences hinder the comparison of the findings across studies. The extent of methodological heterogeneity between the included studies was not quantified since this is useful for the interpretation of a meta-analysis [48] and it was not the aim of the current study to perform such analysis. Studies based on more homogeneous methodologies would enable to better compare the findings of trials. Nevertheless, we decided to include studies irrespective of their differences in methodologies to provide a broad overview of the impact of osteopathic care in the treatment of spinal complaints. Several of these methodological shortcomings were already addressed in previous literature reviews [15–18] examining the impact of osteopathic care for spinal complaints, but also in reviews of the effect of osteopathic care for other conditions such as irritable bowel syndrome [49], lower urinary tract symptoms in women [50], pediatric conditions [20], and length of stay in preterm infants [51].
A number of limitations need to be addressed. First, only studies published from 1995 on were eligible for inclusion. It is thus possible that we have missed relevant papers prior to 1995. Second, there is a risk of reporting bias, since only studies published in English, French, German, or Dutch were considered. Third, the review focused on the outcomes 'pain', 'functional status', 'medication use', and 'health status'. We are aware that other outcomes may also be worthwhile to study such as the impact of osteopathic care on productivity and satisfaction with treatment. Fourth, five studies were derived from the 'grey literature' which is not peer-reviewed. However, since only randomized controlled study designs were considered, these studies met this inclusion criterion. Moreover, the quality of these papers was also assessed using the checklist as recommended by the Cochrane Back Review Group. Fifth, assessment of the risk of bias was performed by one researcher, while the 'Cochrane Back and Neck Group' indicate that risk of bias in the studies should be independently assessed by at least two authors [26].
In conclusion, the findings of the current literature review suggested that osteopathic care may improve pain and functional status in patients suffering from spinal complaints. A clear distinction was observed between studies conducted in the US and those in Europe, in favor of the latter. Today, no clear conclusions of the impact of osteopathic care for spinal complaints can be drawn. Further studies with larger study samples also assessing the long-term impact of osteopathic care for spinal complaints are required to further strengthen the body of evidence.
Appendix 1 Search strategy Medline (Pubmed)
1. Low back pain [MeSH]
2. Back pain [MeSH]
3. Neck pain [MeSH]
4. Pelvic pain [MeSH]
5. Pelvic girdle pain [MeSH]
6. Spine [MeSH]
7. Spinal [title/abstract]
9. Manipulation, osteopathic [MeSH]
10. Manipulation, spinal [MeSH]
11. Osteopathic medicine [MeSH]
12. Osteopathy [title/abstract]
13. Osteopathic [title/abstract]
14. Manipulative [title/abstract]
15. Manipulation [title/abstract]
17. Comparative effectiveness research [MeSH]
18. Pragmatic clinical trial [MeSH]
19. Effectiveness [title/abstract]
20. Efficacy [title/abstract]
Limits: publication date 01/01/1995–31/05/2018; humans
Supporting information
S1 Table. PRISMA 2009 checklist.
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Medigap Insurance in Lakeville, MA
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More Massachusetts Cities Nearby:
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text:
Home in Texas Review 17 Main Idea Drawing Conclusions
- Jonas Kennedy
- 1 years ago
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1 Home in Texas Revi iew 17 Main Idea Drawing Conclusions
2 1. Angelina looked at the calendar and sighed. It was Cinco de Mayo, and she was missing one of her favorite holidays. Back at her old home, everyone would be getting ready to celebrate. Angelina wished she were back in Puebla with her friends. She often dreamed of returning to Mexico. Things were so different in Texas. Sometimes she thought she would never get used to it. It was hard to believe that so much had changed in just one year. May 5 is probably just another day here in Texas, Angelina said to herself. 2. Angelina thought of the Cinco de Mayo parade her family had attended the previous year in Puebla. She remembered how the parade route had looked last year. It was always decorated with beautiful Mexican flags. Each year her family would wake up early and hurry to the parade. If they got there too late, they wouldn t get a good spot where they could see everything. 3. However, today Papá had gotten the family up early, but it wasn t for a parade. He had business downtown. Angelina hoped Papá would take the family out for a hamburger later for lunch. 4. Thinking about food made her miss the holiday even more. She knew that many booths were already lining the parade route in Puebla. She wished she could be there eating mole. It was her favorite food. She thought of the thick, spicy-sweet sauce spread over chicken. Then she felt even more homesick. 5. At last it was time to go. As Angelina and her parents got into their car, Angelina asked, What kind of business do you have to do, Papá? 6. I just have to see a few people downtown, he replied. Angelina thought she saw him wink at Mamá. 7. He probably thinks I m too young to understand, she thought. 8. Before long they were making their way through the downtown streets. Angelina thought the streets were unusually crowded. Then she saw a line of people forming on each side of the city s main street. Could it be a parade? Papá, what is this? she asked excitedly. 9. Why, it s the Cinco de Mayo parade, of course, he said, laughing. You didn t think we would miss it just because we moved to Texas, did you? 10. I don t understand, Angelina said. Isn t Cinco de Mayo a Mexican holiday? 11. Yes, of course, Papá said. But many families like us have moved from Mexico and now live in Texas. Other Mexican families have been in Texas a very long time. To remember their past, people celebrate Cinco de Mayo here, too.
3 12. Angelina couldn t believe it. Suddenly the whole day seemed brighter. After Papá parked the car, Angelina and her parents found a good spot where they could watch the parade. Soon Angelina heard the boom of a drum and the sounds of a large marching band playing Mexican music. Angelina tapped her foot and nodded her head to the beat. Next came the dancers, followed by a mariachi band. The women twirled around in their red, blue, and orange dresses to the band s music. Their full skirts spread straight out as they spun past the crowds of people. The men in their fancy black-and-gold suits danced around the women. One dancer even pulled Angelina from the crowd to dance with him. She had never thought she would have such fun today! 13. After the parade Angelina s family walked across the street to the many booths set up there. The smell of food filled the air. Angelina asked Papá and Mamá to take her straight to a booth that sold mole. The mole had never tasted so good! While they ate, the family enjoyed listening to a mariachi band. Angelina clapped and sang along to her favorite songs as the band played. 14. Angelina s family spent the whole day at the celebration. That night red, green, and gold fireworks flashed brightly against the black sky. The show ended, and it was finally time to leave. Angelina smiled as they walked back to the car. She suddenly felt that Texas was a lot more like home.
4 1. How do Angelina s feelings about her new home change by the end of this story? a. She wants to move back to Puebla. b. She doesn t like Cinco de Mayo parades anymore. c. She thinks Cinco de Mayo isn t fun. d. She feels better about living in Texas. 2. In Puebla, why did Angelina and her parents hurry to the parade each year? a. Papá had business there. b. They wanted to visit the food booths early in the day. c. Angelina wanted to help get the parade ready. d. They wanted a good spot where they could watch the parade. 3. What is paragraph 2 mainly about? a. What Cinco de Mayo is like in Puebla? b. The beautiful flags on the parade route c. The business that Papá has downtown d. The food people eat for Cinco de Mayo 4. Papá tells Angelina that he has business downtown because he a. doesn t want to take her to the parade b. wants Angelina to be surprised by the parade c. doesn t want Angelina to worry about him d. wants to take Angelina downtown for lunch
5 5. Soon Angelina heard the boom of a drum and sounds of a large marching band playing Mexican music. Playing in this sentence is the same as a. have fun b. performing c. fool around d. occupy yourself 6. When Angelina s family arrives downtown, why are the streets so crowded? a. People are gathering to watch the parade. b. People are busy hanging flags around the square. c. Many people have business downtown. d. Many people have moved to Angelina s new town. 7. Which sentence from this story shows that Mamá knows that Papá is taking the family to see the parade? a. Sometimes she thought she would never get used to it. b. Each year her family would wake up early and hurry to the parade. c. Angelina thought she saw him wink at Mamá d. He probably thinks I m too young to understand, she thought. 8. Why does Angelina sigh when she looks at the calendar? a. She doesn t want to help Papá. b. She has to get up early in the morning. c. She thinks she is missing a fun holiday. d. S he doesn t want to go downtown.
6 9. What happens right after Angelina and her parents arrive downtown? a. They watch the fireworks. b. Papá meets with some business people. c. Her family gets into the car to leave. d. Angelina sees people lining up for a parade. 10. What is Angelina s problem in this story? a. Papá won t let her go to the parade b. She has forgotten about Cinco de Mayo. c. She misses her home in Puebla. d. Papá has to work on a holiday. 11. Which is the base word in the word unusually? a. un b. use c. usual d. ly 12. In this selection several contractions were used. Write the two words that make up each contraction. a. wasn t b. I m c. it s d. couldn t
7 Answer Key 1 D 2 D 3 A 4 B 5 B 6 A 7 C 8 C 9 D 10 C 11 C 12 wasn t was not I m I am it s it is couldn t could not
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Should You buy a custom domain while starting blogging or learning website designing? What is Custom Domain and the benefits of it ?
According to me the answer is 'No'. If you are a beginner in blogging field or you are just learning website designing then there is no need to buy a domain. There are many websites from where you can get free domain name for your blog or for your website. Example of this types of domain names are (e.g www.yourdomainname.tk, www.yourdomainname.ml, www.yourdomainname.cu.ma etc.) , You can easily get this types of domain names at free of cost for 12 months and if your blog getting popular during this period then you can buy this domain also from that website and trust me you can buy this domain less cheaper then domain names with .com, .in, .org etc. A popular website from where you can get your free domain name for 12 months is www.freenom.com ( Freenom world is a fast and anonymous Public DNS resolver ).
But if you had experience with blogging and you want popularity and if you are looking forward to creating a career in blogging and want to earn, in that case this is a huge mistake. Self -hosted blogs are best options for those who are looking to become professional blogger.
When you sign up for blogger or wordpress.com you get a domain name like,
- www.yourblogname.blogspot.com
- www.yourblogname.wordpress.com
- www.yourblogname.tk
- www.yourblogname.ml
- www.yourblogname.ga
- www.yourblogname.cf
- www.yourblogname.gq
- www.yourblogname.cu.ma etc.
But for professional blogs, these kinds of domains are bad.
Many bloggers who blog using a free blogging platform usually don't like to invest in a custom domain. They keep on blogging for years on the same sub-domain. They feel they can always change to a custom domain when they're getting more traffic. But that's not always true. In most of the case do you know what happens? When there blog getting more traffic they think that if they change their domain name means if they set a custom domain with .com or .in etc. they lost many traffic and they have to start from the beginning. And it is totally true, if your blog or website getting popular and getting more traffic day by day then you never can't change your sub-domain name, if you do so then you have to face a big loss. So if you don't want to face that situation and want to start your blogger career then you should buy a top-level root domain name ( TLD ) .
Problems without custom doman name?
- If you're blogging for a year and can drive lots of traffic, then your blog will have built up some domain authority. But when you switch to a custom domain, you will lose all of that DA, and you'll have to start from the beginning. Even though you can maintain your rank in SERPs, your DA will go back to 0, means you have to start again from zero and facing a big loss in your daily earning.
- When you search for your blog in search engines, your new address won't be visible for a while. It takes time for Google to pass on the link juice (after a 301 redirection) from an old sub-domain to your new root TLD.
- You will need to submit a sitemap to all search engines again.
- You'll need to update your blog's address on all social media profiles
- When you shift from a sub-domain to a custom domain, you need to re-brand and re-market this new domain name. Because if you not give a notice or declare few week ago before changing you sub-domain to a custom domain, may be most of your blog/ website visitor can't find your blog/ website and as a result your traffic will go down.
- If you already do the mistakes, then here are two tips to getting out from this situation and gain high traffic again.
- Don't change your sub-domain. Most of the website provide sub-domains at free of cost for 12 months only and after that they charged you. So if your website or blog is getting popular during this 12 months duration then don't change the sub-domain. after 12 months just renew it because you can earn much more using this sub-domain.
- If you already take decision to change your sub-domain into a custom domain then before changing the sub-domain give a notice on your blog or website that after this date the new address of your website or blog will be www.yournewcustomdomainname.com/.in etc.
- If you already changed your sub-domain to a custom domain and for that your traffic is getting down then give advertisement on social media sites and also if possible on Google Adwords. For publishing and getting more traffic you can use www.quora.com or any other question-answer website as in this website you can find many question regarding a type of website what already you have. So answer that questions and give them the link of your website, as example if you provide pdf on your website and in quora any one find that pdf then you can give him/her the link of your website page so that he/she can get that pdf and you can get traffic.
Benefits Of Having A Custom Domain Name:
- You have better exposure in search engines. Search engines (especially Google) prefer to link to root domains rather than .blogspot.com or .wordpress.com domains or other sub-domains. (Notes: .tk / .ml this type of domains are not root domains ). If you want to know about root domains then Click Here .
- You can also increase your chances of getting approval for your AdSense account. If you created your adsense account using Admob or YouTube or Blogger then your Adsense account is Hosted account and a hosted adsense account can't publish ads on websites or blogger platform, so in that case if you want to convert your Google AdSense account from Hosted to Non-Hosted Adsense account then you have to use a root domain as .com / .in etc.
- Root level domains are a lot more trustworthy in the eyes of users. If you are trying to make money blogging, you'll have a much easier time with a custom domain than you would with a free sub-domain.
- You can have a contact email like email@example.com rather than a Gmail or Yahoo email. Though for this email id you have to pay a lil.
- You can publicize your domain name with ease rather than having to say a long name.
The most important point is that you will have a brand name from day one. so if you want to turn blogging into your profession then purchasing a custom domain is very much important from day 1.
What I'm writting in this blog is from my own experience. I made this mistakes already what I described before, so I can say that if you want blogging into your profession or you want to earn money from your blog or website then you must buy a custom domain. Because it is true that you can earn from your blog or website by various of Ads network as PropellerAds or PopAds or ReveneuHits . But you can't earn that much what you can earn using Google Adsense platform. And from my personal experience I can say that if you have not a root domain address then it is difficult to get approval from adsense.