title: THE EFFECT OF AXIOSCAPULAR AND ROTATOR CUFF EXERCISE TRAINING SEQUENCE IN PATIENTS WITH SUBACROMIAL IMPINGEMENT SYNDROME: A RANDOMIZED CROSSOVER TRIAL. A specific exercise strategy reduced the need for surgery in subacromial pain patients Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. A pragmatic randomised controlled trial of local corticosteroid injection and physiotherapy for the treatment of new episodes of unilateral shoulder pain in primary care Efficacy of Proprioceptive Exercises in Patients with Subacromial Impingement Syndrome: A Single-Blinded Randomized Controlled Study Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults. Evidence for physiotherapy practice: a survey of the Physiotherapy Evidence Database (PEDro). 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Short-Term Effectiveness of Precut Kinesiology Tape Versus an NSAID as Adjuvant Treatment to Exercise for Subacromial Impingement: A Randomized Controlled Trial Clinical effectiveness of kinesiological taping on pain and pain-free shoulder range of motion in patients with shoulder impingement syndrome: a randomized, double blinded, placebo-controlled trial. Efficacy of Hand Behind Back Mobilization With Movement for Acute Shoulder Pain and Movement Impairment: A Randomized Controlled Trial. Neurocognitive therapeutic exercise improves pain and function in patients with shoulder impingement syndrome: a single-blind randomized controlled clinical trial. Interferential laser therapy in the treatment of shoulder pain and disability from musculoskeletal pathologies: a randomised comparative study. Cervicothoracic Manual Therapy Plus Exercise Therapy Versus Exercise Therapy Alone in the Management of Individuals With Shoulder Pain: A Multicenter Randomized Controlled Trial. 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Comparison of efficacy of kinesiological taping and subacromial injection therapy in subacromial impingement syndrome Is Extracorporeal Shockwave Therapy Combined With Isokinetic Exercise More Effective Than Extracorporeal Shockwave Therapy Alone for Subacromial Impingement Syndrome? A Randomized Clinical Trial. A double-blind randomised controlled study comparing subacromial injection of tenoxicam or methylprednisolone in patients with subacromial impingement. Low-level laser therapy in subacromial impingement syndrome. Effects of acupuncture and placebo TENS in addition to exercise in treatment of rotator cuff tendinitis Pulsed radiofrequency versus conventional transcutaneous electrical nerve stimulation in painful shoulder: a prospective, randomized study Comparison of customized versus standard exercises in rehabilitation of shoulder disorders The effects of scapular mobilization in patients with subacromial impingement syndrome: a randomized, double-blind, placebo-controlled clinical trial. Effects of Stretching and Strengthening Exercises, With and Without Manual Therapy, on Scapular Kinematics, Function, and Pain in Individuals With Shoulder Impingement: A Randomized Controlled Trial. [Extracorporeal shockwave therapy (ESWT) as therapeutic option in supraspinatus tendon syndrome? One year results of a placebo controlled study]. Injection of the subacromial bursa in patients with rotator cuff syndrome: a prospective, randomized study comparing the effectiveness of different routes. 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A randomized, clinical trial Supervised Exercises Compared With Radial Extracorporeal Shock-Wave Therapy for Subacromial Shoulder Pain: 1-Year Results of a Single-Blind Randomized Controlled Trial Does Passive Mobilization of Shoulder Region Joints Provide Additional Benefit Over Advice and Exercise Alone for People Who Have Shoulder Pain and Minimal Movement Restriction? A Randomized Controlled Trial The therapeutic role of motor imagery on the functional rehabilitation of a stage II shoulder impingement syndrome
abstract: BACKGROUND While physical therapy is an effective element in the rehabilitation of rotator cuff ( RC ) disease , the most effective sequence of exercise training interventions has not been defined . HYPOTHESIS/ PURPOSE The purpose of this study is to determine if there is a difference in pain or function in patients who are given RC strengthening prior to or after initiating scapular stabilization exercises .  STUDY DESIGN Level I r and omized crossover trial . METHODS This was a prospect i ve study of 26 men and 14 women with a mean age 51 who were diagnosed with subacromial impingement syndrome ( SAIS ) . They were r and omly assigned to one of two groups for a comprehensive and st and ardized rehabilitation program over six visits at an orthopedic outpatient clinic . One group was prescribed a 4-week program of scapular stabilization exercises while the other group began with RC strengthening exercises . The crossover design had each group add the previously excluded four exercises to their second month of rehabilitation . RESULTS The results showed significant improvements in pain ( p < 0.001 ) , function ( p < 0.001 ) , and patient satisfaction ( p < 0.001 ) at all follow-up times for both groups . There was not a statistically significant difference in pain or function at any follow-up period for initiating one group of exercise before the other ( p > 0.05 ) . There was a statistically significant interaction between the patient 's global rating of change at the 4 week follow-up as compared to 8 weeks ( p = 0.04 ) or 16 ( p < 0.001 ) . CONCLUSION Patients with SAIS demonstrate improvement in pain and function with a st and ardized program of physical therapy regardless of group exercise sequencing . LEVEL OF EVIDENCE 1b Background and purpose A programme based on eccentric exercises for treating subacromial pain was in a previous study found effective at 3-month follow-up . The purpose s of the present study were to investigate whether the results were maintained after 1 year and whether the baseline Constant-Murley score , rotator cuff status and radiological findings influenced the outcome . Patients and methods 97 patients on the waiting list for arthroscopic subacromial decompression had been r and omised to a specific exercise programme or unspecific exercises ( controls ) .  After 3 months of exercises , the patients were asked whether they still wanted surgery and this option was available until a 1-year follow-up . 1 year after inclusion or 1 year after surgery , the number of patients who decided to have surgery in each group was compared . The choice of surgery was related to the baseline Constant-Murley score , ultrasound and radiographs taken at inclusion . Results All patients had improved significantly ( p<0.0001 ) in the Constant-Murley score at the 1-year follow-up . Significantly more patients in the control group decided to have surgery ( 63 % ) than those in the specific exercise group ( 24 % ; p<0.0001 ) . Patients who decided to have surgery had a significantly lower baseline Constant-Murley score and more often a full-thickness tear . Patients with partial tears did not differ from those with intact tendons . Interpretation The positive short-term results of specific exercises were maintained after 1 year , and this exercise strategy reduces the need for surgery . Full-thickness tear and a low baseline Constant-Murley score appear to be a predictive marker for a less good outcome . Trial registration number Clinical trials NCT01037673 STUDY DESIGN A prospect i ve r and omized clinical trial . OBJECTIVE To compare the effectiveness of 2 physical therapy treatment approaches for impingement syndrome of the shoulder . BACKGROUND Manual physical therapy combined with exercise is a commonly applied but currently unproven clinical treatment for impingement syndrome of the shoulder . METHODS AND MEASURES Thirty men and 22 women ( age 43 years + /- 9.1 ) diagnosed with shoulder impingement syndrome were r and omly assigned to 1 of 2 treatment groups . The exercise group performed supervised flexibility and strengthening exercises . The manual therapy group performed the same program and received manual physical therapy treatment . Both groups received the selected intervention 6 times over a 3-week period . The testers , who were blinded to group assignment , measured strength , pain , and function before treatment and after 6 physical therapy visits . Strength was a composite score of isometric strength tests for internal rotation , external rotation , and abduction . Pain was a composite score of visual analog scale measures during resisted break tests , active abduction , and functional activities . Function was measured with a functional assessment question naire . The visual analog scale used to measure pain with functional activities and the functional assessment question naire were also measured 2 months after the initiation of treatment . RESULTS Subjects in both groups experienced significant decreases in pain and increases in function , but there was significantly more improvement in the manual therapy group compared to the exercise group . For example , pain in the manual therapy group was reduced from a pretreatment mean ( + /- SD ) of 575.8 ( + /- 220.0 ) to a posttreatment mean of 174.4 ( + /- 183.1 ) . In contrast , pain in the exercise group was reduced from a pretreatment mean of 557.1 ( + /- 237.2 ) to a posttreatment mean of 360.6 ( + /- 272.3 ) . Strength in the manual therapy group improved significantly while strength in the exercise group did not . CONCLUSION Manual physical therapy applied by experienced physical therapists combined with supervised exercise in a brief clinical trial is better than exercise alone for increasing strength , decreasing pain , and improving function in patients with shoulder impingement syndrome Objectives : To compare the long term effectiveness of local steroid injections administered by general practitioners with practice based physiotherapy for treating patients presenting in primary care with new episodes of unilateral shoulder pain . Methods : Adults consulting with shoulder pain were recruited by their general practitioner . Patients were r and omly allocated to receive either corticosteroid injections or community based physiotherapy . Primary outcome was self reported disability from shoulder problems at six months . Secondary outcomes included participant ’s global assessment of change ; pain ; function ; “ main complaint ” ; range of shoulder movement ; co- interventions . A study nurse unaware of the treatment allocation performed baseline and follow up assessment s. Analysis was by intention to treat . Results : Over 22 months 207 participants were r and omised , 103 to physiotherapy and 104 to injection . Prognostic variables were similar between the two groups at baseline . Mean ( SD ) improvements in disability scores at six weeks were 2.56 ( 5.4 ) for physiotherapy and 3.03 ( 6.3 ) for injection ( mean difference=−0.5 , 95 % confidence interval ( 95 % CI ) : −2.1 to 1.2 ) and at six months were 5.97 ( 5.4 ) for physiotherapy and 4.55 ( 5.9 ) for injection ( mean difference=1.4 , 95 % CI −0.2 to 3.0 ) . A “ successful outcome ” ( a minimum 50 % drop in the disability score from baseline ) at six months was achieved by 59/99 ( 60 % ) in the physiotherapy group and 51/97 ( 53 % ) in the injection group ( percentage difference=7 % , 95 % CI −6.8 % to 20.4 % ) . Co- interventions were more common in the injection group during follow up . Conclusion : Community physiotherapy and local steroid injections were of similar effectiveness for treating new episodes of unilateral shoulder pain in primary care , but those receiving physiotherapy had fewer co- interventions Objective The objective of this study was to evaluate the effectiveness of proprioceptive exercises on shoulder proprioception , range of motion , pain , muscle strength , and function in patients with subacromial impingement syndrome . Design Sixty-one patients with subacromial impingement syndrome participated in this prospect i ve , single-blind r and omized controlled trial . All patients were r and omly divided into two groups : control group ( conventional physiotherapy , n = 30 ) and intervention group ( proprioceptive exercise and conventional physiotherapy , n = 31 ) . The primary outcome measures were sense of kinesthesia and active and passive repositioning for proprioception at 0 degrees and 10 degrees external rotation at 12 wks . The secondary outcome measures were pain at rest , at night , and during activities of daily living with the visual analog scale ( 0–10 cm ) , the Western Ontario Rotator Cuff index , the American Shoulder and Elbow Surgeons index , range of motion , and isometric muscle strength at both 6 and 12 wks . Results After treatment , significant improvement was found in range of motion , pain , isometric muscle strength , kinesthesia at 0 degrees external rotation , and functional tests in both groups . The intervention group showed a significant improvement in kinesthesia at 10 degrees external rotation and active and passive repositioning at 10 degrees external rotation . When groups were compared , there were no statistically significant differences in any of the parameters at 12 wks . Conclusions Although proprioceptive exercises may provide better proprioceptive acuity , no additional positive effect on other clinical parameters was observed Generalized shoulder pain is a common problem that is difficult to treat and frequently recurrent . The asymptomatic cervical spine must be ruled out as a cause of any shoulder pain , as it can have a similar presentation to an isolated shoulder disorder . Previous studies have shown that lateral cervical glide mobilizations to the asymptomatic cervical spine at C5/6 can affect peripheral pain , but none have examined shoulder pain . A r and omized , blinded , placebo-controlled , cross-over trial was used to examine the immediate effects of cervical lateral glide mobilizations on pain intensity and shoulder abduction painful arc in subjects with shoulder pain . Twenty-one subjects received interventions of both cervical mobilization and placebo over two sessions . Pain intensity using a visual analog scale ( VAS ) and painful arc were assessed prior to and following application of cervical mobilization or placebo intervention . Evaluation of cervical mobilization revealed the shoulder abduction painful arc ( 12.5 degrees + /-15.6 degrees , p=0.002 ) and shoulder pain intensity ( 1.3+/-1.1 cm , p<0.001 ) were significantly decreased . The results of this study suggest that any immediate change in shoulder pain or active shoulder range of motion following cervical mobilizations indicate that treatment directed toward the asymptomatic cervical spine may expedite recovery Evidence -based practice involves the use of evidence from systematic review s and r and omised controlled trials , but the extent of this evidence in physiotherapy has not previously been surveyed . The aim of this survey is to describe the quantity and quality of r and omised controlled trials and the quantity of systematic review s relevant to physiotherapy . The Physiotherapy Evidence Data base ( PEDro ) was search ed . The quality of trials was assessed with the PEDro scale . The search identified a total of 2,376 r and omised controlled trials and 332 systematic review s. The first trial was published in 1955 and the first review was published in 1982 . Since that time , the number of trials and review s has grown exponentially . The mean PEDro quality score has increased from 2.8 in trials published between 1955 and 1959 to 5.0 for trials published between 1995 and 1999 . There is a substantial body of evidence about the effects of physiotherapy . However , there remains scope for improvements in the quality of the conduct and reporting of clinical trials Objectives : To conduct a feasibility study to compare concentric and eccentric rotator cuff strengthening exercises for rotator cuff tendinopathy . Methods : A total of 11 patients with rotator cuff tendinopathy who were on the waiting list for arthroscopic subacromial decompression surgery were r and omised to perform eccentric rotator cuff strengthening exercises , concentric strengthening exercises or no exercises . Patients were evaluated in terms of levels of pain and function using the Oxford Shoulder Score and a Visual Analogue Scale initially , at 4 weeks and at 8 weeks . Results : The study design was found to be acceptable to patients and achieved a high level of 86 % compliance . The drop-out rate was 0 % . Two patients performing eccentric strengthening exercises  improved sufficiently to cancel their planned surgery . Conclusion : Further research in this area is recommended . The study design was feasible and power calculations have been conducted to aid future research planning OBJECTIVES : Conflicting results were reported about the effectiveness of Low level laser therapy on musculoskeletal disorders . The aim of this study was to investigate the effectiveness of 850‐nm gallium arsenide aluminum ( Ga‐As‐Al ) laser therapy on pain , range of motion and disability in subacromial impingement syndrome . METHODS : A total of 52 patients ( 33 females and 19 males with a mean age of 53.59±11.34 years ) with subacromial impingement syndrome were included . The patients were r and omly assigned into two groups . Group I ( n = 30 , laser group ) received laser therapy ( 5 joule/cm2 at each point over maximum 5‐6 painful points for 1 minute ) . Group II ( n = 22 , placebo laser group ) received placebo laser therapy . Initially cold pack ( 10 minutes ) was applied to all of the patients . Also patients were given an exercise program including range of motion , stretching and progressive resistive exercises . The therapy program was applied 5 times a week for 14 sessions . Pain severity was assessed by using visual analogue scale . Range of motion was measured by goniometer . Disability was evaluated by using Shoulder Pain and Disability Index . RESULTS : In group I , statistically significant improvements in pain severity , range of motion except internal and external rotation and SPADI scores were observed compared to baseline scores after the therapy ( p<0.05 ) . In Group II , all parameters except range of motion of external rotation were improved ( p<0.05 ) . However , no significant differences were recorded between the groups ( p>0.05 ) . CONCLUSIONS : The Low level laser therapy seems to have no superiority over placebo laser therapy in reducing pain severity , range of motion and functional disability Background : Repetitive or sustained elevated shoulder postures have been identified as a significant risk factor for occupationally related shoulder musculoskeletal disorders . Construction workers exposed to routine overhead work have high rates of shoulder pain that frequently progresses to functional loss and disability . Exercise interventions have potential for slowing this progression . Aims : To evaluate a therapeutic exercise programme intended to reduce pain and improve shoulder function . Methods : Construction worker volunteers were screened by history and clinical examination to test for inclusion /exclusion criteria consistent with shoulder pain and impingement syndrome . Sixty seven male symptomatic workers ( mean age 49 ) were r and omised into a treatment intervention group ( n = 34 ) and a control group ( n = 33 ) ; asymptomatic subjects ( n = 25 ) participated as an additional control group . Subjects in the intervention group were instructed in a st and ardised eight week home exercise programme of five shoulder stretching and strengthening exercises . Subjects in the control groups received no intervention . Subjects returned after 8–12 weeks for follow up testing . Results : The intervention group showed significantly greater improvements in the Shoulder Rating Question naire ( SRQ ) score and shoulder satisfaction score than the control groups . Average post-test SRQ scores for the exercise group remained below levels for asymptomatic workers . Intervention subjects also reported significantly greater reductions in pain and disability than controls . Conclusions : Results suggest a home exercise programme can be effective in reducing symptoms and improving function in construction workers with shoulder pain Objective To investigate the efficacy of a programme of manual therapy and exercise treatment compared with placebo treatment delivered by physiotherapists for people with chronic rotator cuff disease . Design R and omised , participant and single assessor blinded , placebo controlled trial . Setting Metropolitan region of Melbourne , Victoria , Australia . Participants 120 participants with chronic ( > 3 months ) rotator cuff disease recruited through medical practitioners and from the community . Interventions The active treatment comprised a manual therapy and home exercise programme ; the placebo treatment comprised inactive ultrasound therapy and application of an inert gel . Participants in both groups received 10 sessions of individual st and ardised treatment over 10 weeks . For the following 12 weeks , the active group continued the home exercise programme and the placebo group received no treatment . Main outcome measures The primary outcomes were pain and function measured by the shoulder pain and disability index , average pain on movement measured on an 11 point numerical rating scale , and participants ’ perceived global rating of overall change . Results 112 ( 93 % ) participants completed the 22 week trial . At 11 weeks no difference was found between groups for change in shoulder pain and disability index ( 3.6 , 95 % confidence interval −2.1 to 9.4 ) or change in pain ( 0.7 , −0.1 to 1.5 ) ; both groups showed significant improvements . More participants in the active group reported a successful outcome ( defined as “ much better ” ) , although the difference was not statistically significant : 42 % ( 24/57 ) of active participants and 30 % ( 18/61 ) of placebo participants ( relative risk 1.43 , 0.87 to 2.34 ) . The active group showed a significantly greater improvement in shoulder pain and disability index than did the placebo group at 22 weeks ( between group difference 7.1 , 0.3 to 13.9 ) , although no significant difference existed between groups for change in pain ( 0.9 , −0.03 to 1.7 ) or for the percentage of participants reporting a successful treatment outcome ( relative risk 1.39 , 0.94 to 2.03 ) . Several secondary outcomes favoured the active group , including shoulder pain and disability index function score , muscle strength , interference with activity , and quality of life . Conclusion A st and ardised programme of manual therapy and home exercise did not confer additional immediate benefits for pain and function compared with a realistic placebo treatment that controlled for therapists ’ contact in middle aged to older adults with chronic rotator cuff disease . However , greater improvements were apparent at follow-up , particularly in shoulder function and strength , suggesting that benefits with active treatment take longer to manifest . Trial registration Clinical trials NCT00415441 Abstract Fifty patients with impingement syndrome refractory to long-term conservative treatment were r and omized to three treatment groups . All patients received an injection of 10 ml 0.5 % bupivacaine , in group 1 without corticosteroid , in group 2 with crystalline corticosteroid and in group 3 with lipoid corticosteroid . Treatment in group 1 had to be stopped because of inefficacy . In groups 2 and 3 favorable results were achieved in 19 out of 40 patients .Résumé 50 patients avec conflit sous-aeromial , qui ne montraient pas d’amélioration après un long trâitement conservatif récevaient une injection dans la bourse subacromiale . Le premier groupe récevait une injection contenant un anaesthétique local pur , groupe 2 une mixture d’anaesthétique avec des corticostéroides cristalins et groupe 3 avec des corticostéroides lipoides . Le trâitement du groupe 1 devait être arrété cause d’inificacité . 19 de 40 patients du groupe 2 et 3 montraient une amélioration après 6 mois OBJECTIVE The aim of this study was to determine the effectiveness of Kinesio taping ( KT ) application added to the exercise treatment of subacromial impingement syndrome ( SIS ) . METHODS Thirty-eight ( 25 female , 13 male ) patients with SIS were r and omly divided into therapeutic KT ( n=19 ) and sham KT ( n=19 ) groups . All patients received the same exercise therapy in addition to therapeutic or sham KT at 3-day intervals for 12 days . The groups were compared according to pain , range of motion ( ROM ) , muscle strength and DASH and Constant scores before treatment and at the 5th and 12th treatment days . RESULTS Within group comparisons showed significant improvements in both groups at the 5th and 12th day evaluations ( p<0.05 ) . In comparisons between the groups , pain with movement and DASH scores in the therapeutic group were significantly lower at the 5th day ( p<0.01 ) . There were significant improvements in night pain , pain with movement , DASH score , shoulder external rotation muscle strength , and pain free shoulder abduction ROM in the therapeutic group at the 12th day ( p<0.05 ) . Passive shoulder flexion ROM increased more in the sham group at the 12th day ( p<0.05 ) . CONCLUSION The addition of KT application to the exercise program appears to be more effective than the exercise program alone for the treatment of SIS Summary Background Arthroscopic sub-acromial decompression ( decompressing the sub-acromial space by removing bone spurs and soft tissue arthroscopically ) is a common surgery for subacromial shoulder pain , but its effectiveness is uncertain . We did a study to assess its effectiveness and to investigate the mechanism for surgical decompression . Methods We did a multicentre , r and omised , pragmatic , parallel group , placebo-controlled , three-group trial at 32 hospitals in the UK with 51 surgeons . Participants were patients who had subacromial pain for at least 3 months with intact rotator cuff tendons , were eligible for arthroscopic surgery , and had previously completed a non-operative management programme that included exercise therapy and at least one steroid injection . Exclusion criteria included a full-thickness torn rotator cuff . We r and omly assigned participants ( 1:1:1 ) to arthroscopic subacromial decompression , investigational arthroscopy only , or no treatment ( attendance of one re assessment appointment with a specialist shoulder clinician 3 months after study entry , but no intervention ) . Arthroscopy only was a placebo as the essential surgical element ( bone and soft tissue removal ) was omitted . We did the r and omisation with a computer-generated minimisation system . In the surgical intervention groups , patients were not told which type of surgery they were receiving ( to ensure masking ) . Patients were followed up at 6 months and 1 year after r and omisation ; surgeons coordinated their waiting lists to schedule surgeries as close as possible to r and omisation . The primary outcome was the Oxford Shoulder Score ( 0 [ worst ] to 48 [ best ] ) at 6 months , analysed by intention to treat . The sample size calculation was based upon a target difference of 4·5 points ( SD 9·0 ) . This trial has been registered at Clinical Trials.gov , number NCT01623011 . Findings Between Sept 14 , 2012 , and June 16 , 2015 , we r and omly assigned 313 patients to treatment groups ( 106 to decompression surgery , 103 to arthroscopy only , and 104 to no treatment ) . 24 [ 23 % ] , 43 [ 42 % ] , and 12 [ 12 % ] of the decompression , arthroscopy only , and no treatment groups , respectively , did not receive their assigned treatment by 6 months . At 6 months , data for the Oxford Shoulder Score were available for 90 patients assigned to decompression , 94 to arthroscopy , and 90 to no treatment . Mean Oxford Shoulder Score did not differ between the two surgical groups at 6 months ( decompression mean 32·7 points [ SD 11·6 ] vs arthroscopy mean 34·2 points [ 9·2 ] ; mean difference −1·3 points ( 95 % CI −3·9 to 1·3 , p=0·3141 ) . Both surgical groups showed a small benefit over no treatment ( mean 29·4 points [ SD 11·9 ] , mean difference vs decompression 2·8 points [ 95 % CI 0·5–5·2 ] , p=0·0186 ; mean difference vs arthroscopy 4·2 [ 1·8–6·6 ] , p=0·0014 ) but these differences were not clinical ly important . There were six study -related complications that were all frozen shoulders ( in two patients in each group ) . Interpretation Surgical groups had better outcomes for shoulder pain and function compared with no treatment but this difference was not clinical ly important . Additionally , surgical decompression appeared to offer no extra benefit over arthroscopy only . The difference between the surgical groups and no treatment might be the result of , for instance , a placebo effect or postoperative physiotherapy . The findings question the value of this operation for these indications , and this should be communicated to patients during the shared treatment decision-making process . Funding Arthritis Research UK , the National Institute for Health Research Biomedical Research Centre , and the Royal College of Surgeons ( Engl and ) Background Subacromial pain syndrome ( SAPS ) accounts for around 50 % of all cases of shoulder pain . The most commonly used treatments are glucocorticosteroid ( steroid ) injections and exercise therapy ; however , despite treatment SAPS patients often experience relapse of their symptoms . Therefore the clinical effect of combining steroid and exercise therapy is highly relevant to clarify . The aim of this r and omized controlled trial was to investigate if exercise therapy added to steroid injection in patients with SAPS will improve the effect of the injection therapy on shoulder pain . Methods In this two-arm r and omized trial running over 26 weeks , patients with unilateral shoulder pain ( > 4 weeks ) and thickened subacromial bursa ( > 2 mm on US ) were included . At baseline all participants received two steroid injections into the painful shoulder with an interval of one week . Subsequently they were r and omized ( 1:1 ) to either 10 weeks exercise of the involved shoulder ( intervention group ) or exercise of the uninvolved shoulder ( control group ) . The patients were re-examined after the exercise program ( at week 13 ) and again at week 26 . The primary outcome assessed after 26 weeks was change in shoulder pain analyzed using the intention-to-treat principle ( non-responder imputation ) . Results Ninety-nine SAPS patients ( 58 female ) participated ( 49 intervention/50 control ) . At both follow up visits ( week 13 and 26 ) no statistically significant between-group differences in pain changes on a visual analog scale ( mm ) were seen ( 13 weeks : pain at rest 1.7 ( 95 % CI –3.6 to 7.0 ; P = 0.53 ) ; pain in activity 2.2 ( 95 % CI –6.5 to 10.9 ; P = 0.61 ) , 26 weeks : rest 5.6 ( 95 % CI –0.9 to 12.1 ; P = 0.09 ) ; activity 2.2 ( 95 % CI –6.8 to 11.2 ; P = 0.62 ) . The reduction in pain was most evident in the control group at all four pain measurements . The only difference between groups was seen by US examination at week 13 , where fewer participants with impingement were observed in the intervention group compared with the controls ( 9 vs. 19 participants ; P = 0.03 ) . Conclusion Exercise therapy in the painful shoulder in SAPS patients did not improve the effectiveness of steroid injections for shoulder pain in patients with unilateral SAPS and enlarged subacromial bursa on US examination . Trial registration Clinical Trials.gov ( NCT01506804 ) . Registration date 5 May 2011 OBJECTIVES To investigate the effect of manual physiotherapy and exercises compared with exercises alone in patients with shoulder impingement syndrome one year after inclusion . DESIGN R and omized controlled trial . SUBJECTS Patients with shoulder impingement of more than 4 weeks . METHODS The intervention group received individualized manual physiotherapy plus individualized exercises ; the control group received individualized exercises only . Both groups had 10 treatments over 5 weeks ; afterwards all patients continued their exercises for another 7 weeks at home . Primary outcomes were the Shoulder Pain and Disability Index and Patients ' Global Impression of Change . The Generic Patient-Specific Scale was used as secondary outcome . Costs were recorded in a log-book . RESULTS Ninety patients were included in the study and 87 could be analyzed at 1-year follow-up . Both groups showed significant improvements in all outcome measures , but no difference was detected between the groups . Only costs differed significantly in favour of the control group ( p = 0.03 ) after 5 weeks . CONCLUSION Individualized exercises result ed in lower costs than manual physiotherapy and showed a significant effect on pain and functioning within the whole group after one year . Exercises should therefore be considered as a basic treatment . Due to the progressive improvement that occurred during the follow-up period with individualized exercises further treatments should be delayed for 3 to 4 months Objective To evaluate if a specific exercise strategy , targeting the rotator cuff and scapula stabilisers , improves shoulder function and pain more than unspecific exercises in patients with subacromial impingement syndrome , thereby decreasing the need for arthroscopic subacromial decompression . Design R and omised , participant and single assessor blinded , controlled study . Setting Department of orthopaedics in a Swedish university hospital . Participants 102 patients with long st and ing ( over six months ) persistent subacromial impingement syndrome in whom earlier conservative treatment had failed , recruited through orthopaedic specialists . Interventions The specific exercise strategy consisted of strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers in combination with manual mobilisation . The control exercise programme consisted of unspecific movement exercises for the neck and shoulder . Patients in both groups received five to six individual guided treatment sessions during 12 weeks . In between these supervised sessions the participants performed home exercises once or twice a day for 12 weeks . Main outcome measures The primary outcome was the Constant-Murley shoulder assessment score evaluating shoulder function and pain . Secondary outcomes were patients ’ global impression of change because of treatment and decision regarding surgery . Results Most ( 97 , 95 % ) participants completed the 12 week study . There was a significantly greater improvement in the Constant-Murley score in the specific exercise group than in the control exercise group ( 24 points ( 95 % confidence interval 19 to 28.0 ) v 9 points ( 5 to 13 ) ; mean difference between group : 15 points ( 8.5 to 20.6 ) ) . Significantly more patients in the specific exercise group reported successful outcome ( defined as large improvement or recovered ) in the patients ’ global assessment of change because of treatment : 69 % ( 35/51 ) v 24 % ( 11/46 ) ; odds ratio 7.6 , 3.1 to 18.9 ; P<0.001 . A significantly lower proportion of patients in the specific exercise group subsequently chose to undergo surgery : 20 % ( 10/51 ) v 63 % ( 29/46 ) ; odds ratio 7.7 , 3.1 to 19.4 ; P<0.001 ) . Conclusion A specific exercise strategy , focusing on strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers , is effective in reducing pain and improving shoulder function in patients with persistent subacromial impingement syndrome . By extension , this exercise strategy reduces the need for arthroscopic subacromial decompression within the three month timeframe used in the study . Trial registration Clinical trials Subacromial impingement syndrome ( SAIS ) is a major contributing factor of shoulder pain ; and treatment approaches ( Kinesio ® taping [ KT ] , Exercise [ EX ] , manual therapy [ MT ] , and high-intensity laser therapy [ HILT ] ) have been developed to treat the pain . The key objective of this study was to compare the effects of KT , MT , and HILT on the pain , the range of motion ( ROM ) , and the functioning in patients with SAIS . Seventy patients with SAIS were r and omly divided into four groups based on the treatment(s ) each group received [ EX ( n = 15 ) , KT + EX ( n = 20 ) , MT + KT + EX ( n = 16 ) , and MT + KT + HILT + EX ( n = 19 ) ] . All the patients were assessed before and at the end of the treatment ( 15th day ) . The main outcome assessment s included the evaluation of severity of pain by visual analogue scale ( VAS ) and shoulder flexion , abduction , and external rotation ROM measurements by a universal goniometry . Shoulder pain and disability index ( SPADI ) was used to measure pain and disability associated with shoulder pathology . Statistically significant differences were found in the treatment results of all parameters in MT + KT + EX and HILT + MT + KT + EX groups ( p < 0.05 ) . When the means of ROM and SPADI results of three groups were compared , statistically significant differences were found between all the groups ( p < 0.05 ) . These differences were significant especially between the groups MT + KT + EX and KT + EX ( p < 0.05 ) and HILT + MT + KT + EX and KT + EX ( p < 0.05 ) . HILT and MT were found to be more effective in minimizing pain and disability and increasing ROM in patients with SAIS . Further studies with follow-up periods are required to determine the advantages of these treatments conclusively OBJECTIVE To evaluate the effects of pulsed electromagnetic field ( PEMF ) and exercises in reducing pain and improving function and muscle strength in patients with shoulder impingement syndrome ( SIS ) . DESIGN Double-blind , r and omized controlled trial with a 3-month posttreatment follow-up . SETTING Outpatient rehabilitation of a public hospital . PARTICIPANTS Patients ( N=56 ) between 40 and 60 years of age , with a diagnosis of SIS , were r and omly assigned to receive active PEMF ( n=26 ; mean age , 50.1y ) or placebo PEMF ( n=30 ; mean age , 50.8y ) . INTERVENTIONS After 3 weeks of active or placebo PEMF , both groups performed the same program of exercises that focused on shoulder strengthening . MAIN OUTCOME MEASURES A visual analog scale , the University of California/Los Angeles shoulder rating scale , the Constant-Murley shoulder score , and h and held dynamometry for muscle strength were used as outcome measures at baseline ( pretreatment ) , at 3 weeks ( after active or placebo PEMF ) , at 9 weeks ( postexercise ) , and at 3 months posttreatment . RESULTS Patients in the active PEMF group had a higher level of function and less pain at all follow-up time frames compared with baseline ( P<.05 ) . However , the placebo PEMF group had increased function and reduced pain only at the 9-week and 3-month follow-ups (P<.05)-that is , after performing the associated exercises . For the shoulder dynamometry , the active PEMF group had increased strength for lateral rotation at 9 weeks ( P<.05 ) , and increased strength for medial rotation at 9 weeks and 3 months ( both P<.05 ) when compared with baseline . There was no significant difference for shoulder strength in the placebo PEMF group ( P>.05 ) , as well as no significant differences ( P>.05 ) for all outcome measures . CONCLUSIONS The combination of PEMF and shoulder exercises is effective in improving function and muscle strength and decreasing pain in patients with SIS . However , these results should be carefully interpreted because of the lack of differences between groups BACKGROUND AND PURPOSE Exercise therapy is a commonly used conservative therapy for long-term subacromial pain . However , there is no consensus regarding what type of exercises and dosage is most effective . The aim of this study was to compare the effect of two exercise programmes : 1 ) high-dosage ( HD ) medical exercise therapy versus 2 ) low-dosage ( LD ) exercise therapy programme for subjects with long-term subacromial pain . METHODS This study used a r and omized , controlled clinical trial with an intention-to-treat analysis . Sixty-one subjects were r and omly assigned by concealment either to an HD medical exercise therapy group ( n = 31 ) or to an LD exercise therapy group ( n = 30 ) . Pain ( visual analogue scale [ VAS ] ) and function ( Shoulder Rating Question naire [ SRQ ] ) were measured at inclusion , at end of treatment and at 6 and 12 months follow-up . RESULTS There were no differences between groups at inclusion ( baseline ) regarding any variables . During the three months treatment period , five subjects ( 8 % ) dropped out , and another seven ( 11 % ) dropped out at one-year follow-up . At the end of treatment , both pain and function had improved significantly in favour of the HD therapy , between-group differences in VAS were -2.7 ( -3.9 to 0.9 ) , and for activity limitations , the between-group differences in the SRQ increased by 24.5 points ( 14.5 - 35.7 ) . The differences between groups were both statistically and clinical ly significant at 6 and 12 months follow-up . CONCLUSION In subjects with long-term subacromial pain syndrome , HD medical exercise therapy is superior to a conventional LD exercise programme . For clinicians to obtain similar positive results with HD medical exercise therapy , factors such as good communication skills , constant close personal supervision during exercise treatment and having from three to five subjects in a group setting are important Context The shoulder impingement syndrome includes conditions , such as rotator cuff tendinosis and shoulder bursitis . Conservative management may include corticosteroid injections ( CSIs ) or manual physical therapy ( MPT ) . Contribution In this r and omized , controlled trial , groups of patients with the shoulder impingement syndrome receiving CSI or MPT  showed similar symptom improvements that did not differ significantly . Compared with the MPT group , the CSI group used more health care re sources during the 1-year follow-up . Caution The trial recruited only patients referred to MPT . Implication Manual physical therapy and CSI produced similar clinical outcomes in patients with the shoulder impingement syndrome . The Editors The shoulder impingement syndrome ( SIS ) is a generic term used for patients with shoulder pain that encompasses the rotator cuff syndrome , tendinosis of the rotator cuff muscles , and bursitis in the shoulder area ( 1 ) . It has a cumulative incidence between 5 and 30 per 1000 person-years ( 2 , 3 ) . Conservative treatment options include corticosteroid injections ( CSIs ) and physical therapy . Subacromial CSI is one of the most common procedures used by orthopedists , rheumatologists , and general practitioners ( 4 , 5 ) . However , evidence to support long-term efficacy is conflicting ( 610 ) . Clinical practice guidelines can not recommend for or against CSI for rotator cuff pathology without evidence of tears ( 11 ) . Four recent systematic review s have differing conclusions on the efficacy of CSI for SIS ( 6 , 8 , 9 , 12 ) , but the consensus suggests that any benefit may only be short-term . Although manual physical therapy ( MPT ) may be effective for SIS management ( 1321 ) , 2 recent systematic review s found no clear evidence to suggest additional benefits of MPT to other interventions ( 22 , 23 ) , indicating the need for further research . Data are also lacking about the patterns and timing of CSI and MPT use for patients with SIS . Studies suggest that a CSI is often considered initially ( 4 , 5 ) , whereas a referral to physical therapy may occur only 24 % of the time ( 24 ) . Other studies introduced CSI only after 6 weeks of physical therapy was unsuccessful ( 5 ) . Some investigations evaluated the effect of providing CSI before , or in conjunction with , MPT or shoulder exercises ( 14 , 25 , 26 ) , but CSI and MPT have not been directly compared . The objective of this study was to compare the 1-year effectiveness of CSI and MPT  for SIS management . Methods Design Overview This pragmatic , r and omized , controlled trial compared 2 treatments for patients with SIS : subacromial CSI and MPT . The primary end point was 1-year improvement on the Shoulder Pain and Disability Index ( SPADI ) . Secondary outcomes included changes in Global Rating of Change ( GRC ) scale and Numeric Pain Rating Scale ( NPRS ) scores and shoulder-related health care use . We followed the SPIRIT ( St and ard Protocol Items : Recommendations for Interventional Trials ) statement at the time of protocol development ( 27 ) , and our reporting followed the CONSORT ( Consoli date d St and ards of Reporting Trials ) extension for pragmatic clinical trials ( 28 ) . The study was approved by the Madigan Army Medical Center Institutional Review Board , the trial was registered ( Clinical Trials.gov : NCT01190891 ) , and the protocol was published with open access ( 29 ) . Setting and Participants Consecutive patients aged 18 to 65 years with a primary symptom of unilateral shoulder pain referred from family practice and orthopedic clinics to the physical therapy department at Madigan Army Medical Center were screened for eligibility during their initial visit in the physical therapy clinic . Exclusion criteria included a history of shoulder dislocation , fracture , or adhesive capsulitis ; history of CSI or physical therapy for the shoulder pain in the past 3 months ; baseline SPADI score less than 20 % ; reproduction of shoulder symptoms with cervical spine examination ; history of systemic or neurologic disease affecting the shoulder ; positive rotator cuff lag sign or history of full-thickness rotator cuff tear ; pending litigation ; or inability to attend physical therapy for 3 consecutive weeks . Patients at this medical center included a mix of active-duty and retired military service members and their families . Copayments were not required for care . R and omization and Interventions The r and omization schedule was computer-generated , with assignments placed in opaque , sequentially numbered envelopes by an off-site investigator not involved with patient care or follow-up . Treatment allocation was revealed after collection of baseline outcomes . Patients and treating clinicians were not blind to the intervention . The research assistant who collected outcome assessment s at each time point was blind to group assignment . Two physical therapists provided the MPT , and 1 physician administered all of the injections . Patients were allowed to continue any current medications prescribed by their primary care providers ( PCPs ) . MPT Group At the first session , the physical therapists performed a st and ardized clinical examination to identify relevant impairments ( weakness , mobility , or pain ) . The MPT intervention consisted of a combination of joint and soft-tissue mobilizations ; manual stretches ; contractrelax techniques ; and reinforcing exercises directed to the shoulder girdle or thoracic or cervical spine . Specific details of the treatment are published ( 29 ) . Patients did not receive identical treatments , but the MPT techniques were matched to individual impairments identified on examination . Patients were treated twice weekly over a 3-week period , a typical episode of care for SIS , by the same physical therapy in most cases . Home exercises were prescribed to reinforce clinic interventions ( 29 ) . The physical therapists were fellowship-trained in MPT from an American Physical Therapy Associationcredentialed program . CSI Group A credentialed family practice physician with sports medicine fellowship training injected 40 mg of triamcinolone acetonide to the subacromial space of the symptomatic shoulder ( 29 ) . Each participant received a h and out explaining the effects of the steroid injection and how to manage potential side effects . As many as 3 total injections could be administered by the study physician ( > 1 month apart ) during the 1-year period . Patients received printed instructions to perform a gentle gravity-assisted distraction and oscillatory pendulum exercise . Patients were discouraged , but not prohibited , from seeking additional care for at least the first month ( study -related treatment period ) . At the 1- , 3- , and 6-month follow-up periods , patients were also given written instructions and a number to call if they believed that they were not improving and needed additional care . A study coordinator , who was not involved with data collection or treatment , fielded these calls . She advised patients in the MPT group to return to their PCP for additional care and facilitated contact with the physician providing the injection for patients in the CSI group . Each case was managed individually , and another CSI was administered if the patient and physician mutually agreed that it was appropriate . Patients in either group could return to their PCP if they felt the need , and the PCP would manage the patient as they thought best , potentially including a CSI or referral to physical therapy . These patients would not see the same physical therapist or physician who administered the initial study intervention . Outcomes and Follow-up Outcome measurements were administered at baseline , 1 month , 3 months , 6 months , and 1 year . The SPADI is a 100-point , 13-item , self-administered question naire that is divided into 2 subscales : a 5-item pain subscale and an 8-item disability subscale . It is valid , is responsive to change , and accurately discriminates between improving and worsening status ( 30 , 31 ) . The minimal clinical ly important difference for the SPADI is a change between 8 and 13 points ( 6 % to 10 % ) ( 32 ) . The GRC is an instrument that measures overall perceived changes in the participant 's quality of life ( 33 ) . It provides a valid measurement of change in patients ' perceived status ( 34 ) . A GRC score of 3 rating points or greater is clinical ly meaningful ( 35 ) . An 11-point NPRS ranging from 0 ( no pain ) to 10 ( worst imaginable pain ) was used to assess pain intensity ( 36 ) . This scale has been demonstrated to be a reliable , generalizable , and internally consistent measure of clinical and experimental pain intensity ( 37 , 38 ) . The suggested minimal clinical ly important difference for the NPRS is a change of 2 points ( 39 ) . A research assistant blinded to treatment allocation collected health care use information from electronic health records at the 1-year follow-up using an established process ( 40 , 41 ) . This included additional use after completion of the study interventions . We identified shoulder-related visits to physical therapists , PCPs , rheumatologists , and orthopedists , as well as frequency and types of procedures , including additional steroid injections , magnetic resonance imaging , and radiography , similar to other studies ( 42 ) . A second clinician manually verified the electronic health record information to ensure that the care was related to the same shoulder condition . Statistical Analysis The sample size estimated to achieve 80 % power to detect a 12-point difference ( or a 9.2 % change ) in the SPADI , based on a reported minimal clinical ly important difference range of 8 to 13 points ( 32 ) , with an SD of 10 points , a 2-tailed test , and an level of 0.05 was 43 participants per group . To allow for a conservative withdrawal rate of approximately 20 % , we recruited 104 participants . The primary analyses of effectiveness included all available data from patients who received their assigned treatment ( that is , the CSI or at least 1 session of MPT ) . We used a linear mixed-effects model , which is flexible in accommodating data assumed to be missing at STUDY DESIGN Single-blind r and omized trial . OBJECTIVES To compare the effects of cervical and shoulder thrust manipulation ( TM ) and exercise on pain sensitivity , and to explore associations with clinical outcomes in patients with shoulder pain . BACKGROUND Experimental studies indicate that spinal TM has an influence on central pain processes , supporting its application for treatment of extremity conditions . Direct comparison of spinal and peripheral TM on pain sensitivity has not been widely examined . METHODS Seventy-eight participants with shoulder pain ( 36 female ; mean ± SD age , 39.0 ± 14.5 years ) were r and omized  to receive 3 treatments of cervical TM ( n = 26 ) , shoulder TM ( n = 27 ) , or shoulder exercise ( n = 25 ) over 2 weeks . Twenty-five healthy participants ( 13 female ; mean ± SD age , 35.2 ± 11.1 years ) were assessed to compare pain sensitivity with that in clinical participants at baseline . Primary outcomes were changes in local ( eg , shoulder ) and remote ( eg , tibialis anterior ) pressure pain threshold and heat pain threshold occurring over 2 weeks . Secondary outcomes were shoulder pain intensity and patient-rated function at 4 , 8 , and 12 weeks . Analysis -of-variance models and partial-correlation analyses were conducted to examine comparative effects and the relationship between measures . RESULTS At baseline , clinical participants demonstrated lower local ( mean difference , - 1.63 kg ; 95 % confidence interval [ CI ] : -2.40 , -0.86 ) and remote pressure pain threshold ( mean difference , -1.96 kg ; 95 % CI : -3.09 , -0.82 ) and heat pain threshold ( mean difference , -1.15 ° C ; 95 % CI : -2.06 , -0.24 ) compared to controls , suggesting enhanced pain sensitivity . Following intervention , there were no between-group differences in pain sensitivity or clinical outcome ( P>.05 ) . However , improvements were noted , regardless of intervention , for pressure pain threshold ( range of mean differences , 0.22 - 0.32 kg ; 95 % CI : 0.03 , 0.43 ) , heat pain threshold ( range of mean differences , 0.30 - 0.58 ; 95 % CI : 0.06 , 0.96 ) , pain intensity ( range of mean differences , -1.79 to -1.45 ; 95 % CI : -2.34 , -0.94 ) , and function ( range of mean differences , 3.15 - 3.82 ; 95 % CI : 0.69 , 6.20 ) at all time points . We did not find an association between pain sensitivity changes and clinical outcome ( P>.05 ) . Conclusion Clinical participants showed enhanced pain sensitivity , but did not respond differently to cervical or peripheral TM . In fact , in this sample , cervical TM , shoulder TM , and shoulder exercise had similar pain sensitivity and clinical effects . The lack of association between pain sensitivity and clinical pain and function outcomes suggests different ( eg , nonspecific ) pain pathways for clinical benefit following TM or exercise . LEVEL OF EVIDENCE Therapy , level 1b Aim : To test the hypothesis that work related mechanical and psychosocial factors predict new onset shoulder pain  in newly employed workers . Methods : Two year prospect i ve study of newly employed workers from 12 diverse occupational setting s. At baseline , 1081 subjects provided information on work related mechanical and psychosocial risk factors , and current pain status . Results : In all , 803 ( 74 % ) subjects were free from shoulder pain at baseline . Of those , 638 ( 79 % ) responded at 12 months and 476 ( 88 % ) at 24 months . New onset shoulder pain was reported by 93 ( 15 % ) and 73 ( 15 % ) subjects respectively . An increased risk of symptom onset was found in subjects reporting mechanical exposures involving heavy weights including lifting with one or two h and s , carrying on one shoulder , lifting at or above shoulder level , and pushing or pulling . Working with h and s above shoulder level was also predictive of new onset shoulder pain . Of the psychosocial factors examined , the strongest predictor was monotonous work . Those individuals with any other previous pain also had an increased risk of new onset shoulder pain at follow up . In multivariate analysis , lifting heavy weights with one or two h and s , pushing or pulling heavy weights , working with h and s above shoulder level , and monotonous work were independently associated with new onset shoulder pain . Conclusions : This study supports the hypothesised relation between mechanical risk factors and shoulder pain . In general , work related psychosocial factors were modestly associated with new onset shoulder pain . However , monotonous work was a strong risk factor for new onset shoulder pain STUDY DESIGN Prospect i ve , r and omized , double-blinded , clinical trial using a repeated- measures design . OBJECTIVES To determine the short-term clinical efficacy of Kinesio Tape ( KT ) when applied to college students with shoulder pain , as compared to a sham tape application . BACKGROUND Tape is commonly used as an adjunct for treatment and prevention of musculoskeletal injuries . A majority of tape applications that are reported in the literature involve nonstretch tape . The KT method has gained significant popularity in recent years , but there is a paucity of evidence on its use . METHODS AND MEASURES Forty-two subjects clinical ly diagnosed with rotator cuff tendonitis/impingement were r and omly assigned to 1 of 2 groups : therapeutic KT group or sham KT group . Subjects wore the tape for 2 consecutive 3-day intervals . Self-reported pain and disability and pain-free active ranges of motion ( ROM ) were measured at multiple intervals to assess for differences between groups . RESULTS The therapeutic KT group showed immediate improvement in pain-free shoulder abduction ( mean + /- SD increase , 16.9 degrees + /- 23.2 degrees ; P = .005 ) after tape application . No other differences between groups regarding ROM , pain , or disability scores at any time interval were found . CONCLUSION KT may be of some assistance to clinicians in improving pain-free active ROM immediately after tape application for patients with shoulder pain . Utilization of KT for decreasing pain intensity or disability for young patients with suspected shoulder tendonitis/impingement is not supported . LEVEL OF EVIDENCE Therapy , level 1b- Objectives : The primary aim of this study was to investigate the effect of medical exercise therapy in shoulder impingement patients , along with possible correlations between impairment variables . Study Design : A prospect i ve unblended r and omized clinical trial . Methods : Over four months , 61 participants were r and omly assigned into a high- grade d exercise therapy group ( HD ) ( n=31 ) and into a low- grade d exercise therapy group ( LD ) ( n=30 ) . Prognostic variables were similar between the groups at baseline . Five ( 8 % ) patients dropped out during the treatment period , and another four ( 6 % ) dropped out before followup . Pain was a composite score of a visual analogue scale ( VAS ) . Isometric strength was measured during four resisted break tests on the shoulder . Function was measured by means of a functional assessment question naire ( Shoulder Rating Question naire , SRQ ) . Both groups trained three times per week for twelve weeks , with tests pre- and posttraining and six months follow-up . Results : The HD group achieved significantly ( p < 0.05 ) better outcome effects than the LD group for pain , range of motion , isometric functional strength and function , but both groups increased function from pretest to posttest . Conclusions : In patients with uncomplicated subacromial pain syndrome , medical exercise therapy is an efficient treatment alternative , where high- grade doses should be emphasized . A major limitation is that the measurements were not undertaken by another person than the treating physiotherapists Our aim was to describe the differences in the presence of trigger points ( TrPs ) in the shoulder muscles and to investigate the presence of mechanical hypersensitivity in patients with unilateral shoulder impingement and healthy controls . Twelve patients with strictly unilateral shoulder impingement and 10 matched controls were recruited .  TrPs in the levator scapula , supraspinatus , infraspinatus , subscapularis , pectoralis major , and biceps brachii muscles were explored . TrPs were considered active if the local and referred pain reproduced the pain symptoms and the patient recognized the pain as a familiar pain . Pressure pain thresholds ( PPT ) were assessed over the levator scapulae , supraspinatus , infraspinatus , pectoralis major , biceps brachii , and tibialis anterior muscles . Both explorations were r and omly done by an assessor blinded to the subjects ’ condition . Patients with shoulder impingement have a greater number of active ( mean ± SD : 2.5 ± 1 ; P < 0.001 ) and latent ( mean ± SD : 2 ± 1 ; P = 0.003 ) TrPs when compared to controls ( only latent TrPs , mean ± SD : 1 ± 1 ) . Active TrPs in the supraspinatus ( 67 % ) , infraspinatus ( 42 % ) , and subscapularis ( 42 % ) muscles were the most prevalent in the patient group . Patients showed a significant lower PPT in all muscles when compared to controls ( P < 0.001 ) . Within the patient group a significant positive correlation between the number of TrPs and pain intensity ( rs = 0.578 ; P = 0.045 ) was found . Active TrPs in some muscles were associated to greater pain intensity and lower PPTs when compared to those with latent TrPs in the same muscles ( P < 0.05 ) . Significant negative correlations between pain intensity and PPT levels were found . Patients with shoulder impingement showed widespread pressure hypersensitivity and active TrPs in the shoulder muscles , which reproduce their clinical pain symptoms . Our results suggest both peripheral and central sensitisation mechanisms in patients with shoulder impingement syndrome Background : Dysfunction in the kinetic chain caused by poor scapula stabilization can contribute to shoulder injuries and Shoulder Impingement Syndrome ( SIS ) . The purpose of this study was to compare the effectiveness of two treatment approaches scapular stabilization based exercise therapy and physical therapy in patients with SIS . Methods : The study is a r and omized clinical trial in which 68 patients with SIS were r and omly assigned in two groups of exercise therapy ( ET ) and physical therapy ( PT ) and received 18 sessions of treatment . Pain , shoulders ' range of abduction and external rotation , shoulder protraction , scapular rotation and symmetry as well as postural assessment and Pectoralis minor length were evaluated pre and post intervention . The paired- sample t test and the independent sample t test were applied respectively to determine the differences in each group and between two groups . Results : Our findings indicated significant differences in abduction and external rotation range , improvement of forward shoulder translation and increase in the flexibility of the involved shoulder between the two groups ( respectively ; p=0.024 , p=0.001 , p<0/0001 , p<0/0001 ) . No significant difference was detected in pain reduction between the groups ( p=0.576 ) . Protraction of the shoulder ( p<0.0001 ) , forward head posture ( p<0/0001 ) and mid thoracic curvature ( p<0.0001 ) revealed a significant improvement in the ET group . Apparent changes occurred in scapular rotation and symmetry in both groups but no significant differences were observed between the two groups ( respectively ; p=0.183 , p=0.578 ) . Conclusion : The scapular stabilization based exercise intervention was successful in increasing shoulder range , decreasing forward head and shoulder postures and Pectoralis minor flexibility Objective The aim of this study was to compare the accuracy of blind vs. ultrasonography-guided corticosteroid injections in subacromial impingement syndrome and determine the correlation between accuracy of the injection location and clinical outcome . Design Forty-six patients with subacromial impingement syndrome were r and omized for ultrasonography-guided ( group 1 , n = 23 ) and blind corticosteroid injections ( group 2 , n = 23 ) . Magnetic resonance imaging analysis  was performed immediately after the injection . Changes in shoulder range of motion , pain , and shoulder function were recorded . All patients were assessed before the injection and 6 wks after the injection . Results Accurate injections were performed in 15 ( 65 % ) group 1 patients and in 16 ( 70 % ) group 2 patients . There was no statistically significant difference in the injection location accuracy between the two groups ( P > 0.05 ) . At the end of the sixth week , regardless of whether the injected mixture was found in the subacromial region or not , all of the patients showed improvements in all of the parameters evaluated ( P < 0.05 ) . Conclusions Blind injections performed in the subacromial region by experienced individuals were reliably accurate and could therefore be given in daily routines . Corticosteroid injections in the subacromial region were very effective in improving the pain and functional status of patients with subacromial impingement syndrome during the short-term follow-up Abstract Scapula taping is a commonly used adjunctive treatment for shoulder im- pingement pathology . However , this intervention has not previously been subject to formal investigation . A pilot single-blind r and omized controlled trial was conducted to evaluate facilitatory taping as an adjunct to routine physiotherapy management . Twenty-two sub- jects with unilateral shoulder impingement symptoms were r and omized into a taping with routine physiotherapy or a routine physiotherapy only group . The intervention group had scapula taping applied three times per week for the first two weeks of their treatment . All subjects were assessed at baseline , then at 2 and 6 weeks after the commencement of treat- ment . Pain and functional ability were assessed using the Shoulder Pain and Disability In- dex , range of shoulder elevation , and self-reported pain on elevation . At 2 weeks , the taping group demonstrated a strong trend toward reduced pain both on self-reported activity ( SPADI pain subscale mean for taping 27.0 versus 41.5 for control ) and pain during mea- sured abduction ( mean VAS 22.8 for taped , 46.8 for control ) , statistical power being limited by small sample size . No similar trend was evident in the SPADI disability subscale . The magnitude of the differences was reduced at 6-week follow-up . This study provides prelimi- nary evidence for a short-term role for scapula taping as an adjunct to routine physiother- apy in the management of shoulder impingement symptoms but also highlights the need for consideration on a case basis relating to risk factors for skin reaction BACKGROUND Subacromial impingement syndrome ( SIS ) is the most common reason for shoulder pain .  Ultrasound and laser are the physical therapy modalities , in conservative treatment of SIS . AIM The aim of this study was to define and compare the efficacy of ultrasound , laser and exercise in the treatment of SIS . DESIGN This was a r and omized controlled trial with-pre and post-treatment evaluations SETTING Out- patients referred to physical medicine and rehabilitation unit . POPULATION This study was performed on 52 patients with SIS . The patients were r and omly allocated into three groups METHODS The patients were treated five days a week for three weeks with hotpack+ultrasound+exercise ( the first group ) ; hotpack+laser+exercise ( the second group ) , or hotpack+exercise ( the third group ) . The pre and post treatment ranges of motion were measured in the patients . The visual analogue scale ( VAS ) was used to evaluate the severity of pain . Constant scoring was used to evaluate the shoulder functions and the results were compared after the treatment . RESULTS When the post-treatment results of the groups were compared with the pretreatment results , there was a statistically significant improvement in each of the three groups , in the pain , the range of motion and the functional improvement at the shoulder ( P<0.05 ) . However , the inter-group comparison did not reveal any statistically significant difference in the parameters indicating improvement ( P>0.05 ) . CONCLUSION The results of this study demonstrated that ultrasound and laser treatments were not superior to each other in the treatment of SIS . CLINICAL REHABILITATION IMPACT . Exercise treatment forms the base for the conservative treatment Abstract Study design : R and omized clinical trial . Objectives : To evaluate the effects of high-velocity , low-amplitude thrust manipulations ( HVLATMs ) and various messages on patients with musculoskeletal shoulder symptoms . Background : Previous studies indicated that HVLATM directed at the thoracic spine and ribs result ed in improvements of shoulder range of motion , pain , and disability in patients with musculoskeletal shoulder symptoms . These studies did not explore if the outcome was dependent on thrust location , clinician communication with the patient , or if there were any lasting effects . Methods : A consecutive sample of 100 patients with shoulder pain was r and omized into four groups . Patients received one intervention session including : six thoracic HVLATM ( spine versus scapula ) , a message about HVLATM ( neutral versus positive ) , and st and ardized home exercises . Outcome measures included shoulder Numeric Pain Rating Scale ( NPRS ) , NPRS with impingement testing , and Shoulder Pain and Disability Index ( SPADI ) . Measurements were recorded prior to intervention , immediately following intervention , and at short-term follow-up . Kruskal – Wallis statistics were used for between-group comparisons and Wilcoxon signed ranks for within-group comparisons . Results : Eighty-eight patients ( 22 per group ) completed the study . Statistically significant differences were found for within-group comparisons for most time points assessed . No statistical differences were found for between-group comparisons . Conclusion : Patients improved following the interventions . Neither the type of HVLATM nor the message conveyed to the patients had a significant effect on the patients ’ improvements . Level of evidence : BACKGROUND Shoulder pain in nursing professionals may lead to limitations in occupational and daily activities and consequently interfere with quality of life . OBJECTIVE To compare the effects of two physical therapy programs which differed in the proprioceptive exercises used on the nursing professionals with rotator cuff disorder , according to quality of life , work satisfaction indicators , and pain intensity . METHOD This study was an experimental , r and omized , prospect i ve , comparative trial with quantitative data analysis . The data sampling was carried out between the months of June 2010 and July 2011 by means of a question naire containing socio-demographic and professional information , the Western Ontario Rotator Cuff Index ( WORC ) , the Occupational Stress Indicator ( OSI ) , and the Visual Numeric Scale ( VNS ) . Based on r and omization , subjects were divided into two groups . Group 1 ( control ) was su bmi tted to stretching and strengthening exercises and cryotherapy . Group 2 ( experimental ) was treated with the same protocol as the control group , with the addition of proprioception exercises . The data was analyzed by means of the Statistical Package for the Social Science version 16.0 for Windows . RESULTS After physical therapy intervention , significant reduction in pain levels occurred in both groups , with a significant improvement in quality of life for Group 2 . No changes were observed in the work satisfaction indicators after the two types of physical therapy interventions . CONCLUSIONS The proprioceptive exercises were important in the treatment of musculoskeletal disorders , however the results did not allow us to determine which treatment was the most effective as there was no significant difference between groups OBJECTIVE To determine whether dexketoprofen administered by phonophoresis or iontophoresis is more effective for the treatment of subacromial impingement syndrome ( SIS ) than conventional ultrasound therapy . DESIGN R and omised clinical trial . SETTING University hospital . PARTICIPANTS Ninety-nine participants with SIS without a complete tear of the rotator cuff were assigned at r and om to three intervention groups . INTERVENTION GROUPS Participants received ultrasound ( n=32 ) , phonophoresis with dexketoprofen ( 50mg/session ) ( n=33 ) or iontophoresis with dexketoprofen ( 50mg/session ) ( n=34 ) . All participants completed 20 treatment sessions plus exercise therapy and cryotherapy . OUTCOME MEASURES A visual analogue scale ( VAS ) , the Constant-Murley Scale ( CMS ) and the Disabilities of the Arm , Shoulder and H and ( DASH ) question naire were administered pre-treatment ( baseline ) , post-treatment and 1 month post-treatment . RESULTS At baseline , there were no differences between the groups . Post-treatment , VAS score improved by -1.2 points and CMS score improved by 8.9 points in the ultrasound group compared with the iontophoresis group [ 95 % confidence interval ( CI ) -0.2 to -2.2 and 95 % CI 17.0 to 0.7 , respectively ] . CMS score improved by 7.1 points in the phonophoresis group compared with the iontophoresis group ( 95 % CI 14.8 to -0.7 ) . At 1 month post-treatment , no significant differences were detected between the groups . VAS , CMS and DASH scores of all groups improved post-treatment and at 1 month post-treatment . CONCLUSION Ultrasound , iontophoresis with dexketoprofen and phonophoresis with dexketoprofen can improve pain , shoulder function , and physical functioning and symptoms in the upper limb in patients with SIS without a complete tear of the rotator cuff . CLINICAL TRIALS . GOV REGISTRATION NUMBER NCT01748188 OBJECTIVE To investigate the effect of individualized manual physiotherapy and exercises compared with individualized exercises alone in patients with shoulder impingement syndrome . DESIGN R and omized controlled trial . SUBJECTS Patients with shoulder impingement of more than 4 weeks ' duration . METHODS Patients in the intervention group were treated with individually adapted exercises and examination-based physiotherapy . Controls were treated with individually adapted exercises only . Both groups had 10 treatment sessions over a period of 5 weeks and subsequently continued their exercises at home for another 7 weeks . Results were analysed at 5 and 12 weeks after the start of the study . Primary outcome measures were : Shoulder Pain and Disability Index , and Patient 's Global Impression of Change . Secondary outcome measures were : mean weekly pain score ; Generic Patient-Specific Scale ; and Patients ' Satisfaction with Treatment . RESULTS A total of 46 patients were r and omized to the intervention group and 44 to the control group . Although both groups showed significant improvements , there was no difference between groups for the primary and secondary outcomes at any time . Only the results for mean pain differed at 5 weeks in favour of the intervention group . CONCLUSION Individually adapted exercises were effective in the treatment of patients with shoulder impingement syndrome .  Individualized manual physiotherapy contributed only a minor amount to the improvement in pain intensity . However , further research is necessary to confirm these results before definite recommendations can be made Objective . To compare effects of ultrasound- ( US- ) guided percutaneous electrolysis combined with an eccentric exercise program of the rotator cuff muscles in subacromial pain syndrome . Methods . Thirty-six patients were r and omized and assigned into US-guided percutaneous electrolysis ( n = 17 ) group or exercise ( n = 19 ) group . Patients were asked to perform an eccentric exercise program of the rotator cuff muscles twice every day for 4 weeks . Participants assigned to US-guided percutaneous electrolysis group also received the application of galvanic current through acupuncture needle on each session once a week ( total 4 sessions ) . Shoulder pain ( NPRS ) and disability ( DASH ) were assessed at baseline , after 2 sessions , and 1 week after the last session . Results . The ANOVA revealed significant Group∗Time interactions for shoulder pain and disability ( all , P < 0.01 ) : individuals receiving US-guided percutaneous electrolysis combined with the eccentric exercises experienced greater improvement than those receiving eccentric exercise alone . Conclusions . US-guided percutaneous electrolysis combined with eccentric exercises result ed in small better outcomes at short term compared to when only eccentric exercises were applied in subacromial pain syndrome . The effect was statistically and clinical ly significant for shoulder pain but below minimal clinical difference for function . Future studies should investigate the long-term effects and potential placebo effect of this intervention Background Shoulder pain is a very common presentation in primary care . Evidence of benefit for subacromial corticosteroid injection is inconclusive and confined largely to studies with short follow-up . We plan a large , definitive , primary -care-based trial to determine efficacy and safety in patients with rotator cuff tendinopathy , and conducted a pilot trial to explore feasibility . Methods Six general practitioners ( GPs ) from Oxfordshire , UK underwent up date training in assessing painful shoulders and injecting the subacromial space . Each then recruited patients aged 35 to 74 years from primary care complaining of shoulder pain lasting no more than 6 months . Eligible participants were r and omized to receive either methylprednisolone acetate 40 mg with lidocaine 1 % ( total volume 1 ml ) , or lidocaine 1 % alone ( total volume 1 ml ) , injected into the subacromial space . The participants were blinded to treatment allocation . Feasibility outcomes were rates of recruitment , withdrawal , adherence to the protocol , completeness of follow-up , and success of patient masking . Clinical outcomes were the Oxford Shoulder Score ( OSS ) at baseline and at 4 and 12 weeks , and responses to three satisfaction questions at 2 , 4 and 12 weeks . Outcome data were collected by postal question naires . Results A total of 40 participants were r and omized ( 80 % of the target 50 participants ) over 26 weeks giving an overall recruitment rate  of 1.5 participants per week . Rates of follow-up were maintained to a high level for the full 12 weeks . Four participants requested a ‘ rescue ’ corticosteroid injection but no patients withdrew . The trial GPs gave high scores for their confidence that the patient had remained blinded to treatment allocation during the procedure . The OSS at 4 and 12 weeks and the responses to the satisfaction questions are reported . Conclusions It is feasible to recruit participants with shoulder pain in the primary care setting for a blinded , r and omized trial of corticosteroid injection . Online r and omization of participants from the practice is also feasible , and postal question naires provide an effective means of gathering outcome data in this area of study . The lessons learned from this pilot will usefully inform the design of a large , definitive efficacy trial in primary care . Trial registration Current Clinical Trials IS RCT We have performed a double-blind placebo-controlled trial of moderate doses of extracorporeal shock-wave therapy ( ESWT ) for non-calcific tendonitis of the rotator cuff . Adults ( 74 ) with chronic tendonitis of the rotator cuff were r and omised to receive either active ( 1500 pulses ESWT at 0.12 mJ/mm2 ) or sham treatment , monthly for three months . All were assessed before each treatment , and at one and three months after the completion of treatment . The outcome was measured with regard to pain in the shoulder , including a visual analogue score for night pain , and a disability index . There were no significant differences between the two groups before treatment . The mean duration of symptoms in both groups was 23.3 months . Both showed significant and sustained improvements from two months onwards . There was no significant difference between them with respect to change in the Shoulder Pain and Disability Index ( SPADI ) scores or night pain over the six-month period . A mean ( + /-SD ; range ) change in SPADI of 16.1 + /- 27.2 ( 0 to 82 ) in the treatment group and 24.3 + /- 24.8 ( -11 to 83 ) in the sham group was noted at three months . At six months the mean changes were 28.4 + /- 25.9 ( -24 to 69 ) and 30.4 + /- 31.2 ( -12 to 88 ) , respectively . Similar results were noted for night pain . We conclude that there is a significant and sustained placebo effect after moderate doses of ESWT in patients with non-calcific tendonitis of the rotator cuff , but there is no evidence of added benefit when compared with sham treatment OBJECTIVES Rotator cuff tendinopathy is a common source of shoulder pain characterised by persistent and /or recurrent problems for a proportion of sufferers . The aim of this study was to pilot the methods proposed to conduct a substantive study to evaluate the effectiveness of a self-managed loaded exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy . DESIGN A single-centre pragmatic unblinded parallel group pilot r and omised controlled trial . SETTING One private physiotherapy clinic , northern Engl and . PARTICIPANTS Twenty-four participants with rotator cuff tendinopathy . INTERVENTIONS The intervention was a programme of self-managed loaded exercise . The control group received usual physiotherapy treatment . MAIN OUTCOMES Baseline assessment comprised the Shoulder Pain and Disability Index ( SPADI ) and the Short-Form 36 , repeated three months post r and omisation . RESULTS The recruitment target was met and the majority of participants ( 98 % ) were willing to be r and omised . 100 % retention was attained with all participants completing the SPADI at three months . Exercise adherence rates were excellent ( 90 % ) . The mean change in SPADI score was -23.7 ( 95 % CI -14.4 to -33.3 ) points for the self-managed exercise group and -19.0 ( 95 % CI -6.0 to -31.9 ) points for the usual physiotherapy treatment group . The difference in three month SPADI scores was 0.1 ( 95 % CI -16.6 to 16.9 ) points in favour of the usual physiotherapy treatment group . CONCLUSIONS In keeping with previous research which indicates the need for further evaluation of self-managed loaded exercise for rotator cuff tendinopathy , these methods and the preliminary evaluation of outcome offer a foundation and stimulus to conduct a substantive study Subacromial impingement syndrome ( SIS ) is a frequent cause of shoulder pain . Our purpose in this double-blinded , r and omized , and controlled study was to demonstrate whether the pulsed electromagnetic field ( PEMF ) provides additional benefit when used with other conservative treatment modalities in acute phase rehabilitation program of SIS . Forty-six patients with unilateral shoulder pain who had been diagnosed as having SIS were included in this trial . The cases were r and omly separated into two groups . All cases received a treatment program for 3 weeks consisting of Codman ’s pendulum exercises and subsequent cold pack gel application on shoulders with pain 5 times a day , restriction of daily activities that require the h and s to be used over the head , and meloxicam tablet 15 mg daily . One group was given PEMF ; the other group was given sham PEMF daily , 25 min per session , 5 days per week for 3 weeks . Shoulder pain during rest and activity and which causes disturbance of sleep was evaluated using a visual analogue scale , and total Constant score investigated shoulder function . Daily living activities were evaluated by shoulder disability question naire . Results were assessed before and after treatment . When compared with the baseline values , significant improvements in all these variables were observed at the end of the treatment in both groups ( p < 0.05 ) . No significant difference between treatments was observed for any of these variables ( p > 0.05 ) . There is no convincing evidence that electromagnetic therapy is of additional benefit in acute phase rehabilitation program of SIS HYPOTHESIS The objective of this study was to compare the efficacy of subacromial injection of triamcinolone compared to injection of ketorolac in the treatment of external shoulder impingement syndrome . METHODS Thirty-two patients diagnosed with external shoulder impingement syndrome were included in this double-blinded r and omized controlled clinical trial . Each patient was r and omized into the steroid group or nonsteroidal anti-inflammatory drugs ( NSAID ) group . The steroid syringe contained 40 mg triamcinolone ; and the NSAID syringe contained 60 mg ketorolac . Each patient was evaluated in terms of arc of motion , visual analog scale ( VAS ) for evaluating pain , and the UCLA ( The University of California at Los Angeles ) shoulder rating scale . RESULTS At 1 month follow-up , both treatment arms result ed in increased range of motion and decreased pain . The steroid group decreased in active abduction while the NSAID group increased ( steroid : 134 ° , NSAID : 151 ° , P = .03 ) . The mean improvement in the UCLA shoulder rating scale at 4 weeks was 7.15 for the NSAID group and 2.13 for the steroid group ( P = .03 ) . Subgroup analysis of the UCLA scale demonstrated an increase in both forward flexion strength ( P = .04 ) and patient satisfaction ( P = .03 ) in the NSAID group . No significant difference could be seen in all other outcome measures . CONCLUSION In this study , an injection of ketorolac result ed in greater improvements in the UCLA shoulder rating scale than an injection of triamcinolone at 4 weeks follow-up . While both triamcinolone and ketorolac are effective in the treatment of isolated subacromial impingement , ketorolac appears to have equivalent if not superior efficacy ; all the while decreasing patient exposure to the potential side-effects of corticosteroids STUDY DESIGN R and omized controlled trial with immediate follow-up . OBJECTIVES To evaluate the immediate effects of a low-amplitude , high-velocity thrust thoracic spine manipulation ( TSM ) on pain and scapular kinematics during elevation and lowering of the arm in individuals with shoulder impingement syndrome ( SIS ) . The secondary objective was to evaluate the immediate effects of TSM on scapular kinematics during elevation and lowering of the arm in individuals without symptoms . BACKGROUND Considering the regional interdependence among the shoulder and the thoracic and cervical spines , TSM may improve pain and function in individuals with SIS . Comparing individuals with SIS to those without shoulder pathology may provide information on the effects of TSM specifically in those with SIS . METHODS Fifty subjects ( mean ± SD age , 31.8 ± 10.9 years ) with SIS and 47 subjects ( age , 25.8 ± 5.0 years ) asymptomatic for shoulder dysfunction were r and omly assigned to 1 of 2 interventions : TSM or a sham intervention . Scapular kinematics were analyzed during elevation and lowering of the arm in the sagittal plane , and a numeric pain rating scale was used to assess shoulder pain during arm movement at preintervention and postintervention . RESULTS For those in the SIS group , shoulder pain was reduced immediately after TSM and the sham intervention ( mean ± SD preintervention , 2.9 ± 2.5 ; postintervention , 2.3 ± 2.5 ; P<.01 ; moderate effect size [ Cohen d = 0.2 ] ) . Scapular internal rotation increased 0.5 ° ± 0.02 ° ( P = .04 ; small effect size [ Cohen d<0.1 ] ) during elevation of the arm after TSM and sham intervention in the SIS group only . Subjects with and without SIS who received TSM and asymptomatic subjects who received the sham intervention had a significant increase ( 1.6 ° ± 2.7 ° ) in scapular upward rotation postintervention ( P<.05 ; small effect size [ Cohen d<0.2 ] ) , which was not considered clinical ly significant . Scapular anterior tilt increased 1.0 ° ± 4.8 ° during elevation and lowering of the arm postmanipulation ( P<.05 ; small effect size [ Cohen d<0.2 ] ) in the asymptomatic subjects who received TSM . CONCLUSION Shoulder pain in individuals with SIS immediately decreased after a TSM . The observed changes in scapular kinematics following TSM were not considered clinical ly important . LEVEL OF EVIDENCE Therapy , level 4 . J Orthop Sports Phys Ther 2014;44(7):475 - 487 . Epub 22 May 2014 . doi:10.2519/jospt.2014.4760 OBJECTIVE To perform a cost-effectiveness analysis of subacromial corticosteroid injection combined with exercise compared with exercise alone in patients with moderate to severe shoulder pain from subacromial impingement syndrome . METHODS A within-trial cost-effectiveness analysis with 232 patients r and omized to physiotherapy-led injection combined with exercise ( n = 115 ) or exercise alone ( n = 117 ) . The analysis was from a health care perspective with 24-week follow-up . Re source use information was collected from all patients on interventions , medication , primary and secondary care contacts , private health care use and over-the-counter purchases . The measure of outcome was quality -adjusted life years ( QALYs ) , calculated from EQ-5D responses at baseline and three further time points . An incremental cost-effectiveness analysis was conducted . RESULTS Mean per patient NHS costs ( £ 255 vs £ 297 ) and overall health care costs ( £ 261 vs £ 318 ) were lower in the injection plus exercise arm , but this difference was not statistically significant . Total QALYs gained were very similar in the two trial arms ( 0.3514 vs 0.3494 QALYs ) , although slightly higher in the injection plus exercise arm , indicating that injection plus exercise may be the dominant treatment option . At a willingness to pay of £ 20,000 per additional QALY gained , there was a 61 % probability that injection plus exercise was the most cost-effective option . CONCLUSION Injection plus exercise delivered by therapists may be a cost-effective use of re sources compared with exercise alone and lead to lower health care costs and less time off work . TRIAL REGISTRATION International St and ard R and omised Controlled Trial Number Register , http://www.controlled-trials.com/is rct n/ , IS RCT 25817033 Local steroid injections are common for treatment of impingement syndrome .  Corticosteroid injections methods are basically in two formats , blind or with image guidance . The aim of this study is to compare the effect of ultrasound-guided in comparison with blind corticosteroid injections in patients with impingement syndrome . This study is a r and omized clinical trial study undertaken in patients with diagnosis of impingement syndrome done in Isfahan University of Medical Science clinics from February 2014 to February 2015 . The number of all patients registered in the study is 48 ; and then 40 patients were allocated to either  control group r and omly which received blind steroid injection or case group that underwent ultrasound-guided steroid injection . The clinical symptoms were assessed using Shoulder Pain and Disability Index ( SPADI ) question naire , Visual Analogue Scale ( VAS ) and shoulder range of motion ( ROM ) using goniometer at baseline and six weeks after the injection . Data analysis revealed a significant difference in the mean of the VAS , SPADI and shoulder ROM in both groups 6 weeks after intervention ( P < 0.05 ) . Patients with ultrasound guided corticosteroid injection had statistically significant improvements in function and shoulder ROM ( abduction , flexion ) compared to blind injection group after 6 weeks ( P<0.05 ) . There was not significant differences in pain ( VAS ) and internal and external rotation between these two groups ( p>0.05 ) . Our findings suggest that US image guided can improve the shoulder function of patients with impingement syndrome , and thus can be considered in comprehensive care programs of these patients for fast speed of rehabilitation Introduction Return to work following an occupational injury is a multifactoral process although many traditional clinic-based rehabilitation programs do not appreciate the importance of workplace factors . A r and omized controlled trial was conducted to investigate the effect of workplace-based rehabilitation program on the return to work outcome of work-related rotator cuff disorder , which is based on the therapeutic use of actual work facilities and work environment . Methods A total of 103 workers were recruited and r and omly assigned into Clinic-based Work Hardening ( CWH ) or Workplace-based Work Hardening ( WWH ) groups . The CWH group were given traditional generic work hardening training while WWH group received workplace-based work hardening training with rehabilitative principles of athletic rotator cuff pathology , biomechanics and specific job activities . Results After four weeks , a higher return to work rate was obtained in WWH group compared to CWH group ( 71.4 % vs. 37 % , p < 0.01 ) . A statistically significant difference ( p < 0.05 ) was also noted in lowering of self-reported shoulder problems and functional work capabilities in the WWH group versus the CWH group . Conclusion Workplace-based rehabilitation program appeared to be more effective in facilitating the return to work process of the injured worker as assessed immediately following intervention . In particular this approached was associated with many of the psychosocial workplace factors related to separation from the work routine . The influence of peer group and /or employer could be minimized . This initial attempt with rotator cuff injuries appears promising however long-term outcome needs to be determined The purpose of this clinical trial is to compare the effectiveness of a scapular-focused treatment with a control therapy in patients with shoulder impingement syndrome . Therefore , a r and omized clinical trial with a blinded assessor was used in 22 patients with shoulder impingement syndrome . The primary outcome measures included self-reported shoulder disability and pain . Next , patients were evaluated regarding scapular positioning and shoulder muscle strength . The scapular-focused treatment included stretching and scapular motor control training . The control therapy included stretching , muscle friction , and eccentric rotator cuff training . Main outcome measures were the shoulder disability question naire , diagnostic tests for shoulder impingement syndrome , clinical tests for scapular positioning , shoulder pain ( visual analog scale ; VAS ) , and muscle strength . A large clinical ly important treatment effect in favor of scapular motor control training was found in self-reported disability ( Cohen ’s d = 0.93 , p = 0.025 ) , and a moderate to large clinical ly important improvement in pain during the Neer test , Hawkins test , and empty can test ( Cohen ’s d 0.76 , 1.04 , and 0.92 , respectively ) . In addition , the experimental group demonstrated a moderate ( Cohen ’s d = 0.67 ) improvement in self-experienced pain at rest ( VAS ) , whereas the control group did not change . The effects were maintained at three months follow-up Shoulder pain is the third most common musculoskeletal problem and accounts for 5 % of general practitioner consultations . Although many treatments are described , there is no consensus on optimal treatment and up to 40 % of patients still have pain 12 months after initially seeking help for pain . Previously , the effect of transcutaneous pulsed radiofrequency treatment ( TCPRFT ) was evaluated in a retrospective audit that showed good pain relief for a mean 395 days and justified this r and omized sham controlled trial . In this study , 51 patients entered into a r and omized double-blinded , placebo controlled study of TCPRFT .  Patients were assessed at 4 and 12 weeks by a blinded observer and compared with baseline . We observed sustained reductions in pain at night , pain with activity , and functional improvement at 4 and 12 weeks with active but not sham TCPRFT . The 25 subjects who received active treatment showed statistically significant reductions of 24/100 in pain at night and 20/100 of pain with activity at 4 weeks and 18/100 and 19/100 , respectively , at 12 weeks from baseline . Statistically significant lower Brief Pain Inventory pain and function scores ( 4 and 12 weeks ) , improved pain self-efficacy ( 4 weeks ) , Oxford Shoulder scores ( 12 weeks ) , and internal rotation ( 12 weeks ) were seen . Pain at both rest and shoulder elevation were not improved by active treatment . No complications were seen . This study of a simple , low risk , outpatient treatment confirms the findings of our earlier study of TCPRFT for knee pain and shoulder pain audit that transcutaneous pulsed radiofrequency treatment may help some people with painful shoulders OBJECTIVES To determine ( 1 ) the prevalence of selected common musculoskeletal disorders in patients referred for electrodiagnosis when cervical radiculopathy is suspected and ( 2 ) whether these findings predict electrodiagnostic study outcome . DESIGN Prospect i ve study . SETTING Electrodiagnostic laboratories in departments of physical medicine and rehabilitation at 5 participating institutions . PARTICIPANTS A total of 191 subjects undergoing electrodiagnostic evaluations for upper-limb symptoms when cervical radiculopathy was suspected . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Prevalence of certain musculoskeletal disorders ( myofascial pain , shoulder impingement , lateral epicondylitis , de Quervain 's tenosynovitis ) and outcomes of electrodiagnostic testing  ( normal study , cervical radiculopathy , or another electrodiagnostically confirmed diagnosis ) . RESULTS The total prevalence of musculoskeletal disorders was 42 % . The prevalence in those with a normal study was 69 % , compared with 29 % in those with cervical radiculopathy ( P<.001 ) and 45 % in those with another diagnosis ( P=.02 ) . CONCLUSIONS Musculoskeletal disorders are common in patients with suspected cervical radiculopathy . Although the presence of certain musculoskeletal disorders makes having a normal electrodiagnostic evaluation significantly more likely , the high prevalence among both patients with normal studies and those with radiculopathy and other disorders limits the usefulness of this information in precisely predicting study outcome . The presence of musculoskeletal disorders should not preclude electrodiagnostic testing when otherwise indicated Shoulder impingement syndrome ( SIS ) is a complex , multi-factorial problem that is treated with a variety of different conservative options . One conservative option that has shown effectiveness is manual therapy to the thoracic spine . Another option , manual therapy to the cervical spine , has been studied only once with good results , evaluating short-term outcomes , in a small sample size . The purpose of this study was to investigate the benefit of neck manual therapy for patients with SIS . The study was a r and omised , single blinded , clinical trial where both groups received pragmatic , evidence -based treatment to the shoulder and one group received neck manual therapy .  Subjects with neck pain were excluded from the study .  Comparative pain , disability , rate of recovery and patient acceptable symptom state ( PASS ) measures were analyzed on the 68 subjects seen over an average of 56.1 days ( st and ard deviation (SD)=55.4 ) . Eighty-six percent of the sample reported an acceptable change on the PASS at discharge . There were no between-groups differences in those who did or did not receive neck manual therapy ; however , both groups demonstrated significant within-groups improvements . On average both groups improved 59.7 % ( SD=25.1 ) for pain and 53.5 % ( SD=40.2 ) for the Quick Disabilities of the Shoulder and H and Question naire ( QuickDASH ) from baseline . This study found no value when neck manual therapy was added to the treatment of SIS . Reasons may include the lack of therapeutic dosage provided for the manual therapy approach or the lack of benefit to treating the neck in subjects with SIS who do not have concomitant neck problems Objective To compare the effectiveness of subacromial corticosteroid injection combined with timely exercise and manual therapy ( injection plus exercise ) or exercise and manual therapy alone ( exercise only ) in patients with subacromial impingement syndrome . Design Pragmatic r and omised clinical trial . Setting Primary care based musculoskeletal service . Patients Adults aged 40 or over with subacromial impingement syndrome with moderate or severe shoulder pain . Interventions Injection plus exercise or exercise only . Main outcome measures Primary outcome was the difference in improvement in the total shoulder pain and disability index at 12 weeks . Results 232 participants were r and omised ( 115 to injection plus exercise , 117 to exercise only ) . The mean age was 56 ( range 40 - 78 ) , 127 were women , and all had had a median of 16 weeks of shoulder pain ( interquartile range 12 - 28 ) . At week 12 there was no significant difference between the groups in change in total pain and disability index ( mean difference between change in groups 3.26 ( 95 % confidence interval −0.81 to 7.34 ) , P=0.116 ) . Improvement was significantly greater in the injection plus exercise group at week 1 ( 6.56 , 4.30 to 8.82 ) and week 6 ( 7.37 , 4.34 to 10.39 ) for the total pain and disability index ( P<0.001 ) , with no differences at week 24 ( −2.26 , −6.77 to 2.25 , P=0.324 ) . Conclusions In the treatment of patients with subacromial impingement syndrome , injection plus exercise and exercise only are similarly effective at 12 weeks . Trial registration IS RCT 25817033 ; EudraCT No 2005 - 003628 - 20 BACKGROUND Thoracic SMT can improve symptoms in patients with subacromial impingement syndrome . However , at this time the mechanisms of SMT are not well established . It is possible that changes in pain sensitivity may occur following SMT . OBJECTIVES To assess the immediate pain response in patients with shoulder pain following thoracic spinal manipulative therapy ( SMT )  using pressure pain threshold ( PPT ) , and to assess the relationship of change in pain sensitivity to patient-rated outcomes of pain and function following treatment . DESIGN R and omized Controlled Study . METHODS Subjects with unilateral subacromial impingement syndrome ( n = 45 ) were r and omly assigned to receive treatment with thoracic SMT or sham thoracic SMT . PPT was measured at the painful shoulder ( deltoid ) and unaffected regions ( contralateral deltoid and bilateral lower trapezius areas ) immediately pre- and post-treatment . Patient-rated outcomes were pain ( numeric pain rating scale - NPRS ) , function ( Pennsylvania Shoulder Score - Penn ) , and global rating of change ( GROC ) . RESULTS There were no significant differences between groups in pre-to post-treatment changes in PPT ( p ≥ 0.583 ) nor were there significant changes in PPT within either group ( p ≥ 0.372 ) following treatment . NPRS , Penn and GROC improved across both groups ( p < 0.001 ) , but there were no differences between the groups ( p ≥ 0.574 ) . CONCLUSION There were no differences in pressure pain sensitivity between participants receiving thoracic SMT versus sham thoracic SMT . Both groups had improved patient-rated pain and function within 24 - 48 h of treatment , but there was no difference in outcomes between the groups STUDY DESIGN R and om allocation of subjects into a placebo-controlled , crossover study . OBJECTIVES To investigate the effect of changing thoracic and scapular posture on shoulder flexion and scapular plane abduction range of motion in asymptomatic subjects , and in subjects with subacromial impingement syndrome . BACKGROUND Changes in upper body posture and concomitant imbalance of the muscle system have been proposed as one of the etiological mechanisms leading to subacromial impingement syndrome . Although clinicians commonly assess posture and devise rehabilitation programs to correct posture , there is little evidence to support this practice . METHODS AND MATERIAL S Selected postural , range of movement , and pain measurements were investigated in 60 asymptomatic subjects and 60 subjects with subacromial impingement syndrome , prior to and following thoracic and scapular taping intended to change their posture .  RESULTS Changing posture had an effect on all components of posture measured ( P<.001 ) and these changes were associated with a significant increase ( P<.001 ) in the range of motion in shoulder flexion and abduction in the plane of the scapula . Changing posture was not found to have a significant effect on the intensity of pain experienced by the symptomatic subjects , although the point in the range of shoulder elevation at which they experienced their pain was significantly higher ( P<.001 ) . CONCLUSIONS The findings of this investigation suggest that changing 1 or more of the components of posture may have a positive effect on shoulder range of movement and the point at which pain is experienced Subacromial corticosteroid injection is one of the most frequently used management tools in subacromial impingement syndrome ( SIS ) despite controversial reports on the efficacy . Our purpose , in this single blinded , r and omised and controlled study was to clarify whether the corticosteroid injection provides additional benefit when used with other conservative treatment modalities in 48 patients with stage 2 SIS . The patients were r and omly divided into three groups according to the two therapeutic injections applied with a 10-day interval : group 1 : 10 cc of 1 % lignocaine + 40 mg of methylprednisolone for the first and second injections , group 2 : 10 cc of 1 % lignocaine + 40 mg of methylprednisolone for the first injection and only 10 cc of 1 % lignocaine for the second injection , group 3 : only 10 cc of 1 % lignocaine for the first and second injections . All the patients were prescribed 500 mg of naproxen sodium to use two times daily , instructed to rest and perform Codman ’s pendulum exercises during the first 15 days . Shoulder pain during rest , activity , and causing disturbance of sleep was evaluated using a visual analogue scale and shoulder function was investigated by total Constant score and its subsectional parameters which are pain , daily living activities , active range of motion and strength before the therapy and 1 and 3 months after the therapy onset . Significant improvements from the baseline values in all pain and function parameters were observed at the first and second evaluation in all groups . Group 1 patients had more favourably improved values in pain causing sleep disturbance and daily living activity parameters than group 2 and 3 patients only in the 1st month after therapy onset . We found that subacromial corticosteroid injections in the acute or subacute phase of SIS provided additional short-term benefit without any complication when used together with nonsteroidal anti-inflammatory drugs ( NSAIDs ) and exercise Background There is evidence supporting the use of extracorporeal shock wave therapy ( ESWT ) in calcific tendinopathy of the rotator cuff , but the best current evidence does not support its use in non-calcifying tendinopathy . We conducted a r and omized placebo-controlled trial to investigate the efficacy and safety of low energy ESWT for non-calcifying tendinopathy of the rotator cuff . Methods 20 patients with non-calcifying supraspinatus tendinopathy ( NCST ) were r and omized to an active or a sham treatment group . Physical , blood , roentgenographic , and MRI examinations of the shoulder were conducted to verify that patients met the inclusion and exclusion criteria . These examinations were repeated six and twelve weeks after treatments . Effectiveness was determined by comparison of the mean improvement in the Constant and Murley score ( CMS ) between the treatment and the placebo groups at three months . Safety was assessed by analyzing the number and severity of adverse events . Results All the patients completed the investigation protocol . At the final follow-up , significant improvement in the total CMS score and most of the CMS subscales was observed in the ESWT group when compared to the baseline values . Significantly higher total CMS , and significantly higher scores for CMS pain and ROM were observed in the ESWT group when compared to the placebo . No serious adverse events were noted after ESWT . Conclusions Patients suffering from NCST may benefit from low energy ESWT , at least in short-term . The application protocol of ESWT is likely to play a key-role in a successful treatment . Future investigations should be undertaken on the long-term effects of this technique for the treatment of NCST.Trial registration Current Controlled Trials IS RCT [ Purpose ] This study examined the effects of scapular stabilization exercises immediately after surgery on pain and function in patients diagnosed with shoulder impingement syndrome . [ Subjects ] The subjects were assigned by r and om sampling to an experimental group ( n=15 ) to which stabilization exercise was applied and a  control group ( n=15 ) to which ordinary physical treatment was applied . [ Methods ] To evaluate the degree of pain , a 100 mm visual analogue scale ( VAS ) was used . The Constant-Murley Scale ( CMS ) was used to evaluate the functions of the shoulder joints . To determine the range of motion , a goniometer was used to measure range of shoulder motion . The  simple shoulder test ( SST ) was used to determine the condition of the shoulder joints of the subjects . [ Results ] There were significant differences in all the items of the experimental group . The results of comparison of the therapeutic effect in the experimental and control groups revealed significant differences in active abduction , passive abduction , VAS , SST , and the CMS , except for pain . [ Conclusion ] The results suggest that shoulder stabilization exercise positively affects pain alleviation and functional recovery in shoulder impingement patients [ Purpose ] A prospect i ve , r and omized , single-blind study was performed in order to compare the efficacy of ultrasound treatments of various duration s for patients with subacromial impingement syndrome . [ Subjects and Methods ] One hundred patients who had been diagnosed with subacromial impingement syndrome by clinical examination and magnetic resonance imaging were included in this study . Patients were r and omly divided into two groups of fifty patients per group . The first group received 15 sessions of therapeutic ultrasound ( 4 minutes ) , superficial heat and transcutaneous electrical stimulation therapy combined with exercise . The second group received the same treatment except that each of the 15 ultrasound sessions were eight minutes in length . The patients were evaluated before and after the treatment . A visual analog scale ( VAS ) was used to assess pain , the University of California at Los Angeles ( UCLA ) and Constant Scale were used to assess shoulder function and the Beck Depression Inventory ( BDI ) was used to quantify depressive symptoms . [ Results ] There were no statistically significant differences between the groups in age , time since the onset of pain , sex , education and depression levels prior to the treatment . The post-treatment evaluation of patients VAS , UCLA , Constant , and BDI scores showed statistically significant within group improvements . When the two groups were compared , we found no statistically significant differences in the Constant activities of daily living , Constant external rotation , Constant force and BDI scores . However , the second group scored better than the first group in all the remaining parameters . [ Conclusion ] Ultrasound therapy was found to have beneficial effects on pain and functional status in the treatment of subacromial impingement syndrome . Eight minutes of ultrasound treatment was shown to be more effective than 4 minutes of ultrasound treatment BACKGROUND Various manual therapy procedures are increasingly more often being used in the treatment of shoulder complex dysfunctions . The objective of the present study was to investigate whether manual therapy can improve the range of motion in the glenohumeral joint and alleviate pain in patients with chronic rotator cuff injuries MATERIAL AND METHODS The participants were r and omly assigned to an experimental group and a control group of 15 patients each . Both groups received a st and ard combination therapy involving TENS , ultrasound therapy and kinesiotherapy . Additionally , the experimental group took part in a treatment programme design ed by the authors composed of selected elements of various manual therapy techniques . Outcome evaluation focused on changes in the range of motion in the glenohumeral joint and changes in pain intensity ( VAS scale ) during the performance of functional tests . The results were subjected to statistical analysis . RESULTS More rapid and more significant pain reduction and more significant improvement in the range of motion of the glenohumeral joint across all movements tested were obtained in the experimental group . CONCLUSION The inclusion of manual therapy in st and ard comprehensive physiotherapy applied in the rehabilitation of patients with chronic rotator cuff injuries of the glenohumeral joint significantly improves treatment effectiveness Background Shoulder impingement syndrome is a common musculoskeletal complaint leading to significant reduction of health and disability .  Physiotherapy is often the first choice of treatment although its effectiveness is still under debate . Systematic review s in this field highlight the need for more high quality trials to investigate the effectiveness of physiotherapy interventions in patients with subacromial impingement syndrome . Methods / Design This r and omized controlled trial will investigate the effectiveness of individualized physiotherapy in patients presenting with clinical signs and symptoms of subacromial impingement , involving 90 participants aged 18 - 75 . Participants are recruited from outpatient physiotherapy clinics , general practitioners , and orthopaedic surgeons in Germany . Eligible participants will be r and omly allocated to either individualized physiotherapy or to a st and ard exercise protocol using central r and omization . The control group will perform the st and ard exercise protocol aim ing to restore muscular deficits in strength , mobility , and coordination of the rotator cuff and the shoulder girdle muscles to unload the subacromial space during active movements . Participants of the intervention group will perform the st and ard exercise protocol as a home program , and will additionally be treated with individualized physiotherapy based on clinical examination results , and guided by a decision tree . After the intervention phase both groups will continue their home program for another 7 weeks . Outcome will be measured at 5 weeks and at 3 and 12 months after inclusion using the shoulder pain and disability index and patients ' global impression of change , the generic patient-specific scale , the average weekly pain score , and patient satisfaction with treatment . Additionally , the fear avoidance beliefs question naire , the pain catastrophizing scale , and patients ' expectancies of treatment effect are assessed . Participants ' adherence to the protocol , use of additional treatments for the shoulder , direct and indirect costs , and sick leave due to shoulder complaints will be recorded in a shoulder log-book . Discussion To our knowledge this is the first trial comparing individualized physiotherapy based on a defined decision making process to a st and ardized exercise protocol . Using high- quality method ologies , this trial will add evidence to the limited body of knowledge about the effect of physiotherapy in patients with SIS.Trial registration Current Controlled Trials IS RCT There is little known about the specific manual therapy techniques used to treat painfully limited shoulders and their effects on range of movement ( ROM ) and pressure pain threshold ( PPT ) . The objective of this study was to investigate the initial effects of a Mulligan 's mobilization with movement ( MWM ) technique on shoulder ROM in the plane of the scapula and PPT in participants with anterior shoulder pain . A repeated measures , double-blind r and omized-controlled trial with a crossover design was conducted with 24 subjects ( 11 males and 13 females ) .  ROM and PPT were measured before and after the application of MWM , sham and control conditions . Significant and clinical ly meaningful improvements in both ROM ( 15.3 % , F (2,46)=16.31 P=0.00 ) and PPT ( 20.2 % , F(2,46)=3.44 , P=0.04 ) occurred immediately after post treatment . The results indicate that this specific manual therapy treatment has an immediate positive effect on both ROM and pain in subjects with painful limitation of shoulder movement . Further study is needed to evaluate the duration of such effects and the mechanism by which this occurs Objective To compare the effectiveness of ultrasound guided corticosteroid injection in the subacromial bursa with systemic corticosteroid injection in patients with rotator cuff disease . Design Double blind r and omised clinical trial . Setting Outpatient clinic of a physical medicine and rehabilitation department in Oslo , Norway . Patients 106 patients with rotator cuff disease lasting at least three months . Interventions Ultrasound guided corticosteroid and lidocaine injection in the subacromial bursa and lidocaine injection in the gluteal region ( local group ) ; corticosteroid and lidocaine injection in the gluteal region and ultrasound guided lidocaine injection in the subacromial bursa ( systemic group ) . Main outcome measures Difference in improvement in the overall shoulder pain and disability index score after six weeks . Results Six weeks after the intervention , the mean difference in improvement in overall shoulder pain and disability index score between the local group and the systemic group was −5.2 ( 95 % confidence interval −13.9 to 3.5 ) ; it was −4.1 ( −12.3 to 4.1 , P=0.32 ) after adjustment for baseline score . A small but statistically significant difference in improvement between groups occurred in favour of the local group for two secondary outcome measures : the Western Ontario rotator cuff index ( 8.1 , 0.7 to 15.6 ) and change in main complaint ( 2.0 , 0 to 4 ) . Conclusions No important differences in short term outcomes were found between local ultrasound guided corticosteroid injection and systemic corticosteroid injection in rotator cuff disease . Trial registration Clinical trials NCT00640575 [ Purpose ] The aim of this prospect i ve , double-blind , r and omized , placebo-controlled study was to evaluate the effects of therapeutic continuous ultrasound ( US ) on patients with rotator cuff disease . [ Subjects and Methods ] Twenty-two patients were treated with a st and ard physiotherapy program consisting of a hot-pack , transcutaneous electrical nerve stimulation ( TENS ) , exercises , and US that was supervised by the same physiotherapist . The patients were r and omly assigned to either a group that received true US ( n=11 ) or one that received sham US ( n=11 ) . [ Results ] There were significant differences between the pre- and post-intervention UCLA Shoulder Rating Scale and Constant-Murley Shoulder Outcome scores , VAS , and external rotation ( ER ) peak torque 60 ° /second values for both the true and sham US groups . However , the between-group differences were not statistically significant . [ Conclusion ] In patients with rotator cuff disease , physiotherapy interventions effectively treat the pain , improve the clinical status , and increase the muscle strength of the shoulder ER at a low constant angular velocity , with functional improvement being seen immediately after treatment . However , at the end of the intervention , the US had yielded no additional efficacy to the physiotherapy treatment regimen of the patients with rotator cuff disease There is evidence for the efficacy of acupuncture treatment for chronic shoulder pain , but it remains unclear which acupuncture modes are most effective . We compared the effect of trigger point acupuncture ( TrP ) , with that of sham ( SH ) acupuncture treatments , on pain and shoulder function in patients with chronic shoulder pain . The participants were 18 patients ( 15 women , 3 men ; aged 42 - 65 years ) with nonradiating shoulder pain for at least 6 months and normal neurological findings . The participants were r and omized into two groups , each receiving five treatment sessions . The TrP group received treatment at trigger points for the muscle , while the other group received SH acupuncture treatment on the same muscle . Outcome measures were pain intensity ( visual analogue scale , VAS ) and shoulder function ( Constant-Murley Score : CMS ) . After treatment , pain intensity between pretreatment and 5 weeks after TrP decreased significantly ( p<0.001 ) . Shoulder function also increased significantly between pretreatment and 5 weeks after TrP ( p<0.001 ) . A comparison using the area under the outcome curves demonstrated a significant difference between groups ( p=0.024 ) . Compared with SH acupuncture therapy , TrP therapy appears more effective for chronic shoulder pain Objectives : To describe the effects of 2 pain treatments for shoulder impingement syndrome ( SIS ) , and illustrate how investigators can use pain quality information to underst and treatment response differences . Material s and Methods : This study presents pain quality data from a r and omized open-label study comparing the effects of an injection of triamcinolone and up to twice daily application of a heated lidocaine/tetracaine ( Trilexis ) patch in individuals with SIS . Study participants completed a measure of pain quality at baseline and again on study days 14 , 28 , and 42 following initiation of 2 treatments for SIS . Baseline and posttreatment pain quality scores were graphed to provide a visual representation of treatment-associated changes . Analyses of variance were used to examine the differences between treatment conditions in changes in pain quality with treatment . Results : Both treatments result ed in substantial ( and similar ) pretreatment to posttreatment improvements in many pain qualities . However , differences in the time course of treatment effects were observed for itchy and heavy qualities . Discussion : Although 2 different pain treatments appear to have the same effects when only pretreatment to posttreatment changes are examined , treatment differences emerged when the time course of treatment is examined . The findings support the importance of assessing both pain qualities and time course of treatment as outcome domains . The results illustrate how investigators can use data from clinical trials to provide a more fine-tuned description of treatment effects , providing knowledge that could be helpful in selecting treatment options at the individual patient level . Summary : Examination of the effects of pain treatments on pain qualities over time will help research ers and clinicians underst and if certain pain quality domains respond faster to one treatment versus another , and may identify differences between treatments that would not be observed by measures of global pain intensity alone Objectives Treatment for degenerative rotator cuff disease of the shoulder includes physiotherapy . Dynamic humeral centering ( DHC ) aims at preventing subacromial impingement , which contributes to the disease . The goal of this study was to assess the effectiveness of DHC . Method 69 patients with shoulder pain and impingement syndrome were prospect ively included in a single-centre r and omised trial with a 12-month follow-up . Patients and assessor were blinded to the study hypothesis and treatment , respectively . DHC and non-specific mobilisation as control were performed for 6 weeks , in 15 supervised individual outpatient sessions , and patients performed daily home exercises . The planned primary outcome was the Constant score including subscores for pain , activity , mobility and strength at 3 months . Secondary outcomes were the Constant score and subscores at 12 months , and medication use for pain at 3 and 12 months . Results The DHC group did not differ from the control group in the total Constant score at 3 months . However , the DHC group showed a higher Constant subscore for pain ( 12.2 ( SD 2.8 ) vs 9.9 ( 2.9 ) , least square means difference 2.1 , 95 % CI 0.7 to 3.5 , p=0.004 ) . At 3 months , the DHC group also showed a higher rate of no medication use ( 96.7 % vs 71 % , proportional difference 25.7 , 95 % CI 3.7 to 51.9 , p=0.012 ) . There was no other intergroup difference . Conclusions There was no difference in the total Constant score between DHC and controls . However , pain was improved at 3 months after DHC . The differences found in subscores for pain should be explored in future studies . Trial registration clinical trials.gov Identifier : NCT 01022775 The effects of balneotherapy on chronic shoulder pain were studied . In this single-blind , r and omized , follow-up study involving 46 patients with chronic shoulder pain , one group of patients received physiotherapy — exercise and transcutaneous electrical nerve stimulation— and the other group received balneotherapy in addition to physiotherapy for 4 weeks on 15 occasions . The following parameters were recorded before treatment ( at week 0 ) and after treatment ( at weeks 4 , 7 , and 13 ) : Shoulder Pain and Disability Index ( SPADI ) , the Short Form ( 36 ) Health Survey ( SF-36 ) and EuroQuol-5D ( EQ-5D ) quality of life question naires , pain at rest and on movement on the visual analog scale ( VAS ) , and active and passive range of motion . The SPADI pain , function , and total scores and the VAS scores at rest and on movement significantly improved in both groups after treatments . A greater improvement was observed in the balneotherapy group compared to the control group ; regarding some parameters ( VAS score on movement and SPADI function score at visit 2 ; VAS score at rest at visits 3 and 4 ) , the difference between the groups was significant . The improvement of SF-36 and EQ-5D quality of life scores and the active range of motion was more pronounced in the balneotherapy group , the difference between the groups was not significant , except for EQ-5D at visit 2 . Improvement of passive range of motion was not significant . Balneotherapy may have a beneficial effect on the clinical parameters and quality of life of patients with chronic shoulder pain . The number of patients should be increased Objective Local injections are widely used in patients with a painful shoulder . The aim of this study was to evaluate the possible impact of patients ’ visual information on the effectiveness of ultrasound (US)-guided local injections on anxiety levels and shoulder pain . Design A total of 151 patients , scheduled for local injection owing to shoulder pain , were r and omly assigned into two groups in a consecutive order . Patients in group I ( n = 72 ) were provided information related to US findings and allowed to watch the procedures from the monitor , whereas patients in group II ( n = 79 ) received the injection only without any collaboration . Data were collected from both groups immediately before and after injections through visual analog scale and question naire ( the State-Trait Anxiety Inventory [ STAI ] forms 1 and 2 ) . Results US-guided local injections provided significant improvement of anxiety and pain in both groups , irrespective of providing visual information . Group I and group II comparisons with respect to the visual analog scale , STAI 1 , and STAI 2 yielded significant difference only for postinjection STAI 2 in group I ( P = 0.006 ) . Intragroup comparisons revealed significant differences between preinjection and postinjection values ( group I : visual analog scale , P = 0.001 ; STAI form 1 , P = 0.001 ; STAI form 2 , P = 0.002 ; group II : visual analog scale , P = 0.001 ; STAI form 1 , P = 0.002 ; STAI form 2 , P = 0.042 ) . There was no significant difference between the groups in terms of postinjection satisfaction levels from the procedures ( P = 0.824 ) . Conclusions Performing US-guided shoulder injections with patient visual information provides positive contributions to coping with pain and anxiety . In particular , the patient collaboration – based US-guided injections have positive consequences on patients ’ long-st and ing “ trait-anxiety ” levels Previous research suggests that Mulligan 's Mobilisation-with-Movement ( MWM ) technique for the shoulder produces an immediate improvement in movement and pain . The aims of this study were to investigate the time course of the effects of a single MWM technique and to ascertain the effects of adding tape following MWM in people with shoulder pain . Twenty-five participants ( 15 males , 10 females ) , who responded positively to an initial application of MWM , were r and omly assigned to MWM or MWM-with-Tape .  Range of movement ( ROM ) , pressure pain threshold ( PPT ) and current pain severity ( PVAS ) were measured pre- and post-intervention , 30-min , 24-h and one week follow-up . Following a one-week washout period , participants were crossed over to receive a single session of the opposite intervention with follow-up measures repeated . ROM significantly improved with MWM-with-Tape and was sustained over one week follow-up ( p < 0.001 ; 18.8 ° , 95 % confidence intervals ( CI ) 7.3 - 30.4 ) , and in PVAS up to 30-min follow-up ( 38.4 mm , 95 % CI 20.6 - 56.1 mm ) . MWM demonstrated an improvement in ROM ( 11.8 ° , 95 % CI 1.9 - 21.7 ) and PVAS ( 40.4 mm , 95 % CI 27.8 - 53.0 mm ) , but only up to 30-min follow-up . There was no significant improvement in PPT for either intervention at any time point . MWM-with-Tape significantly improved ROM over the one-week follow-up compared to MWM alone ( 15.9 ° , 95 % CI 7.4 - 24.4 ) . Both MWM and MWM-with-Tape  provide a short-lasting improvement in pain and ROM , and MWM-with-Tape also provides a sustained improvement in ROM to one-week follow-up , which is superior to MWM alone STUDY DESIGN Planned secondary analysis of a r and omized clinical trial . OBJECTIVES To examine : 1 ) patients ' baseline expectations for treatment outcome of thoracic high velocity low amplitude thrust manipulations ( HVLATM ) to the thoracic spine for shoulder pain ; 2 ) if the message conveyed by the clinician changed the patients ' expectation ; 3 ) any differences in outcome based on expectation independent of messaging . ; and 4 ) any differences in outcome for those patients whose expectations significantly changed as a result of the messaging . BACKGROUND Thoracic HVLATM may be an effective intervention for patients suffering from musculoskeletal shoulder pain . The role of expectation in the treatment effectiveness of this intervention has not been established . METHODS Subjects ' expectations regarding the effectiveness of  HVLATM  on shoulder pain were recorded at baseline . This was reassessed immediately following the provision of positive or neutral instructional set . The subjects then received a thoracic or scapular HVLATM . The Shoulder Pain and Disability Index ( SPADI ) and the numeric pain rating scale ( NPRS ) were used as outcomes measures . RESULTS There was a 10 subject change ( 23 % ) in positive expectation that was statistically significant ( p = 0.019 ) following a positive message . There was no statistically significant difference in pain and function when these subjects were compared to all other subjects . CONCLUSION Although patients ' expectations of positive outcome significantly changed when providing a positive instructional set , these changes did not translate into clinical ly significant short term changes in shoulder pain and function . LEVEL OF EVIDENCE 1b BACKGROUND AND PURPOSE There is still a lack of evidence about the beneficial effects of ultrasound ( US ) intervention for the management of soft tissue problems . Thus , this study was design ed to assess the effectiveness of US over a placebo intervention when added to other physical therapy interventions and exercise in the management of shoulder disorders . SUBJECTS AND METHODS Forty patients who were diagnosed by ultrasonography or magnetic resonance imaging to have a periarticular soft tissue disorder of the shoulder were r and omly assigned to either a group that received true US ( n=20 ; mean time since onset of pain=8.7 months , SD=8.8 , range=1 - 36 ) or a group that received sham US ( n=20 ; mean time since onset of pain=8.1 months , SD=10.8 , range=1 - 42 ) . Besides true or sham US ( 10 minutes ) , superficial heat ( 10 minutes ) , electrical stimulation ( 15 minutes ) , and an exercise program ( 15 - 30 minutes ) were administered to both groups 5 days each week for 3 weeks . RESULTS Subjects showed within-group improvements in pain , range of motion , Shoulder Disability Question naire scores , and Health Assessment Question naire scores with the intervention , but the differences did not reach significance when compared between the groups . DISCUSSION AND CONCLUSION The results suggest that true US , compared with sham US , brings no further benefit when applied in addition to other physical therapy interventions in the management of soft tissue disorders of the shoulder Background : Subacromial impingement syndrome ( SAIS ) is a painful condition result ing from the entrapment of anatomical structures between the anteroinferior corner of the acromion and the greater tuberosity of the humerus . Objective : The aim of this study was to evaluate the short-term effectiveness of high-intensity laser therapy ( HILT ) versus ultrasound ( US ) therapy in the treatment of SAIS . Design : The study was design ed as a r and omized clinical trial . Setting : The study was conducted in a university hospital . Patients : Seventy patients with SAIS were r and omly assigned to a HILT group or a US therapy group . Intervention : Study participants received 10 treatment sessions of HILT or US therapy over a period of 2 consecutive weeks . Measurements : Outcome measures were the Constant-Murley Scale ( CMS ) , a visual analog scale ( VAS ) , and the Simple Shoulder Test ( SST ) . Results : For the 70 study participants ( 42 women and 28 men ; mean [ SD ] age=54.1 years [ 9.0 ] ; mean [ SD ] VAS score at baseline=6.4 [ 1.7 ] ) , there were no between-group differences at baseline in VAS , CMS , and SST scores . At the end of the 2-week intervention , participants in the HILT group showed a significantly greater decrease in pain than participants in the US therapy group . Statistically significant differences in change in pain , articular movement , functionality , and muscle strength ( force-generating capacity ) ( VAS , CMS , and SST scores ) were observed after 10 treatment sessions from the baseline for participants in the HILT group compared with participants in the US therapy group . In particular , only the difference in change of VAS score between groups ( 1.65 points ) surpassed the accepted minimal clinical ly important difference for this tool . Limitations : This study was limited by sample size , lack of a control or placebo group , and follow-up period . Conclusions : Participants diagnosed with SAIS showed greater reduction in pain and improvement in articular movement functionality and muscle strength of the affected shoulder after 10 treatment sessions of HILT than did participants receiving US therapy over a period of 2 consecutive weeks OBJECTIVES A r and omized , double-blind , clinical trial study was conducted with the aim of determining the efficacy of adding laser ( 830 nm ) to ultrasound ( US ) and exercise for the management of shoulder tendonitis . METHODS 42 subjects ( n=21 , in adding laser group and n=21 , in US and exercise group ) received a course of 10 sessions treatment over one month in the shoulder region . Outcome measures such as Visual Analogue Scale ( VAS ) , Tenderness Severity Scale ( TSS ) , Constant Murley Score ( CMS ) and Manual Muscle Testing ( MMT ) were performed before treatment and at the end of 4 weeks treatment . In addition , follow up were performed 2 months after the end of treatment based on the degree of pain improvement . RESULTS VAS , TSS and CMS improved significantly ( P=0.001 ) in both groups , however the muscle strengths only improved significantly in adding laser group ( P < 0.01 ) . CONCLUSION It seems that both protocol s of physical therapy interventions were effective in relieving the signs and symptoms of shoulder tendonitis . Furthermore , adding low level laser therapy ( LLLT ) to the US and exercise was more efficient in improving the muscle strength in patients with shoulder tendonitis over a period of three months . However , it should be emphasized that , the current results might be due to the effects of laser and exercise instead of laser , us and exercise ( as we had no independent group for US ) Rotator cuff tendinitis is one of the main causes of shoulder pain . The objective of this study was to evaluate the possible additive effects of low-power laser treatment in combination with conventional physiotherapy endeavors in these patients . A total of 50 patients who were referred to the Physical Medicine and Rehabilitation Clinic with shoulder pain and rotator cuff disorders were selected .  Pain severity measured with visual analogue scale ( VAS ) , abduction , and external rotation range of motion in shoulder joint was measured by goniometry , and evaluation of daily functional abilities of patients was measured by shoulder disability question naire . Twenty-five of the above patients were r and omly assigned into the control group and received only routine physiotherapy . The other 25 patients were assigned into the experimental group and received conventional therapy plus low-level laser therapy ( 4 J/cm2 at each point over a maximum of ten painful points of shoulder region for total 5 min duration ) . The above measurements were assessed at the end of the third week of therapy in each group and the results were analyzed statistically . In both groups , statistically significant improvement was detected in all outcome measures compared to baseline ( p < 0.05 ) . Comparison between two different groups revealed better results for control of pain ( reduction in VAS average ) and shoulder disability problems in the experimental group versus the control ( 3.1 ± 2.2 vs. 5 ± 2.6 , p = 0.029 and 4.4 ± 3.1 vs. 8.5 ± 5.1 , p = 0.031 , respectively ) after intervention . Positive objective signs also had better results in the experimental group , but the mean range of active abduction ( 144.92 ± 31.6 vs. 132.80 ± 31.3 ) and external rotation ( 78.0 ± 19.5 vs. 76.3 ± 19.1 ) had no significant difference between the two groups ( p = 0.20 and 0.77 , respectively ) . As one of physical modalities , gallium-arsenide low-power laser combined with conventional physiotherapy has superiority over routine physiotherapy from the view of decreasing pain and improving the patient ’s function , but no additional advantages were detected in increasing shoulder joint range of motion in comparison to other physical agents The aim of this clinical trial was to evaluate the effectiveness of therapeutic MD on pain , functional capacity , muscle strength , quality of life , and depression in patients with subacromial impingement syndrome ( SIS ) . A total of 40 inpatient subjects with definite SIS were included in this study . These patients were sequentially r and omized into 2 groups . Group 1 ( n = 20 ) received therapeutic MD . Group 2 ( n = 20 ) was served as control group and received sham MD . Superficial heat and exercise program were given to both groups . Both of the programs were performed 5 times weekly for 3 weeks . Patients were assessed before treatment ( BT ) , after treatment ( AT ) , and at a 1-month follow-up ( F ) . Outcome measures included visual analogue scale , goniometry , Shoulder Pain and Disability Index , Shoulder Disability Question naire , shoulder isokinetic muscle testing , h and grip strength , Short Form 36 , and Beck Depression Index . The patients with SIS in each group had significant improvements in pain , shoulder ROM , disability , shoulder muscles and grip strength , quality of life , and depression AT and F when compared with their initial status ( P < 0.05 ) . There was no statistically significant difference between the groups according to all the parameters regarding the change scores between AT – BT test and F – BT test ( P > 0.05 ) . A 2,450-MHz MD regimen showed no beneficial effects in patients with SIS , so the superficial heat and exercise program , as it is efficient , may be preferable for the treatment of SIS , alone BACKGROUND Research ers have demonstrated moderate evidence for the use of exercise in the treatment of subacromial impingement syndrome ( SAIS ) . Recent evidence also supports eccentric exercise for patients with lower extremity and wrist tendinopathies . However , only a few investigators have examined the effects of eccentric exercise on patients with rotator cuff tendinopathy . PURPOSE To compare the effectiveness of an eccentric progressive resistance exercise ( PRE ) intervention to a concentric PRE intervention in adults with SAIS . STUDY DESIGN R and omized Clinical Trial . METHODS Thirty-four participants with SAIS were r and omized into concentric ( n = 16 , mean age : 48.6 ± 14.6 years ) and eccentric ( n = 18 , mean age : 50.1 ± 16.9 years ) exercise groups . Supervised rotator cuff and scapular PRE 's were performed twice a week for eight weeks . A daily home program of shoulder stretching and active range of motion ( AROM ) exercises was performed by both groups . The outcome measures of the Disabilities of the Arm , Shoulder , and H and ( DASH ) score , pain-free arm scapular plane elevation AROM , pain-free shoulder abduction and external rotation ( ER ) strength were assessed at baseline , week five , and week eight of the study . RESULTS Four separate 2x3 ANOVAs with repeated measures showed no significant difference in any outcome measure between the two groups over time . However , all participants made significant improvements in all outcome measures from baseline to week five ( p < 0.0125 ) . Significant improvements also were found from week five to week eight ( p < 0.0125 ) for all outcome measures except scapular plane elevation AROM . CONCLUSION Both eccentric and concentric PRE programs result ed in improved function , AROM , and strength in patients with SAIS . However , no difference was found between the two exercise modes , suggesting that therapists may use exercises that utilize either exercise mode in their treatment of SAIS . LEVEL OF EVIDENCE Therapy , level 1b Objectives : To evaluate the clinical effectiveness of a self-managed single exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy . Design : Multi-centre pragmatic unblinded parallel group r and omised controlled trial . Setting : UK National Health Service . Participants : Patients with a clinical diagnosis of rotator cuff tendinopathy . Interventions : The intervention was a programme of self-managed exercise prescribed by a physiotherapist in relation to the most symptomatic shoulder movement . The control group received usual physiotherapy treatment . Main outcome measures : The primary outcome measure was the Shoulder Pain & Disability Index ( SPADI ) at three months . Secondary outcomes included the SPADI at six and twelve months . Results : A total of 86 patients ( self-managed loaded exercise n=42 ; usual physiotherapy n=44 ) were r and omised . Twenty-six patients were excluded from the analysis because of lack of primary outcome data at the 3 months follow-up , leaving 60 ( n=27 ; n=33 ) patients for intention to treat analysis . For the primary outcome , the mean SPADI score at three months was 32.4 ( SD 20.2 ) for the self-managed group , and 30.7 ( SD 19.7 ) for the usual physiotherapy treatment group ; mean difference adjusted for baseline score : 3.2 ( 95 % Confidence interval -6.0 to + 12.4 P = 0.49 ) . By six and twelve months there remained no significant difference between the groups . Conclusions : This study does not provide sufficient evidence of superiority of one intervention over the other in the short- , mid- or long-term and hence a self-management programme based around a single exercise appears comparable to usual physiotherapy treatment OBJECTIVE The aim of this study was to compare the effectiveness of low-level laser therapy and ultrasound therapy in the treatment of subacromial impingement syndrome . MATERIAL S AND METHODS Thirty one patients with subacromial impingement syndrome were r and omly assigned to low-level laser therapy group ( n=16 ) and ultrasound therapy group ( n=15 ) . Study participants received 10 treatment sessions of low-level laser therapy or ultrasound therapy over a period of two-consecutive weeks ( five days per week ) . Outcome measures ( visual analogue pain scale , Shoulder Pain and Disability Index -SPADI- , patient 's satisfactory level and sleep interference score ) were assessed before treatment and at the 1st and 3rd months after treatment . All patients were analyzed by the intent-to-treat principle . RESULTS Mean reduction in VAS pain , SPADI disability and sleep interference scores from baseline to after 1 month , and 3 months of treatment was statistically significant in both groups ( P < 0.05 ) . However , there was no significant difference in the mean change in VAS pain , SPADI disability and sleep interference scores between the two groups ( P > 0.05 ) . The mean level of patient satisfaction in group 1 at the first and third months after treatment was 72.45 ± 23.45 mm and 71.50 ± 16.54 mm , respectively . The mean level of patient satisfaction in group 2 at the first and third months after treatment was 70.38 ± 21.52 mm and 72.09 ± 13.42 mm , respectively . There was no significant difference in the mean level of patient satisfaction between the two groups ( p > 0.05 ) . CONCLUSIONS The results suggest that efficacy of both treatments were comparable to each other in regarding reducing pain severity and functional disability in patients with subacromial impingement syndrome . Based on our findings , we conclude that low-level laser therapy may be considered as an effective alternative to ultrasound based therapy in patients with subacromial impingement syndrome especially ultrasound based therapy is contraindicated BACKGROUND Muscle imbalance between serratus anterior ( SA ) , upper trapezius ( UA ) , middle trapezius ( MT ) , and lower trapezius ( LT ) muscles has been observed in subjects with subacromial impingement syndrome ( SAIS ) . OBJECTIVE ( 1 ) To investigate the effect of electromyography ( EMG ) biofeedback training on muscle balance ratios and scapular kinematics in healthy adults and subjects with SAIS . ( 2 ) To investigate whether the effects of EMG biofeedback on muscle balance ratios are different between groups . DESIGN Twelve healthy adults and 13 subjects with SAIS were recruited in this study .  EMG  was used to record the activity of scapular muscles . The ratios ( UT/SA , UT/MT , and UT/LT ) during exercises with/without EMG biofeedback were calculated . Scapular kinematics were recorded before and after exercises with/without EMG biofeedback . RESULTS For the subjects with SAIS , muscle balance ratios were lower during forward flexion with EMG biofeedback than during exercise only ( UT/SA : 70.3 - 45.2 ; UT/LT : 124.8 - 94.6 ) . Additionally , similar results were found during side-lying external rotation ( UT/MT : 58.5 - 36.4 ) . For the scapular upward rotation and tipping in both groups , there were no significant differences with and without EMG biofeedback . CONCLUSION EMG biofeedback improved the scapular muscular balance during training exercises in both groups . Further clinical trials should investigate the long-term effects of EMG biofeedback STUDY DESIGN Controlled laboratory study . OBJECTIVES To assess scapular kinematics and electromyographic signal amplitude of the shoulder musculature , before and after thoracic spine manipulation ( TSM ) in subjects with rotator cuff tendinopathy ( RCT ) . Changes in range of motion , pain , and function were also assessed . BACKGROUND There are various treatment techniques for RCT . Recent studies suggest that TSM may be a useful component in the management of pain and dysfunction associated with RCT . METHODS Thirty subjects between 18 and 45 years of age , who showed signs of RCT , participated in this study . Changes in scapular kinematics and muscle activity , as well as changes in shoulder pain and function , were assessed pre-TSM and post-TSM using paired t tests and repeated- measures analyses of variance . RESULTS TSM did not lead to changes in range of motion or scapular kinematics , with the exception of a small decrease in scapular upward rotation ( P = .05 ) . The only change in muscle activity was a small but significant increase in middle trapezius activity ( P = .03 ) . After TSM , subjects demonstrated decreased pain during performance of the Jobe empty-can ( mean ± SD change , 2.6 ± 1.1 ) , Neer ( 2.6 ± 1.3 ) , and Hawkins-Kennedy ( 2.8 ± 1.3 ) tests ( all , P<.001 ) . Subjects also reported decreased pain with shoulder flexion ( mean ± SD change , 2.0 ± 1.5 ; P<.001 ) and improved shoulder function ( force production , 2.5 ± 1.4 kg ; Penn Shoulder Score , 7.7 ± 9.4 ; sports/performing arts module of the Disabilities of the Arm , Shoulder and H and question naire , 16.4 ± 13.2 ) ( all , P<.001 ) . CONCLUSION Immediate improvements in shoulder pain and function post-TSM are not likely explained by alterations in scapular kinematics or shoulder muscle activity . For people with pain associated with RCT , TSM may be an effective component of their treatment plan to improve pain and function . However , further r and omized controlled studies are necessary to better vali date this treatment approach . LEVEL OF EVIDENCE Therapy , level 4 OBJECTIVE The purpose of this study was to compare the immediate effects of mobilization with movement ( MWM ) to a sham technique in patients with shoulder impingement syndrome . METHODS A r and omized controlled trial was performed . Forty-two patients ( mean ± SD age , 55 ± 9 years ; 81 % female ) satisfied eligibility criteria , agreed to participate , and were r and omized into an MWM group ( n = 21 ) or sham manual contact ( n = 21 ) . The primary outcome measures including pain intensity , pain during active range of motion , and maximal active range of motion were assessed by a clinician blinded to group allocation . Outcomes were captured at baseline and after 2 weeks of MWM treatment or sham intervention . The primary analysis was the group × time interaction . RESULTS The 2 × 2 analysis of variance revealed a significant group × time interaction for pain intensity during shoulder flexion ( F = 7.054 ; P = .011 ) , pain-free shoulder flexion ( F = 32.853 ; P < .001 ) , maximum shoulder flexion ( F = 18.791 ; P < .01 ) , and shoulder external rotation ( F = 7.950 ; P < .01 ) in favor of the MWM group . No other significant differences were found . CONCLUSIONS Patients with shoulder impingement syndrome who received 4 sessions of MWM exhibited significantly better outcomes for pain during shoulder flexion , pain-free range of shoulder flexion , maximal shoulder flexion , and maximal external rotation than those patients who were in the sham group QUESTION Are there different effects of home exercises and supervised exercises on pain and disability for people with subacromial impingement ? DESIGN R and omised trial with two treatment arms , concealed allocation , blinded assessment of some outcomes , and intention-to-treat analysis . PARTICIPANTS Forty-six patients with subacromial impingement were recruited from an interdisciplinary outpatient clinic of physical medicine and rehabilitation at a university hospital in Norway . INTERVENTION The home exercise group had one supervised exercise treatment followed by exercises at home for 6 weeks . The supervised exercise group had up to 10 supervised exercise treatments in addition to home exercises for 6 weeks . OUTCOME MEASURES The primary outcome was the Shoulder Pain and Disability Index ( SPADI ) . Secondary outcome variables were : average pain during the past week , the Fear Avoidance Beliefs Question naire , participant satisfaction with treatment , active range of motion , work status and clinical shoulder tests . Pain was assessed weekly and all outcomes were assessed at 6 weeks . Participants were free to seek ongoing treatment of their choice until 26 weeks , when the SPADI was assessed again . RESULTS While both groups improved considerably , the groups did not differ significantly on the SPADI after the intervention at 6 weeks ( 0 points , 95 % CI -14 to 14 ) or when followed up at 26 weeks ( -2 points , 95 % CI -21 to 17 ) . There were no between-group differences for pain at any time . The remaining outcomes also did not differ significantly , except for the clinical tests of shoulder impingement . In the supervised exercise group , 11 out of 23 participants had two or more positive tests , compared to 18 out of 21 in the home exercise group . CONCLUSION Supervision of more than the first session of a 6-week exercise regimen did not cause significant differences in pain and disability in people with subacromial impingement . TRIAL REGISTRATION NCT01257113 OBJECTIVE Local steroid injections and community-based physiotherapy have been shown to be of similar benefit for treating shoulder pain presenting to primary care . This paper presents a cost consequences analysis of a prospect i ve economic evaluation , conducted alongside a r and omized clinical trial ( RCT ) of corticosteroid injections versus physiotherapy for new episodes of unilateral shoulder pain , to determine the economic implication s of injection versus physiotherapy . METHODS A pragmatic RCT with 207 patients r and omized to either physiotherapy ( n = 103 ) or local steroid injection ( n = 104 ) was conducted . The re source inputs required were identified for each treatment arm in terms of capital , staff and consumables . These were measured for the period up to 6 months post-r and omization . Outcome measures included shoulder disability , shoulder pain , global assessment of health change and the EQ5D , all at 6 months . A sensitivity analysis was performed around the general practitioner minor surgical fee . RESULTS Analysis is presented on the 199 patients for which the general practice record review ( 101 physiotherapy , 98 injection ) was available . The total mean costs , per patient , were 71.28 pound sterling for the injection group and 114.60 pound sterling for the physiotherapy group . The difference in average total cost per patient was 43.32 pound sterling ( 95 % bootstrap confidence interval : 16.21 pound sterling , 68.03 pound sterling ) . This is a statistically significant difference in cost . Outcome was similar in both groups across all measures following intervention . Smaller mean differences in cost were observed between the treatment groups in the sensitivity analysis , but the difference remained in favour of injection over physiotherapy . CONCLUSIONS This study has shown , given similar clinical outcomes across the treatment groups , that corticosteroid injections were the cost-effective option for patients presenting with new episodes of unilateral shoulder pain in primary care This prospect i ve , r and omized trial was performed to compare the results of treating subacromial impingement syndrome of the shoulder by a guided self-training program with the treatment by conventional physiotherapy or a functional brace .  Sixty patients with the diagnosis of an outlet impingement syndrome of the shoulder ( Neer I and II ) were treated either by strengthening the depressors of the humeral head with a guided self-training program , by conventional physiotherapy , or by wearing a functional brace . The Constant-Murley score was assessed after 6 and 12 weeks . Shoulder pain was monitored with a visual analog scale . All three groups showed a significant improvement in shoulder function as well as a significant reduction in pain . There were no statistically significant differences among the groups . Guided self-training can lead to results similar to those of conventional physiotherapy . The comparable effect of the functional brace remains unclear and might be explained by an influence on proprioception OBJECTIVE Evaluate the efficacy of acupuncture associated with physiotherapy for patients with painful shoulder . METHODS In a multicentre controlled r and omized study , participants were recruited with a clinical diagnosis of unilateral subacromial syndrome from six rehabilitation medicine departments belonging to the Public Health System in two Spanish regions . All participants received 15 sessions of physiotherapy during the 3 weeks that the treatment lasted and were r and omized to additionally receive , once a week , acupuncture or mock TENS ( transcutaneous electrical nerve stimulation ) . The primary outcome measure was the change in the Constant-Murley Score ( CMS ) for functional assessment of the shoulder , at 4 weeks after r and omization . This study is registered as an International St and ard R and omized Controlled Trial , number IS RCT N28687220 . RESULTS A total of 425 patients were recruited . The mean score ( s.d . ) on the CMS had increased by 16.6 ( 15.6 ) points among the acupuncture group , compared with 10.6 ( 13.5 ) points in the control group , and the mean difference between the two groups was statistically significant ( 6.0 points ; 95 % CI 3.2 , 8.8 points ; P < 0.001 ) . By the end of the treatment , 53 % of the patients in the acupuncture group had decreased their consumption of analgesics , compared with a corresponding 30 % among the control group ( P < 0.001 ) . CONCLUSIONS Single-point acupuncture in association with physiotherapy improves shoulder function and alleviates pain , compared with physiotherapy as the sole treatment . This improvement is accompanied by a reduction in the consumption of analgesic medicaments The subacromial syndrome is the most common source of shoulder pain . The mainstays of conservative treatment are non-steroidal anti-inflammatory drugs and exercise therapy . Recently , low-level laser therapy ( LLLT ) has been popularized in the treatment of various musculoskeletal disorders . The aim of this study is to evaluate the additive effects of LLLT with exercise in comparison with exercise therapy alone in treatment of the subacromial syndrome . We conducted a r and omised clinical study of 80 patients who presented to clinic with subacromial syndrome ( rotator cuff and biceps tendinitis ) . Patients were r and omly allocated into two groups . In group I ( n = 40 ) , patients were given laser treatment ( pulsed infrared laser ) and exercise therapy for ten sessions during a period of 2 weeks . In group II ( n = 40 ) , placebo laser and the same exercise therapy were given for the same period . Patients were evaluated for the pain with visual analogue scale ( VAS ) and shoulder range of motion ( ROM ) in an active and passive movement of flexion , abduction and external rotation before and after treatment . In both groups , significant post-treatment improvements were achieved in all parameters ( P = 0.00 ) . In comparison between the two groups , a significant improvement was noted in all movements in group I ( P = 0.00 ) . Also , there was a substantial difference between the groups in VAS scores ( P = 0.00 ) which showed significant pain reduction in group I. This study indicates that LLLT combined exercise is more effective than exercise therapy alone in relieving pain and in improving the shoulder ROM in patients with subacromial syndrome OBJECTIVE The study investigated the effectiveness of stretching , strengthening exercises , and the scapular stabilization exercises on the pain , shoulder range of motion ( ROM ) , muscle strength , joint position sense ( JPS ) , scapular dyskinesis and quality of life ( OL ) in the patients with subacromial impingement syndrome ( SIS ) . METHODS 27 women and 13 men , mean age 51 ( 24 - 71 ) years old , were included in this study . All the patients were separated into 2 groups according to simple r and om table . Stretching and strengthening exercises were given to the group I ( n=20 ) and scapular stabilization exercises were added to the group II ( n=20 ) . The pain severity , shoulder ROM , muscle strength , JPS , lateral scapular slide test ( LSST ) , Western Ontario Rotator Cuff ( WORC ) Index were evaluated before and after treatment . Patients completed a 6-week rehabilitation program , three times a week . RESULTS The results showed that all measurements improved statistically in both groups after treatment ( p < 0.05 ) . And the improvements in the muscle strength , JPS and scapular dyskinesia were significantly different in group II ( p < 0.05 ) . CONCLUSION It is suggested that in the treatment of SIS ; scapular stabilization exercises , given with stretching and strengthening exercises , can be more effective in increasing the muscle strength , developing the JPS and decreasing the scapular dyskinesis Objective : To compare the short-term effectiveness of precut kinesiology tape ( PCT ) to a nonsteroidal anti-inflammatory drug ( NSAID ) as adjuvant treatment to exercise physiotherapy in improving pain and function in patients with shoulder impingement . Design : R and omized , controlled assessor-blind parallel- design trial with 3 groups . Setting : Academic-community hospital . Patients : One hundred patients ( mean age : 48 ± 12.3 , 61 men , 39 women ) with a diagnosis of subacromial impingement ( SAI ) syndrome were r and omized to a treatment group from October 2009 to June 2012 . Eighty-one patients completed the study . Interventions : Patients were r and omized to one of the 3 treatment groups : PCT and Exercise ( n = 33 ) , NSAID and Exercise ( n = 29 ) , or Exercise only ( n = 38 ) for a 4 session 2-week intervention with a registered physiotherapist . Main Outcome Measures : Numeric pain rating scales for pain at rest and pain with arm elevation , the Simple Shoulder Test ( SST ) , and the Constant Score were assessed pretreatment and post-treatment . Results : A statistically significant reduction in pain at rest and pain with arm elevation , as well as improvement in SST and Constant Score were observed in all 3 treatment groups , with minimal clinical ly important differences shown on pain with elevation and SST scores . Between-group differences on all outcome measures were not statistically significant or clinical ly meaningful . Conclusions : The improvements in pain and function observed with an NSAID or PCT as adjuvant treatments were no greater than with rehabilitation exercise alone . If adjuvant treatment is desired , PCT seems to be better tolerated than an NSAID , although the difference did not reach significance . Clinical Relevance : The routine addition of adjuvant treatment is not supported by the results of this study . As adjuvant therapy , PCT seems to be better tolerated  than an NSAID . If desired , clinicians may consider incorporating PCT along with an exercise component in the conservative treatment of SAI syndrome BACKGROUND Kinesiological taping ( KT ) is commonly used to improve symptoms associated with musculoskeletal disorders . However , review of the literature revealed minimal evidence to support the use of KT in treatment of shoulder disorders and controversy exists regarding the effect of KT in patients with shoulder impingement syndrome ( SIS ) . OBJECTIVE The purpose of this study was to investigate the effect of KT on pain intensity during movement , pain experienced during the night ( nocturnal pain ) , and pain-free shoulder range of motion ( ROM ) immediately after taping , after three days and after one week , in patients with SIS . DESIGN R and omized , Double blinded , Placebo-controlled design . PARTICIPANTS A total of 30 patients with SIS participated in this study . Patients were assigned r and omly to a control ( N = 15 ) and an experimental group ( N = 15 ) . METHODS The patients in the experimental group received a st and ardized therapeutic KT . The st and ardized , placebo neutral KT was applied for control group . KT was applied two times with a three day interval , remaining on during the 3 day interval . Both groups followed the same procedures . Pain-free active ROM during shoulder abduction , flexion , and elevation in the scapular plane was measured . Visual analogue scale ( VAS ) for pain intensity during movement or nocturnal pain and was assessed at baseline , immediately after KT , after three days , and one week after KT . RESULTS The result of repeated measures ANOVA showed a significant change in pain level during movement , nocturnal pain , and pain-free ROM ( p = 0.000 ) after KT in the experimental group . In the ANCOVA , controlling for pre-test scores , change in pain level at movement ( p = 0.009 ) and nocturnal pain ( p = 0.04 ) immediately after KT was significantly greater in the experimental group than in control group . There was no significant difference in ROM measures ( p > 0.05 ) between groups immediately after KT . No significant differences were found between the two groups in the after one week measurements of pain intensity and shoulder ROM . CONCLUSION The KT produces an immediate improvement in the pain intensity at movement and nocturnal pain in patients with SIS . LEVEL OF EVIDENCE 1 OBJECTIVE The aim of this study was to investigate the effects of h and -behind-back ( HBB ) Mulligan mobilization with movement ( MWM ) techniques on acute shoulder pain , impairment , and disability . METHODS This double-blind , r and omized , controlled trial recruited 44 patients with acute shoulder pain and movement impairment presenting to an Indian general hospital . Participants were allocated to receive either MWM and exercise/hot pack ( n = 22 ) or exercise/hot pack alone ( n = 22 ) . The average duration of symptoms was 4.1 and 4.7 weeks in the exercise and MWM groups , respectively . The primary outcome was HBB range of motion ( ROM ) . Secondary variables were shoulder internal rotation ROM , pain intensity score , and shoulder disability identified by the shoulder pain and disability index . All variables were evaluated by a blinded assessor before and immediately after 9 treatment sessions over 3 weeks . RESULTS Paired t tests revealed that both groups demonstrated statistically significant improvements ( P < .001 ) with large effect sizes for all variables . However , for all variables , the MWM-with-exercise group showed significantly greater improvements ( P < .05 ) than the exercise group . H and -behind-back ROM showed a mean difference of 9.31 ° ( 95 % confidence interval , 7.38 - 11.27 ) , favoring greater improvement in the MWM-with-exercise group . CONCLUSIONS In this study , the outcomes of patients with acute shoulder pain and disability receiving  shoulder HBB MWM with exercise improved greater than those receiving exercise/hot packs alone BACKGROUND Traditional rehabilitation improves pain and function in patients with shoulder impingement syndrome .  Neurocognitive rehabilitation has shown to be highly effective after surgical reconstruction of the anterior cruciate ligament . However , its effects in patients with shoulder impingement syndrome have not yet been established . AIM The aim of the study was to compare the effects of neurocognitive therapeutic exercise , based on proprioception and neuromuscular control , on pain and function in comparison to traditional therapeutic exercise in patients with shoulder impingement syndrome . DESIGN Single-blind r and omized , non-inferiority clinical trial . SETTING Outpatient clinic of Geriatrics and Physiatrics , University Hospital . POPULATION Forty-eight patients with shoulder impingement syndrome ( Neer stage I ) and pain lasting for at least three months . METHODS Participants were r and omly allocated ( 1:1 ) to either neurocognitive therapeutic exercise or traditional therapeutic exercise . Both treatments were provided one-hour session , three times a week for five weeks . The primary outcome measure was the short form of the Disability of the Arm , Shoulder and H and Question naire ( Quick-DASH question naire ) for the assessment of physical ability and symptoms of the upper extremity . SECONDARY OUTCOME MEASURES Constant-Murley shoulder outcome score for the determination of range of motion , pain and strength ; American Shoulder and Elbow Surgeons Society st and ardized shoulder assessment form for the evaluation of physical ability in daily-living tasks ; a visual analogue scale for pain assessment at rest and during movements ; Likert score for the estimation of participant satisfaction . ENDPOINTS before treatment , end of treatment , 12 and 24 weeks after the completion of each intervention for all outcome measures , except for the Likert score that was evaluated only at the end of treatment . FOLLOW-UP 24 weeks . RESULTS At the end of treatment and at follow-up , both treatment groups experienced improvements in all outcomes measures relative to baseline values , except for the visual analogue scale at rest that was unaffected by traditional therapeutic exercise . For all outcome measures , changes over time were greater in the neurocognitive therapeutic exercise group relative to the traditional therapeutic exercise group . The level of satisfaction with treatment was higher for participants in the neurocognitive therapeutic exercise group . CONCLUSION Neurocognitive rehabilitation is effective in reducing pain and improving function in patients with shoulder impingement syndrome , with benefits maintained for at least 24 weeks . CLINICAL REHABILITATION IMPACT skills and function of the shoulder can greatly benefit from neurocognitive rehabilitation BACKGROUND Interference is an important feature of the waves . When two or more in phase light waves meet , a new and reinforced wave is generated . Shoulder pain is a common clinical problem and laser is one of the treatments frequently used to relieve it . OBJECTIVE To test the safety of interferential laser therapy generated by two independent low level lasers and compare its effectiveness with conventional single laser therapy in the reduction of  shoulder musculoskeletal pain and associated disability . DESIGN R and omised and single-blind controlled clinical trial . SETTING Physiotherapy Unit and Rehabilitation Department of Ramon y Cajal University Hospital ( Madrid ) . PARTICIPANTS 200 patients with shoulder musculoskeletal pain were r and omly assigned in two groups , 100 people each . INTERVENTIONS Group I , experimental ( n=100 ) received interferential laser , placing two probes opposite each other over the shoulder joint . Group II , control ( n=100 ) received conventional laser therapy , using a single probe along with a second inactive dummy probe . Lasers used were GaAlAs diode ( 810 nm , 100 mW ) , in continuous emission . Laser was applied in contact mode through ten sessions , on 5 shoulder points ( 7 Joules/point ) per session . MAIN OUTCOME MEASURES visual analogue scale ( VAS ) score and shoulder pain disability index ( SPADI ) , recorded before and after laser treatment . RESULTS There were no differences between both groups in the reduction of pain , either assessed by VAS scale ( median difference=0 , 95 % CI of the difference = -.6 to .5 , p = 0.81 ) or SPADI index ( median difference = .4 , 95 % CI of the difference = -2.9 to 3.8 , p = 0.80 ) , using the Mann-Whitney U-test . Comparison between the scores recorded before and after the treatment , within each group , showed significant differences for VAS during movement ( median difference=3 , 95 % CI of the difference = 2.07 to 4 , p < 0.001 ) and SPADI index ( median difference=3.5 , 95 % CI of the difference = 2.67 to 3.85 , Wilcoxon test , p < 0.001 ) , for both groups . CONCLUSIONS In this study , the application of two low level lasers in order to generate interference inside the irradiated tissue showed to be a safe therapy . Both interferential and conventional laser therapy reduced shoulder pain and disability . Nevertheless , differences between them were not detected . Future research in this field could include applying this technique with other laser parameters or application forms Study Design Multicenter r and omized controlled trial . Background Cervicothoracic manual therapy has been shown to improve pain and disability in individuals with shoulder pain , but the incremental effects of manual therapy in addition to exercise therapy have not been investigated in a r and omized controlled trial . Objectives To compare the effects of cervicothoracic manual therapy and exercise therapy to those of exercise therapy alone in individuals with shoulder pain . Methods Individuals ( n = 140 ) with shoulder pain were r and omly assigned to receive 2 sessions of cervicothoracic range-of-motion exercises plus 6 sessions of exercise therapy , or 2 sessions of high-dose cervicothoracic manual therapy and range-of-motion exercises plus 6 sessions of exercise therapy ( manual therapy plus exercise ) .  Pain and disability were assessed at baseline , 1 week , 4 weeks , and 6 months . The primary aim ( treatment group by time ) was examined using linear mixed-model analyses and the repeated measure of time for the Shoulder Pain and Disability Index ( SPADI ) , the numeric pain-rating scale , and the shortened version of the Disabilities of the Arm , Shoulder and H and question naire ( QuickDASH ) . Patient-perceived success was assessed and analyzed using the global rating of change ( GROC ) and the Patient Acceptable Symptom State ( PASS ) , using chi-square tests of independence . Results There were no significant 2-way interactions of group by time or main effects by group for pain or disability . Both groups improved significantly on the SPADI , numeric pain-rating scale , and QuickDASH . Secondary outcomes of success on the GROC and PASS significantly favored the manual therapy-plus-exercise group at 4 weeks ( P = .03 and P<.01 , respectively ) and on the GROC at 6 months ( P = .04 ) . Conclusion Adding 2 sessions of high-dose cervicothoracic manual therapy to an exercise program did not improve pain or disability in patients with shoulder pain , but did improve patient-perceived success at 4 weeks and 6 months and acceptability of symptoms at 4 weeks . More research is needed on the use of cervicothoracic manual therapy for treating shoulder pain . Level of Evidence Therapy , level 1b . Prospect ively registered March 30 , 2012 at www . Clinical Trials.gov ( NCT01571674 ) . J Orthop Sports Phys Ther 2016;46(8):617 - 628 . doi:10.2519/jospt.2016.6319 OBJECTIVES The aim of this r and omized controlled study was to assess the efficacy of manual therapy in the treatment of patients with symptomatic supraspinatus tendinopathy . METHODS Seventy-seven patients ( age range , 30 to 55 years ) with supraspinatus tendinopathy , were r and omly assigned to one of the three treatment groups : a supervised exercise program ( Group 1 ) , a supervised exercise program combined with joint and soft tissue mobilization ( Group 2 ) , or a home-based rehabilitation program ( Group 3 ) . All patients had rehabilitation for 12 weeks . Pain level was evaluated with a visual analogue scale ( VAS ) and the range of motion ( ROM ) was measured with a goniometer . The Modified American Shoulder and Elbow Surgery ( MASES ) score was used in functional assessment . Flexion , abduction , internal and external rotation strengths were measured with a manual muscle test . All patients were evaluated before , and at the 4th and 12th week of the rehabilitation . RESULTS All groups experienced significant decrease in pain and an increase in shoulder muscle strength and function by both the 4th and 12th weeks of treatment ( p<0.05 ) . There was no significant difference between the groups in terms of function ( p>0.05 ) . However , the greatest improvement in functionality was found in Group 2 . CONCLUSION Supervised exercise , supervised and manual therapy , and home-based exercise are all effective and promising methods in the rehabilitation of the patients with subacromial impingement syndrome . The addition of an initial manual therapy may improve the results of the rehabilitation with exercise The evidence to guide use of spinal manipulative therapy ( SMT ) for patients with shoulder pain is limited . A vali date d sham comparator is needed to ascertain the unique effects of SMT . We investigated the plausibility of a thoracic sham-SMT comparator for SMT in patients with shoulder pain . Participants ( n = 56 ) with subacromial impingement syndrome were r and omized to thoracic SMT or a sham-SMT .  An examiner blinded to group assignment took measures pre- and post-treatment of shoulder active range of motion ( AROM ) and perceived effects of the assigned intervention . Treatment consisted of six upper , middle and lower thoracic SMT or sham-SMT . The sham-SMT was identical to the SMT , except no thrust was applied . Believability as an active treatment was measured post-treatment . Believability as an active treatment was not different between groups ( χ(2 ) = 2.19 ; p = 0.15 ) . Perceptions of effects were not different between groups at pre-treatment ( t = 0.12 ; p = 0.90 ) or post-treatment ( t = 0.40 ; p = 0.69 ) , and demonstrated equivalency with 95 % confidence between groups at pre- and post-treatment . There was no significant change in shoulder flexion in either group over time , or in the sham-SMT for internal rotation ( p > 0.05 ) . The SMT group had an increase of 6.49 ° in internal rotation over time ( p = 0.04 ) . The thoracic sham-SMT of this study is a plausible comparator for SMT in patients with shoulder pain . The sham-SMT was believable as an active treatment , perceived as having equal beneficial effects both when verbally described and after familiarization with the treatment , and has an inert effect on shoulder AROM . This comparator can be considered for used in clinical trials investigating thoracic SMT . IRB number : HM 13182 Abstract The purpose of this double-blind , r and omized controlled pilot study was to compare the effectiveness of four physical therapy interventions in the treatment of primary shoulder impingement syndrome : 1 ) supervised exercise only , 2 ) supervised exercise with glenohumeral mobilizations , 3 ) supervised exercise with a mobilization-with-movement ( MWM ) technique , or 4 ) a control group receiving only physician advice .  Thirty-three subjects diagnosed with primary shoulder impingement were r and omly assigned to one of these four groups . Main outcome measures included 24-hour pain ( VAS ) , pain with the Neer and Hawkins-Kennedy tests , shoulder active range of motion ( AROM ) , and shoulder function ( SPADI ) . Repeated- measures analyses indicated significant decreases in pain , improved function , and increases in AROM . Univariate analyses on the percentage of change from pre- to post-treatment for each dependent variable found no statistically significant differences ( P<0.05 ) between the four groups . Although not significant , the MWM and mobilization groups had a higher percentage of change from pre- to post-treatment on all three pain measures ( VAS , Neer , Hawkins-Kennedy ) . The three intervention groups had a higher percentage of change on the SPADI . The MWM group had the highest percentage of change in AROM , and the mobilization group had the lowest . This pilot study suggests that performing glenohumeral mobilizations and MWM in combination with a supervised exercise program may result in a greater decrease in pain and improved function although studies with larger sample s and discriminant sampling methods are needed OBJECTIVE To assess pain , function , quality of life , and muscle strength in patients with shoulder impingement syndrome who participated in muscle strengthening exercises .  METHODS A total of 60 patients diagnosed with shoulder impingement syndrome were selected from the clinics of the Federal University of São Paulo and r and omly distributed into experimental and control groups . Patients were evaluated regarding pain , function , quality of life , muscle strength , and the number of antiinflammatory drugs and analgesics taken . Patients then participated in the progressive resistance training program for the musculature of the shoulder , which was held twice a week for 2 months , while the control group remained on a waiting list . RESULTS Sixty patients were r and omly allocated to the experimental group ( 21 women and 9 men , mean age 56.3 years ) and control group ( 25 women and 5 men , mean age 54.8 years ) . Patients from the experimental group showed an improvement from 4.2 cm to 2.4 cm on a 10-cm visual analog scale ( P < 0.001 ) regarding pain at rest and from 7.4 cm to 5.2 cm ( P < 0.001 ) regarding pain during movement . Function went from 44.0 to 33.2 ( P < 0.007 ) using the Disabilities of the Arm , Shoulder , and H and assessment and domains from the Short Form 36 . There was a statistically significant difference in improvement in pain and function between patients in the experimental group and those in the control group ( P < 0.05 ) . CONCLUSION The progressive resistance training program for the musculature of the shoulder in patients with shoulder impingement syndrome was effective in reducing pain and improving function and quality of life BACKGROUND AND PURPOSE There is no definitive evidence for the efficacy of the physical therapy interventions used for patients with impingement syndrome . The purpose of this study was to compare manual acupuncture and continuous ultrasound , both applied in addition to home exercises , for patients diagnosed with impingement syndrome . SUBJECTS AND METHODS Eighty-five patients with clinical signs of impingement syndrome were r and omly assigned to either a group that received acupuncture ( n=44 ) or a group that received ultrasound ( n=41 ) . Both interventions were given by physical therapists twice a week for 5 weeks in addition to a home exercise program . Scores from 3 shoulder disability measures , combined in the analysis , measured change during a period of 12 months . RESULTS Both groups improved , but the acupuncture group had a larger improvement in the combined score . DISCUSSION AND CONCLUSION The results suggest that acupuncture is more efficacious than ultrasound when applied in addition to home exercises Aim To compare the effectiveness of l and mark-guided local injections and ultrasonography ( USG ) guided injections for shoulder pain . Methods A total 60 consecutive patients with shoulder pain due to soft tissue disorders was enrolled , and r and omly assigned to receive triamcinolone ( 40 mg ) either by l and mark-guided ( LMG , n=30 ) or USG guided ( n=30 ) injection . The patients were evaluated on admission and 6 weeks after the injection . Clinical assessment included demographic and clinical data , a visual analoge scale ( VAS ) for pain ( 0 to 10 cm ) , the Constant scale ( 0 to 100 ) for function , passive and active shoulder range of motion ( ROM ) with goniometric evaluation , and postinjection adverse effects . Results Initial demographic , clinical and USG findings in the groups exhibited no significant differences . Six weeks after injection , the VAS and the Constant score showed a significantly better improvement in USG group compared with LMG group ( mean VAS score decrease : 4.0±1.7 for USG vs. 2.2±0.9 for LMG , P<0.05 ; mean Constant score change : 32.2 for USG vs. 12.2 for LMG , P<0.05 ) . Significant improvements were observed in active and passive ROM values in both groups , USG group values being better . Initially 18 patients in LMG and 24 patients in USG had limited shoulder ROM , of which 6 was returned to normal values in LMG group and 12 in USG group at 6 week after injection ( P<0.05 ) . Conclusions Our results indicate that the injection of corticosteroids to patients with shoulder pain due to soft tissue disorders under the USG-guidance may improve therapeutic effectiveness and reduce adverse effects STUDY DESIGN R and omized controlled trial . OBJECTIVES To determine if thoracic spinal manipulative therapy ( SMT ) alters thoracic kinematics , thoracic excursion , and scapular kinematics compared to a sham SMT in individuals with subacromial impingement syndrome , and also to compare changes in patient-reported outcomes between treatment groups . BACKGROUND Prior studies indicate that thoracic SMT can improve pain and disability in individuals with subacromial impingment syndrome . However , the mechanisms underlying these benefits are not well understood . METHODS Participants with shoulder impingement symptoms ( n = 52 ) were r and omly assigned to receive a single session of thoracic SMT or sham SMT . Thoracic and scapular kinematics during active arm elevation and overall thoracic excursion were measured before and after the intervention . Patient-reported outcomes measured were pain ( numeric pain-rating scale ) , function ( Penn Shoulder Score ) , and global rating of change . RESULTS Following the intervention , there were no significant differences in changes between groups for thoracic kinematics or excursion , scapular kinematics , and patient-reported outcomes ( P>.05 ) . Both groups showed an increase in scapular internal rotation during arm raising ( mean , 0.9 ° ; 95 % confidence interval [ CI ] : 0.3 ° , 1.6 ° ; P = .003 ) and lowering ( 0.8 ° ; 95 % CI : 0.0 ° , 1.5 ° ; P = .041 ) , as well as improved pain reported on the numeric pain-rating scale ( 1.2 points ; 95 % CI : 0.3 , 1.8 ; P<.001 ) and function on the Penn Shoulder Score ( 9.1 points ; 95 % CI : 6.5 , 11.7 ; P<.001 ) . CONCLUSION Thoracic spine extension and excursion did not change significantly following thoracic SMT . There were small but likely not clinical ly meaningful changes in scapular internal rotation in both groups . Patient-reported pain and function improved in both groups ; however , there were no significant differences in the changes between the SMT and the sham SMT groups . Overall , patient-reported outcomes improved in both groups without meaningful changes to thoracic or scapular motion . LEVEL OF EVIDENCE Therapy , level 1b- AIM Rotator cuff problems are common causes of pain and restriction of movement in shoulder . The aim of this study to compare the effect of intra-articular injection of corticosteroid and conventional transcutaneous electrical nerve stimulator ( TENS ) treatment in treatment of rotator cuff tendinitis . METHODS Subjects were r and omly allocated into Group 1 ( intra-articular injection of corticosteroid ) and Group 2 ( conventional transcutaneous electrical nerve stimulation-TENS ) . Outcome measurements were performed using the Visual Analogue Scale ( VAS ) for pain , range of motion ( ROM ) , the Shoulder Disability Question naire ( SDQ ) , the Short Form-36 ( SF-36 ) , and Beck Depression Scale ( BDS ) question naires and paracetamol consumption . RESULTS In both groups , significant improvement was observed in all weeks in VAS , ROM and SDQ scores ( P<0.05 ) . Improvement was detected in most of the SF36 scores at the end of the treatment in both groups ( P<0.05 ) , while no significant change was observed in BDI score ( P>0.05 ) . In both treatment groups ,  paracetamol consumption decreased in time ( P<0.05 ) . When the groups were compared , a significant difference was found between the groups in favor of Group 1 in terms of VAS-at night and VAS-at rest in weeks 1 , 4 and 12 , and VAS-during movement in week 1 and 12 ( P<0.05 ) . The comparison of two groups revealed a significant difference in favor of Group 1 in weeks 1 in the passive abduction and the active and passive IR ROM measurements ( P<0.05 ) . There was also a significant difference in favor of Group 1 observed in weeks 1 in SDQ scores ( P<0.05 ) . CONCLUSION Intra-articular injection of corticosteroid and conventional TENS are efficient in the treatment of rotator cuff tendinitis . When two treatments are compared , it may be concluded that intra-articular steroid injection was more effective especially in the first weeks regarding pain , ROM and disability . Otherwise , use of TENS allow to patients to increase activity level , improve function and quality of life like that in our study . TENS , as it is cheaper , non-invasive , more easily performed and efficient , may be preferable for the treatment of shoulder pain . Further studies are needed to include these results in the prospect i ve treatment guidelines There is a lack of evidence about the efficacy of routinely used interventions in shoulder pain , such as corticosteroid injection and physiotherapy . This pilot study was set up to assess the feasibility of a larger , r and omized controlled trial . Patients with the clinical presentation of a painful arc of less than 6 months ' duration were recruited through their general practitioners . A total of 112 patients were r and omized to 4 groups :  control , physiotherapy , a course of subacromial steroid injections , or both physiotherapy and steroid injections . The primary outcome measure was the Oxford Shoulder Score ( OSS ) . Follow-up was 18 weeks and by postal question naire at 1 year . No significant differences were found within groups between the OSS scores or the Physical Health total of the Medical Outcomes Study Short Form 36 ( SF-36 ) Health Survey at the beginning and end of the trial or at 1 year . By analysis of covariance , no significant differences were found between treatment groups . Larger studies are needed . A power calculation from our data suggests recruitment of more than 800 patients would be required to achieve a 90 % chance of a clinical ly significant difference being detected between these groups Purpose . To investigate the effectiveness of low-level laser therapy ( LLLT ) in addition to exercise programme on shoulder function in subacromial impingement syndrome ( SAIS ) . Method . Sixty-seven patients with SAIS were r and omly assigned to either a group that received laser ( n = 34 ) or a group that received placebo Laser ( n = 26 ) . Pain , functional assessment , disability and muscle strength of shoulder were assessed before and after a 3-week rehabilitation programme . Besides Laser or placebo Laser , superficial cold and progressive exercise programme were administered to both groups , 5 days a week , for 3 weeks . A progressive exercise programme that was done daily twice under supervision in clinic and at home was given to the patients . Results . After the treatment , all outcome measurements had shown significant improvement except muscle strength in both the groups . When the parameters of the improvement were compared , there were no significant differences between the two groups after treatment . Conclusion . We concluded that there is no fundamental difference between LLLT and placebo LLLT when they are supplementing an exercise programme for rehabilitation of patients with shoulder impingement syndrome OBJECTIVE The purpose of this study was to compare the effects of manual therapy with exercise to kinesiotaping with exercise for patients with subacromial impingement syndrome . METHODS R and omized clinical before and after trial was used . Fifty-four patients diagnosed as having subacromial impingement syndrome who were referred for outpatient treatment were included . Eligible patients ( between 30 and 60 years old , with unilateral shoulder pain ) were r and omly allocated to 2 study groups : kinesiotaping with exercise ( n = 28 ) or manual therapy with exercise ( n = 26 ) . In addition , patients were advised to use cold packs 5 times per day to control for pain . Visual analog scale for pain , Disability of Arm and Shoulder Question naire for function , and diagnostic ultrasound assessment for supraspinatus tendon thickness were used as main outcome measures . Assessment s were applied at the baseline and after completing 6 weeks of related interventions . RESULTS At the baseline , there was no difference between the 2 group characteristics ( P > .05 ) . There were significant differences in both groups before and after treatment in terms of pain decrease and improvement of Disability of Arm and Shoulder Question naire scores ( P < .05 ) . No difference was observed on ultrasound for tendon thickness after treatment in both groups ( P > .05 ) . The only difference between the groups was at night pain , result ing in favor of the kinesiotaping with exercise group ( P < .05 ) . CONCLUSION For the group of subjects studied , no differences were found between kinesiotaping with exercise and manual therapy with exercise . Both treatments may have similar results in reducing pain and disability in subacromial impingement in 6 weeks The purpose of this single blinded r and omised controlled trial was to investigate the effects of soft tissue massage on range of motion , reported pain and reported function in patients with shoulder pain . Twenty-nine patients referred to physiotherapy for shoulder pain were r and omly assigned to a treatment group that received six treatments of soft tissue massage around the shoulder ( n = 15 ) or to a control group that received no treatment while on the waiting list for two weeks ( n = 14 ) . Measurements were taken both before and after the experimental period by a blinded assessor . Active range of motion was measured for flexion , abduction and h and -behind-back movements . Pain was assessed with the Short Form McGill Pain Question naire ( SFMPQ ) and functional ability was assessed with the Patient Specific Functional Disability Measure ( PSFDM ) . The treatment group showed significant improvements in range of motion compared with the control group for abduction ( mean 42.2 degrees , 95 % CI 24.1 to 60.4 degrees ) , flexion ( mean 22.6 degrees , 95 % CI 12.4 to 32.8 degrees ) and h and -behind-back ( mean 11.0 cm improvement , 95 % CI 6.3 to 15.6 cm ) . Massage reduced pain as reported on the descriptive section of the SFMPQ by a mean of 4.9 points ( 95 % CI 2.5 to 7.2 points ) and on the visual analogue scale by an average of 26.5 mm ( 95 % CI 5.3 to 47.6 mm ) , and it improved reported function on the PSFDM by a mean of 8.6 points ( 95 % CI 4.9 to 12.3 points ) . We conclude that soft tissue massage around the shoulder is effective in improving range of motion , pain and function in patients with shoulder pain . The mechanisms behind these effects remain unclear Background : Subacromial corticosteroid injections are frequently performed for impingement syndrome of the shoulder . To improve the accuracy of injections , ultrasound can be used . Purpose : To assess the clinical outcome of ultrasound-guided subacromial injections compared with blind subacromial injections for subacromial impingement syndrome . Study Design : R and omized controlled clinical trial ; Level of evidence , 1 . Methods : A total of 56 shoulders with subacromial impingement syndrome were r and omized into 2 groups : 28 shoulders received a subacromial corticosteroid injection with ultrasound guidance ( ultrasound group ) , and 28 shoulders received a subacromial corticosteroid injection without ultrasound guidance ( blind group ) . The visual analog scale ( VAS ) for pain with overhead activities and the American Shoulder and Elbow Surgeons ( ASES ) score were obtained before the injection and at 6 weeks after the injection . Results : The VAS score for pain with overhead activities decreased from 59 ± 5 mm ( mean ± SEM ) before the injection to 33 ± 6 mm at 6 weeks after the injection in the ultrasound group ( P < .001 ) and from 63 ± 4 mm to 39 ± 6 mm , respectively , in the blind group ( P < .001 ) . The decrease in the VAS score was not significantly different between the groups ( P > .999 ) . The ASES score increased from 57 ± 2 before the injection to 68 ± 3 at 6 weeks after the injection in the ultrasound group ( P < .01 ) and from 54 ± 3 before the injection to 65 ± 4 after the injection in the blind group ( P < .01 ) , with no significant difference between the groups ( P = .7 ) . Four shoulders ( 14 % ) in the ultrasound group and 6 shoulders ( 21 % ) in the blind group eventually needed surgery ( P = .7 ) . Conclusion : No significant differences were found in the clinical outcome when comparing ultrasound-guided subacromial injections to blind subacromial injections for subacromial impingement syndrome . Clinical Trial Registration : Australian New Zeal and Clinical Trials Registry : STUDY DESIGN Single-blind r and omized clinical trial , with a follow-up of 24 weeks . OBJECTIVE To determine the effects of hyperthermia via localized microwave diathermy on pain and disability in comparison to subacromial corticosteroid injections in patients with rotator cuff tendinopathy . BACKGROUND Hyperthermia improves symptoms and function in several painful musculoskeletal disorders . However , the effects of microwave diathermy in rotator cuff tendinopathy have not yet been established . METHODS Ninety-two patients with rotator cuff tendinopathy and pain lasting for at least 3 months were recruited from the outpatient clinic of the Department of Orthopaedics and Traumatology , University Hospital , Rome , Italy . Participants were r and omly allocated to either local microwave diathermy or subacromial corticosteroids . The primary outcome measure was the short form of the Disabilities of the Arm , Shoulder and H and Question naire ( QuickDASH ) . Secondary outcome measures were the Constant-Murley shoulder outcome score and a visual analog scale for pain assessment . RESULTS At the end of treatment and at follow-up , both treatment groups experienced improvements in all outcome measures relative to baseline values . Changes over time in QuickDASH , Constant-Murley , and visual analog scale scores were not different between treatment arms . CONCLUSION In patients with rotator cuff tendinopathy , the effects of localized microwave diathermy on disability , shoulder function , and pain are equivalent to those elicited by subacromial corticosteroid injections Background Soft tissue massage and exercise are commonly used to treat episodes of shoulder pain . Objective The study objective was to compare the effects of soft tissue massage and exercise with those of exercise alone on pain , disability , and range of motion in people with nonspecific shoulder pain . Design This was a r and omized controlled trial . Setting The study was conducted in public hospital physical therapy clinics in Sydney , New South Wales , Australia . Participants The study participants were 80 people with an average age of 62.6 years ( SD=12.2 ) who were referred to physical therapists for treatment of nonspecific shoulder pain . Intervention Participants were r and omly assigned to either a group that received soft tissue massage around the shoulder and exercises ( n=40 ) or a group that received exercise only ( n=40 ) for 4 weeks . Measurements The primary outcome was improvement in pain , as measured on a 100-mm visual analog scale , 1 week after the cessation of treatment . Secondary outcomes were disability and active flexion , abduction , and h and -behind-back range of motion . Measurements were obtained at baseline , 1 week after the cessation of treatment , and 12 weeks after the cessation of treatment . Results The between-group difference in pain scores from the baseline to 12 weeks after the cessation of treatment demonstrated a small significant difference in favor of the group receiving exercise only ( mean difference=14.7 mm ) . There were no significant differences between groups in any other variable . Limitations It was not possible to mask therapists or participants to group allocation . Diagnostic tests were not used on participants to determine specific shoulder pathology . Conclusions The addition of soft tissue massage to an exercise program for the shoulder conferred no additional benefit for improving pain , disability , or range of motion in people with nonspecific shoulder pain OBJECTIVE The aim of this study was to evaluate the initial effects of scapular mobilization ( SM ) on shoulder range of motion ( ROM ) , scapular upward rotation , pain , and function . DESIGN Pretest-posttest for 3 groups ( SM , sham , and control ) . SETTING A double-blinded , r and omized , placebo-controlled trial was conducted to evaluate the initial effect of the SM at a sports physiotherapy clinic . PARTICIPANTS 39 subjects ( 22 women , 17 men ; mean age 54.30 + /- 14.16 y , age range 20 - 77 y ) . INTERVENTIONS A visual analog scale , ROM , scapular upward rotation , and function were assessed before and just after SM . SM ( n = 13 ) consisted of the application of superoinferior gliding , rotations , and distraction to the scapula . The sham ( n = 13 ) condition replicated the treatment condition except for the h and positioning . The control group ( n = 13 ) did not undergo any physiotherapy and rehabilitation program . MAIN OUTCOME MEASURES Pain severity was assessed with a visual analog scale . Scapular upward rotation was measured with a baseline digital inclinometer . Constant Shoulder Score ( CSS ) was used to measure shoulder function . RESULTS After SM , we found significant improvements for shoulder ROM , scapular upward rotation , and CSS between pretreatment and posttreatment compared with the sham and control groups . In the sham group , shoulder-ROM values increased or decreased for the shoulder and scapular upward rotation was not changed . Pain , ROM , and physical function of the shoulder were not significantly different in the sham group than in controls ( P > .05 ) . CONCLUSIONS SM may be a useful manual therapy technique to apply to participants with a painful limitation of the shoulder . SM increases ROM and decreases pain intensity We have performed a controlled , r and omised study to analyse the effects of low-energy shock-wave therapy ( ESWT ) on function and pain  in tendinitis of the supraspinatus without calcification . There were 20 patients in the treatment group and 20 in the control group . The former group received 6,000 impulses ( energy flux density , 0.11 mJ/mm2 ) in three sessions after local anaesthesia . The control group had 6000 impulses of sham ESWT after local anaesthesia . The patients were examined at six and 12 weeks after treatment by an independent observer who evaluated the Constant score and level of pain . We found an increase in function and a reduction of pain in both groups ( p < or = 0.001 ) . Statistical analysis showed no difference between the groups for the Constant score and for pain . We therefore do not recommend ESWT for the treatment of tendinitis of supraspinatus The aim of this study was to determine the effect of radial extracorporeal shock-wave therapy ( rESWT ) on patients with chronic tendinitis of the rotator cuff . This was a r and omised controlled trial in which 82 patients ( mean age 47 years ( 24 to 67 ) ) with chronic tendinitis diagnosed clinical ly were r and omly allocated to a treatment group who received low-dose rESWT ( three sessions at an interval 10 to 14 days , 2000 pulses , 0.11 mJ/mm(2 ) , 8 Hz ) or to a placebo group , with a follow-up of six months . The patients and the treating orthopaedic surgeon , who were both blinded to the treatment , evaluated the results . A total of 44 patients were allocated to the rESWT group and 38 patients to the placebo group . A visual analogue scale ( VAS ) score for pain , a Constant-Murley ( CMS ) score and a simple shoulder test ( SST ) score significantly improved in both groups at three and six months compared with baseline ( all p ≤ 0.012 ) . The mean VAS was similar in both groups at three ( p = 0.43 ) and six months ( p = 0.262 ) . Also , the mean CMS and SST scores were similar in both groups at six months ( p = 0.815 and p = 0.834 , respectively ) . It would thus seem that low-dose rESWT does not reduce pain or improve function in patients chronic rotator cuff tendinitis compared with placebo treatment The aim of this prospect i ve , r and omized clinical study was to compare the effectiveness of two physical therapy treatment approaches for impingement syndrome , either by joint and soft tissue mobilization techniques or by a self-training program .  Thirty patients ( Group 1 , n = 15 ; Group 2 , n = 15 ) with the diagnosis of an outlet impingement syndrome of the shoulder were treated either by strengthening the depressors of the humeral head with a guided self-training program  ( Group 1 , age 49.5 ± 7.9 years ) , or by joint and soft tissue mobilization techniques  ( Group 2 , age 48.1 ± 7.5 years ) . Group 1 was instructed with the active range of motion ( ROM ) , stretching and strengthening exercise program including rotator cuff muscles , rhomboids , levator scapulae and serratus anterior with an elastic b and at home at least seven times a week for 10–15 min and Group 2 received a prescription for 12 sessions of joint and soft tissue mobilization techniques , ice application , stretching and strengthening exercise programs and patient education in clinic for three times per week . All patients were tested with visual analog scale ( VAS ) for pain level , goniometric measurement for ROM and algometry for the pain threshold . Function was measured with a functional assessment question naire . The VAS ( 10 cm ) used to measure pain with functional activities and the functional assessment question naire ( Neer ) were also measured 3 months after the initiation of treatment . Subjects in both groups experienced significant decreases in pain and increases in shoulder function , but there was significantly more improvement in the manual therapy group compared to the exercise group . For example , pain in the manual therapy group was reduced from a pre-treatment mean ( ±SD ) of 6.7 ( ±0.3 ) to a post-treatment mean of 2.0 ( ±2.0 ) . In contrast , pain in the exercise group was reduced from a pre-treatment mean of 6.6 ( ±1.4 ) to a post-treatment mean of 3.0 ( ±1.8 ) . ROM at flexion , abduction and external rotation in the manual therapy group improved significantly while ROM in the exercise group did not . There were statistically differences among the groups in function ( P > 0.05 ) . Group 2 showed significantly greater improvements in the Neer Question naire score and shoulder satisfaction score than Group 1 . The patients treated with manual physical therapy applied by experienced physical therapists combined with supervised exercise in a brief clinical trial showed improvement of symptoms including increasing strength , decreasing pain and improving function earlier than with exercise program OBJECTIVE Local corticosteroid injections , commonly accepted by rheumatologists to be effective treating painful shoulder , have shown controversial results . High frequency ultrasonography is an accurate and safe imaging modality for guiding musculoskeletal injections . We prospect ively compared the short term response to r and omized blind injection versus sonographic-guided injection of local corticosteroid in patients with painful shoulder . METHODS We studied 41 consecutive patients with painful shoulder . Patients with previous trauma or chronic inflammatory arthritis were excluded . No patient had received previous physiotherapy or local steroid injection in the shoulder . Patients were r and omized to receive either a blind subacromial injection of 20 mg triamcinolone ( Group 1 , n = 20 ) or a sonographic guided injection of 20 mg triamcinolone ( Group 2 , n = 21 ) by the same rheumatologist blinded to the clinical evaluation . In both groups we recorded shoulder abnormalities and the location of the steroid postinjection by ultrasound . Each patient was clinical ly assessed within 5 days before injection and 6 weeks after injection by another rheumatologist without knowledge of the injection technique performed . Clinical assessment included demographic and clinical data , a visual analog scale ( VAS ) for pain ( 0 - 100 ) , the Shoulder Function Assessment ( SFA ) scale ( 0 - 70 ) , and postinjection adverse effects . No patient received physical therapy during the followup period . Initially , demographic , clinical , and ultrasonographic findings in both groups showed no significant differences . RESULTS Six weeks after injection , the VAS and the SFA score showed a significantly greater improvement in Group 2 compared with Group 1 ( mean VAS score change 34.9 for Group 2 vs 7.1 for Group 1 , p < 0.001 ; and mean SFA score change 15 for Group 2 vs 5.6 for Group 1 , p = 0.012 ) . One patient in Group 1 reported mild postinjection adverse effects . CONCLUSION We suggest that sonographic-guided corticosteroid injections should be indicated , at least , in patients with poor response to previous blind injection to ensure accurate medication placement in order to improve therapeutic effectiveness BACKGROUND Shoulder pain is common in primary health care . Nevertheless , information on the outcome of shoulder disorders is scarce , especially for patients encountered in general practice . AIM To study the course of shoulder disorders in general practice and to determine prognostic indicators of outcome . METHOD For this prospect i ve follow-up study , 11 Dutch general practitioners recruited 349 patients with new episodes of shoulder pain . The participants filled out a question naire at presentation and further ones after 1 , 3 , 6 and 12 months ; these contained questions on the nature , severity and course of the shoulder complaints . The association between potential prognostic indicators and the status of shoulder complaints ( absence or presence of symptoms ) was evaluated after one and 12 months of follow-up . RESULTS After one month , 23 % of all patients showed complete recovery ; this figure increased to 59 % after one year . A speedy recovery seemed to be related to preceding overuse or slight trauma and early presentation . A high risk of persistent or recurrent complaints was found for patients with concomitant neck pain and severe pain during the day at presentation . CONCLUSION A considerable number of patients ( 41 % ) showed persistent symptoms after 12 months . It may be possible to distinguish patients who will show a speedy recovery from those with a high risk of long-st and ing complaints by determining whether there is a history of slight trauma or overuse , an early presentation or an absence of concomitant neck pain OBJECTIVES This study aims to assess and compare the efficacy of subacromial tenoxicam and steroid injections in treating patients with shoulder impingement syndrome . PATIENTS AND METHODS Forty patients having shoulder impingement syndrome with findings of rotator cuff tendinitis or subacromial bursitis on magnetic resonance imaging were included in the study . Patients were r and omized into two subacromial injection groups : patients in the first group ( 10 males , 10 females ; mean age 45.3 years ; range 32 to 67 years ) were administered 20 mg tenoxicam three times by weekly intervals , and patients in the second group ( 8 males , 12 females ; mean age 46.5 years ; range 29 to 73 years ) were administered 40 mg methylprednisolone acetate just for once . Visual analog scale ( VAS ) , active range of motion ( ROM ) of the shoulder joint , and Disabilities of Arm , Shoulder and H and ( DASH ) question naire scores were evaluated at baseline , six weeks after treatment , and first year . RESULTS Visual analog scale , DASH , and active ROM scores in both groups were statistically significantly improved . No statistically significant difference was detected between subacromial tenoxicam and steroid injections in terms of post-treatment VAS , DASH , and active ROM scores . Mean pre- and post-treatment VAS scores in tenoxicam group were 7.8 ( range , 3 - 9 ) and 2.6 ( range , 2 - 4 ) , respectively . Mean pre- and post-treatment VAS scores in steroid group were 6.2 ( range , 3 - 10 ) and 3.6 ( range , 0 - 7 ) , respectively . Mean pre- and post-treatment DASH scores in tenoxicam group were 59.4 ( range , 45 - 80 ) and 14.7 ( range , 8.3 - 25.8 ) , respectively . Mean pre- and post-treatment DASH scores in steroid group were 56.7 ( range , 33.3 - 85.8 ) and 18.1 ( range , 0 - 69.2 ) , respectively . Although the improvement in active ROM was higher in the steroid group , difference between two groups was not statistically significant . CONCLUSION Both subacromial tenoxicam and steroid injections may be successfully used in the treatment of patients with impingement syndrome .  Subacromial tenoxicam injection may be preferred as a first-line intervention in these patients thanks to its safe profile BACKGROUND Shoulder pain or omalgia is one of the main types of osteoarticular pain that can be observed in every-day clinical practice , frequently causing significant functional impairment . The most common cause of shoulder pain is impingement syndrome . OBJECTIVE To decrease the intensity of short- and mid-term pain in the injured shoulder by means of acupuncture . METHOD R and omized controlled trial with two groups of participants : one group received true acupuncture ( TA ) and the other received acupuncture at sham points ( SA ) . The treatment was carried out over 4 weeks , with the participants receiving a session every week . The results were measured immediately after the treatment ( T1 ) and 3 months later ( T2 ) . To evaluate the results , we used the 100 mm Visual Analogue Scale ( VAS ) , and to assess the functionality of the shoulder we employed the UCLA question naire ( 0 - 35 points ) . RESULTS A total of 68 participants were included in the analysis ( TA , n=35 ; SA , n=33 ) , with a mean age of 33.4 years ( SD 12.53 ) . We found significant differences in the analyzed results between the two groups , as we observed a decrease on the intensity of pain for the TA group of 44.13 mm at T1 ( CI 95 % 36.7 ; 51.5 ) and 87.58 mm at T2 ( CI 95 % 28.32 ; 46.81 ) , while the decrease in the FA group was of 19.84 mm at T1 ( CI 95 % 12.2 ; 27.4 ) and 20 mm at T2 ( CI 95 % 10.9 ; 29.09 ) . When the UCLA scores were analyzed , the results were clinical ly meaningful in support of TA in terms of functional assessment of the shoulder . No adverse effects were reported . CONCLUSIONS The use of acupuncture to treat impingement syndrome seems to be a safe and reliable technique to achieve clinical ly significant results and could be implemented in the therapy options offered by the health services The aim of the study was to compare the efficacy of kinesiological taping and subacromial injection therapy in patients with subacromial impingement syndrome ( SIS ) . Seventy patients diagnosed with SIS were r and omly assigned to group 1 ( n = 35 , injection group ) or group 2 ( n = 35 , kinesiological taping group ) . Betamethasone plus prilocaine was injected to subacromial space in the patients in group 1 . In group 2 , tape was applied three times for a period of five consecutive days with a 2-day recovery interval . A 3-month exercise program was prescribed for both groups including stretching and strengthening exercises . All patients were assessed at baseline and at 1 and 3 months post-intervention . Assessment s were made by visual analog scale ( VAS ) for pain , range of motion ( ROM ) measurements , specific tests , and Shoulder Pain and Disability Index ( SPADI ) . Significant differences were detected in VAS and SPADI scores as well as ROM measurements in both groups when compared to baseline ( p > 0.05 ) . No significant differences were detected between the groups except for active flexion degree in favor of group 1 ( p = 0.004 ) . Both kinesiological taping and steroid injection in conjunction with an exercise program were found to be effective in the treatment of SIS . Kinesio taping may be an alternative treatment option in the rehabilitation of SIS especially when a non-invasive technique is needed UNLABELLED Study Design Single-blind r and omized trial . Background Extracorporeal shockwave therapy ( ESWT ) has been shown to produce good results in the treatment of subacromial impingement syndrome ( SAIS ) . The efficacy of a combined administration of ESWT and isokinetic exercise ( IE ) has not yet been studied . Objectives To evaluate the efficacy of focused ESWT combined with IE for the rotator cuff versus focused ESWT alone in the treatment of SAIS . The secondary objective was to assess the isokinetic torque recovery ( external rotation at 210 ° /s , 180 ° /s , and 120 ° /s ) . Methods Thirty participants with SAIS were r and omly assigned to a focused-ESWT group or focused ESWT-plus-IE group . Subjects of both groups received 3 treatment sessions of focused ESWT over a period of 10 days . Participants in the second group also received IE for 10 therapy sessions . Outcome measures were the Constant-Murley score ( CMS ) , the visual analog scale ( VAS ) , and isokinetic parameters ( peak torque and total work calculated from 5 repetitions ) measured with the isokinetic test . Subjects were assessed at baseline , 10 days after the last treatment session with focused ESWT , and after 2 months of follow-up . Results At 2 months posttreatment , participants in the focused ESWT-plus-IE group showed significantly less pain ( focused-ESWT VAS , 3.4 ± 0.8 versus focused ESWT-plus-IE VAS , 1.5 ± 0.5 ; P<.001 ) and greater improvement in functionality ( focused-ESWT CMS , 75.9 ± 6.7 versus focused ESWT-plus-IE CMS , 92.1 ± 6.3 ; P<.001 ) and muscle endurance than the subjects in the focused-ESWT group . Conclusion In subjects with SAIS , combined administration of focused ESWT and IE for the rotator cuff result ed in greater reduction of pain , as well as superior functional recovery and muscle endurance in the short to medium term , compared with ESWT alone . Level of evidence Therapy , 2b . TRIAL REGISTRATION unregistered 2011 trial . J Orthop Sports Phys Ther 2016;46(9):714 - 725 . Epub 5 Aug 2016 . doi:10.2519/jospt.2016.4629 We have carried out a prospect i ve double-blind r and omised controlled trial to compare the efficacy of a single subacromial injection of the non-steroidal anti-inflammatory drug , tenoxicam , with a single injection of methylprednisolone in patients with subacromial impingement . A total of 58 patients were r and omly allocated into two groups . Group A received 40 mg of methylprednisolone and group B 20 mg of tenoxicam as a subacromial injection along with lignocaine . The Constant-Murley shoulder score was used as the primary outcome measure and the Disability of Arm , Shoulder and H and ( DASH ) and the Oxford Shoulder Score ( OSS ) as secondary measures . Six weeks after injection the improvement in the Constant-Murley score was significantly greater in the methylprednisolone group ( p = 0.003 ) than in the tenoxicam group . The improvement in the DASH score was greater in the steroid group and the difference was statistically significant and consistent two ( p < 0.01 ) , four ( p < 0.01 ) and six weeks ( p < 0.020 ) after the injection . The improvement in the OSS was consistently greater in the steroid group than in the tenoxicam group . Although the difference was statistically significant at two ( p < 0.001 ) and four ( p = 0.003 ) weeks after the injection , it was not at six weeks ( p = 0.055 ) . Subacromial injection of tenoxicam does not offer an equivalent outcome to subacromial injection of corticosteroid at six weeks . Corticosteroid is significantly better than tenoxicam for improving shoulder function in tendonitis of the rotator cuff after six weeks BACKGROUND DATA AND OBJECTIVE Although previous studies have evaluated the effect of different kinds of physical therapy in subacromial impingement syndrome ( SIS ) , there have been few investigations assessing the effectiveness of low-level laser therapy ( LLLT ) in shoulder disorders . The goal of this prospect i ve r and omized study was to assess whether gallium-arsenide ( Ga-As ) laser therapy improves the outcome of a comprehensive home exercise program in patients with SIS . MATERIAL S AND METHODS Forty-four newly-diagnosed SIS patients were enrolled in this study . Group 1 patients ( n = 22 ) received Ga-As laser therapy combined with a 12-wk comprehensive home exercise program , and group 2 patients ( n = 22 ) received the same 12-wk comprehensive home exercise program alone .  Night pain , shoulder pain and disability index ( SPADI ) , and University of California-Los Angeles end- result ( UCLA ) scores were used as outcome measures . RESULTS Both groups showed a significant reduction in night pain and SPADI scores at the second and 12th weeks with respect to baseline values , with the exception of the SPADI total score at the second week in group 1 . UCLA results improved significantly in both groups at the 12th in comparison to the second week . There were no significant differences between groups in mean actual changes in night pain and SPADI scores at the second week from baseline . When values at the 12th week were compared to baseline , mean actual changes in night pain differed significantly between the groups , with a larger change in group 1 , but there was no difference between groups in mean actual change in SPADI scores . Second- and 12th-week UCLA scores did not differ between the two groups . CONCLUSION Our study was unable to demonstrate any distinct advantage of low-level laser therapy over exercise alone . Comprehensive home exercise programs should be the primary therapeutic option in the rehabilitation process in SIS Objective : To compare the effect of acupuncture with placebo transcutaneous electrical nerve stimulation ( TENS ) when added to the exercise treatment of rotator cuff tendinitis with respect to pain , shoulder movements and function . Design : Prospect i ve alternate allocation controlled trial . Setting : Outpatient department . Patients : Thirty-three patients ( 12 women and 21 men ) were included in the study . All had clinical ly diagnosed rotator cuff tendinitis . Intervention : Both groups underwent a st and ardized training programme . Each patient received in addition either 10 treatments with acupuncture or placebo TENS , 1 - 2 times per week . Main outcome measures : The parameters investigated were intensity of pain ( measured with visual analogue scale ) , active , passive as well as functional movements in the shoulder ( h and in neck ( HIN ) and pour out of a pot ( POP ) ) . Patients were tested before treatment , after treatment and at a six-month follow-up . Medicine intake , ability to lie on the affected side and sleep disturbances were evaluated . A subjective assessment was made after the treatment and at follow-up . Results : Sixteen patients had acupuncture , 17 placebo TENS . Eight patients endured pain at rest in the placebo TENS group , and 10 in the acupuncture group . After treatment both groups improved , the improvement persisted at the six-month follow-up . Both groups increased range of movement . Except for the functional test HIN in the acupuncture group , there were no differences between the groups regarding other parameters investigated directly after treatment or at six-month follow-up . Conclusion : There is no difference between the effect of additional acupuncture treatment and placebo TENS in the treatment of rotator cuff tendinitis Objective : To compare the efficacy of pulse radiofrequency applied to the suprascapular nerve with the efficacy of conventional transcutaneous electrical nerve stimulation treatment in patients with shoulder pain . Design : A r and omized , controlled trial . Setting : An outpatient physical therapy and rehabilitation clinic . Subjects : Forty patients with shoulder pain lasting at least three months were included in the study . Subjects were r and omly allocated into either a pulsed radiofrequency treatment or a conventional transcutaneous electrical nerve stimulation treatment . All patients received exercise therapy . Main measurements : Outcome measurements were performed using the visual analogue scale for pain and range of motion ; the Shoulder Pain and Disability Index was used for disability ; and the Short Form-36 was used to establish quality of life . All of the measurements were assessed at four points in time ( before the intervention , and for 1 , 4 and 12 weeks afterwards ) . Results : When the groups were compared , no significant difference was found between the groups in terms of visual analogue scale , range of motion , the Shoulder Pain and Disability Index ( except for the Shoulder Pain and Disability Index total score ) , Short Form-36 subscores , and paracetamol consumption for all weeks ( P > 0.05 ) . Conclusion : Our results showed that there is no difference in effect between transcutaneous electrical nerve stimulation and pulsed radiofrequency treatment for shoulder pain Objective ( s ) : ( 1 ) To compare the effectiveness of customized exercises with that of st and ard exercises for the treatment of patients with shoulder disorders . ( 2 ) To determine whether four weeks or eight weeks would be needed to see improvement in outcome measures . Design : A single-blinded r and omized clinical trial . Setting : An outpatient physical therapy clinic affiliated with an academic institution . Subjects : Thirty patients with shoulder disorders were tested and treated between February 2003 and December 2004 . Interventions : Patients were r and omized to a customized or st and ard exercise group . Each patient first underwent a st and ardized physical therapy assessment . Based on the results of the assessment , a classification was determined and a classification-specific exercise programme was instructed to the patients in the customized exercise group . The st and ard exercise group , regardless of classification , received preselected st and ard exercises . Both groups were followed for eight weeks . Main measures : Shoulder range of motion , strength , pain intensity and function were assessed three times ( weeks 0 , 4 and 8) . Results : There were no significant differences between the customized and st and ard exercise groups in measures of shoulder range of motion , strength , pain intensity and function after four or eight weeks of exercise . Patients in both groups had significant improvements in shoulder strength , pain intensity and function . Significant improvements occurred at week 8 , but not at week 4 . Conclusion : The customized shoulder exercises did not provide additional benefit to our shoulder patients than the st and ard exercises OBJECTIVE To determine the effects of scapular mobilization on function , pain , range of motion , and satisfaction in patients with subacromial impingement syndrome ( SAIS ) . DESIGN R and omized , double-blind , placebo-controlled clinical trial . SETTING University hospital clinics in Turkey . PARTICIPANTS 66 participants ( mean ± SD age 52.06 ± 3.71 y ) with SAIS . INTERVENTIONS Participants were r and omized into 3 groups : scapular mobilization , sham scapular mobilization , and supervised exercise . Before the interventions transcutaneous electrical stimulation and hot pack were applied to all groups . Total intervention duration for all groups was 3 wk with a total of 9 treatment sessions . MAIN OUTCOME MEASURES Shoulder function and pain intensity were primary outcome measures ; range of motion and participant satisfaction were secondary outcome measures . Shoulder function was assessed with the short form of the Disabilities of the Arm , Shoulder and H and Question naire ( DASH ) . A visual analog scale was used to evaluate pain severity . Active range of motion was measured with a universal goniometer . A 7-point Likert scale was used to evaluate satisfaction . Outcome measurements were performed at baseline , before visits 5 and 10 , 4 wk after visit 9 , and 8 wk after visit 9 . RESULTS There was no group difference for DASH score ( P = .75 ) , pain at rest ( P = .41 ) , pain with activity ( P = .45 ) , pain at night ( P = .74 ) , and shoulder flexion ( P = .65 ) , external rotation ( P = .63 ) , and internal rotation ( P = .19 ) . There was a significant increase in shoulder motion and function and a significant decrease in pain across time when all groups were combined ( P < .001 ) . The level of satisfaction was not significantly different for any of the questions about participant satisfaction between all groups ( P > .05 ) . CONCLUSION There was not a significant advantage of scapular mobilization for shoulder function , pain , range of motion , and satisfaction compared with sham or supervised-exercise groups in patients with SAIS STUDY DESIGN R and omized controlled trial . OBJECTIVE To evaluate the effects of an exercise protocol , with and without manual therapy , on scapular kinematics , function , pain , and mechanical sensitivity in individuals with shoulder impingement syndrome . BACKGROUND Stretching and strengthening exercises have been shown to effectively decrease pain and disability in individuals with shoulder impingement syndrome . There is still conflicting evidence regarding the efficacy of adding manual therapy to an exercise therapy regimen . METHODS Forty-six patients were assigned to 1 of 2 groups , one of which received a 4-week intervention of stretching and strengthening exercises ( exercise alone ) and the other the same intervention , supplemented by manual therapy targeting the shoulder and cervical spine ( exercise plus manual therapy ) . All outcomes were measured preintervention and postintervention at 4 weeks . Outcome measures were scapular kinematics in the scapular and sagittal planes during arm elevation , function as determined through the Disabilities of the Arm , Shoulder and H and ( DASH ) question naire , pain as assessed with a visual analog scale , and mechanical sensitivity as assessed with pressure pain threshold . RESULTS Independent of the intervention group , small , clinical ly irrelevant changes in scapular kinematics were observed postintervention . A significant group-by-time interaction effect ( P = .001 ) was found for scapular anterior tilt during elevation in the sagittal plane , with a 3.0 ° increase ( 95 % confidence interval [ CI ] : -1.5 ° , 7.5 ° ) relative to baseline in the exercise-plus-manual therapy group compared to a decrease of 0.3 ° ( 95 % CI : -4.2 ° , 4.8 ° ) in the exercise-alone group . Pain , mechanical sensitivity , and the DASH score improved similarly for both groups by the end of the intervention period . CONCLUSION Adding manual therapy to an exercise protocol did not enhance improvements in scapular kinematics , function , and pain in individuals with shoulder impingement syndrome . The noted improvements in pain and function are not likely explained by changes in scapular kinematics Extracorporeal shock wave therapy ( ESWT ) is seen as a therapeutic option in the treatment of chronic supraspinatus tendinitis by some authors . To test whether ESWT comprising 3 x 2000 pulses with the positive energy flux density ED+ of 0.33 mJ/mm2 is clinical ly superior to a sham ESWT treatment , a prospect i ve , r and omized , single-blinded , placebo-controlled study with an independent observer was performed . Forty patients were treated either by verum ESWT or sham ESWT  under local anesthesia . Target criteria were the age-corrected Constant score , pain at rest and during activity on a visual analogue scale , and subjective improvement . Patients who reported no subjective improvement after 12 weeks were deblinded and received verum ESWT if they had belonged to the placebo group ( partial crossover ) . The results of the verum group lie within the range of results for ESWT published by other authors . Patients in the placebo group with local anesthetic showed equally good results . At 12 weeks , and 1 year after intervention , no difference could be found between the verum and placebo groups regarding Constant score , pain , shoulder function , or subjective improvement . The nonresponders to the placebo ESWT continued to show no improvement after receiving verum ESWT . This contradicts a specific ESWT effect . Based on the results of this placebo-controlled study , ESWT appears to have no clinical ly relevant effect on supraspinatus tendinitis . The study underlines the importance of a control group in evaluating new treatment methods for diseases with unknown natural history BACKGROUND Rotator cuff syndrome is often treated with subacromial injection of corticosteroid and local anesthetic . It has not been established if the common injection routes of the bursa are equally accurate . METHODS We conducted a prospect i ve clinical trial involving seventy-five shoulders in seventy-five patients who were r and omly assigned to receive a subacromial injection through an anterior , lateral , or posterior route with respect to the acromion . An experienced physician performed the injections , which contained radiopaque contrast medium , corticosteroid , and local anesthetic . After the injection , a musculoskeletal radiologist , blinded to the injection route , interpreted all of the radiographs . RESULTS The rate of accuracy varied with the route of injection , with a rate of 56 % for the posterior route , 84 % for the anterior route , and 92 % for the lateral route ( p = 0.006 ; chi-square test ) . The accuracy of injection through the posterior route was significantly lower than that through either the anterior or the lateral route ( p < 0.05 for both comparisons ; Poisson regression ) . In addition , the accuracy of injection was significantly lower in females than in males ( p < 0.006 ; chi-square test ) . Among males , no differences between the routes were noted ( with accuracy rates of 89 % for the posterior route , 92 % for the anterior route , and 93 % for the lateral route ) . Among females , however , the accuracy of injection was lower for the posterior route than for either the anterior or the lateral route ( with accuracy rates of 38 % for the posterior route , 77 % for the anterior route , and 91 % for the lateral route ) ( p < 0.05 ) . CONCLUSIONS The anterior and lateral routes of subacromial bursal injection were more accurate than the posterior route . The accuracy of subacromial bursal injection was significantly different between males and females , mainly because of a lower accuracy of bursal injection with use of the posterior route in females . The present study suggests that the posterior route is the least accurate method for injection of the subacromial bursa in females OBJECTIVE To explore the effectiveness of naturopathic care ( NC ) on rotator cuff tendinitis using a prospect i ve r and omized clinical trial design . METHODS Canadian postal workers with rotator cuff tendinitis for a duration of > 6 weeks were r and omized to receive NC ( n = 43 ) or st and ardized physical exercises ( PEs ; n = 42 ) over 12 weeks . Participants in the NC group received dietary counseling , acupuncture , and Phlogenzym ( 2 tablets 3 times/day ) . The PE intervention group received passive , active-assisted , and active range of motion exercises and matched placebo . The primary outcome measure was the Shoulder Pain and Disability Index ( SPADI ) , and secondary outcomes were the pain visual analog scale ( VAS ) , Short Form 36 ( SF-36 ) , Measure Yourself Medical Outcomes Profile ( MYMOP ) , and shoulder maximal range of motion . Participants and assessors were blinded to group and placebo allocation . RESULTS Seventy-seven participants ( 87 % ) completed > or=8 weeks of the trial .  Final total SPADI scores decreased by 54.5 % ( P < 0.0001 ) in the NC group and by 18 % ( P = 0.0241 ) in the PE group . Between-group differences in changes to SPADI scores showed statistically significant decreases in shoulder pain and disability in the NC group compared with the PE group ( P < 0.0001 ) . Significant differences between groups were also observed in the pain VAS , MYMOP , SF-36 , and shoulder extension , flexion , and abduction , with the NC group showing superiority in each outcome . No serious adverse reactions were observed . CONCLUSION NC and PE provided significant improvements , with greater improvement in shoulder function in the NC  group compared with the PE group . Statistically significant improvements in quality of life measures were observed in the NC group as compared with the PE group OBJECTIVES We studied the value of ultrasound ( US ) to define shoulder pathology and guide local steroid injection in comparison with a st and ard injection in the management of the acute painful shoulder . METHODS Seventy consecutive patients with acute shoulder pain were assessed clinical ly and by US . Patients were r and omized to receive either a st and ard subacromial infiltration of 7 mg of betamethasone or a US-guided injection according to the US diagnosis . Follow-up evaluations were performed by an independent assessor who was blinded to the results of the initial US and clinical assessment s. RESULTS Sixty-seven patients completed the study . Both groups showed a significant reduction in both daytime and night pain compared to baseline . The US injection group had significantly less pain at rest at 2 and 6 weeks ( NRS : 1.6 vs 3.3 , P<0.005 ; 3 vs 4.2 , P<0.04 ) . The percentage of good responders was significantly higher in US group at 2 weeks , ( 81 % vs 54 % , P<0.005 ) and 6 weeks ( 64 % vs 38 % , P<0.05 ) . At 2 and 6 weeks , responder rate and activity pain scores as well as Constant score were in favour of US , though did not reach statistical significance . CONCLUSION Local steroid injection for shoulder pain leads to significant improvements in pain and function for up to 12 weeks . An US examination to define the origin of shoulder pain as well as to guide injection provides significant additional benefits for up to 6 weeks . We recommend routine US examination as part of the management of acute shoulder pain Objectives : To test the safety of the diode light therapy and evaluate the advantages of the interferential effect of two light probes versus a conventional light probe in the relief of  shoulder pain and disability caused by shoulder tendinopathies . Design : R and omized single-blind pilot study . Setting : Clinical electrotherapy unit . Participants : A total of 30 patients with shoulder pain from tendinopathies . Interventions : The patients were r and omly assigned into two groups . Group 1 ( n = 15 ) received interferential light therapy generated by two independent and identical cluster probes composed of light emitting and superluminescent diodes . Similarly , two applicators were applied in group 2 ( n = 15 ) , but only one was active , as in conventional clinical therapy . Each multi-diode cluster probe was composed of seven light-emitting diodes at 600 nm and 12 superluminescent diodes at 950 nm . Main outcome measures : Pain was evaluated by visual analogue scale ( VAS ) at day , at night and during several shoulder movements . Shoulder functional status was measured by means of the University California Los Angeles scale ( UCLA ) . Results : Comparison between both treatments using the Mann – Whitney U-test showed better results for the interferential treatment . There were significant differences in pain reduction during abduction ( P < 0.05 ) and external rotation ( P < 0.05 ) , with pain reductions in abduction and external rotation of 1.5 ( ± 1.3 ) and 0.5 ( ± 1.0 ) respectively . Conclusion : Interferential light therapy was safe and effective regarding the shoulder pain reduction during abduction and external rotation movements . The estimated size sample needed for future two-treatment parallel- design studies will require about 60 patients Objective : To estimate the effectiveness of ultrasonophoresis and iontophoresis with sodium diclofenac used in addition to an exercise program for patients with impingement syndrome . Design : Multicentre , double-blind , placebo r and omized controlled trial . Setting : “ Mancha Centro ” Outpatient primary care clinic ( Spain ) . Participants : A total of 175 patients were considered , of whom 88 met criteria and agreed . Intervention : The patients were r and omly assigned to one of three groups : a ) st and ard treatment ( supervised exercises and cryotherapy ) along with placebo iontophoresis and placebo ultrasonophoresis ; b ) st and ard treatment , iontophoresis , and placebo ultrasonophoresis ; and c ) st and ard treatment , ultrasonophoresis , and placebo iontophoresis . All patients received 15 treatment sessions . Outcome measures : Baseline , 6- , and 12-week evaluations were carried out . Functionality , pain , range of motion , strength and quality of life were assessed with the Disabilities of the Arm , Shoulder and H and Question naire ( DASH ) , Constant-Murley score , and SF-36 scale . Results : Ultrasonophoresis group experienced significant decreases in pain compared to the st and ard treatment group ( 12.7 and 13.5 points in “ bodily pain ” dimension of SF-36 ; and 1,5 and 2,2 points in “ pain ” dimension of Constant Murley after 6 and 12 weeks of therapy , respectively ) . They also reported improved range of motion compared to the exercises group ( 2,1 points in Constant-Murley after 6 weeks and 12 weeks ) , better vitality and overall health ( SF-36 dimensions ) . Iontophoresis , however , led to no significant improvements when added to the st and ard treatment . Conclusion : In patients with impingement syndrome , a combination of ultrasonophoresis and an exercise program are better than a combination of iontophoresis and the same exercise program or the exercise program alone OBJECTIVE Evidence for effective management of shoulder impingement is limited . The present study aim ed to quantify the clinical , neurophysiological , and biomechanical effects of a scapular motor control retraining for young individuals with shoulder impingement signs . METHOD Sixteen adults with shoulder impingement signs ( mean age 22 ± 1.6 years ) underwent the intervention and 16 healthy participants ( 24.8 ± 3.1years ) provided reference data . Shoulder function and pain were assessed using the Shoulder Pain and Disability Index ( SPADI ) and other question naires . Electromyography ( EMG ) and 3-dimensional motion analysis was used to record muscle activation and kinematic data during arm elevation to 90 ° and lowering in 3 planes . Patients were assessed pre and post a 10-week motor control based intervention , utilizing scapular orientation retraining . RESULTS Pre-intervention , patients reported pain and reduced function compared to the healthy participants ( SPADI in patients 20 ± 9.2 ; healthy 0 ± 0 ) . Post-intervention , the SPADI scores reduced significantly ( P < .001 ) by a mean of 10 points ( ±4 ) . EMG showed delayed onset and early termination of serratus anterior and lower trapezius muscle activity pre-intervention , which improved significantly post-intervention ( P < .05 ) . Pre-intervention , patients exhibited on average 4.6 - 7.4 ° less posterior tilt , which was significantly lower in 2 arm elevation planes ( P < .05 ) than healthy participants . Post-intervention , upward rotation and posterior tilt increased significantly ( P < .05 ) during 2 arm movements , approaching the healthy values . CONCLUSION A 10-week motor control intervention for shoulder impingement increased function and reduced pain . Recovery mechanisms were indicated by changes in muscle recruitment and scapular kinematics . The efficacy of the intervention requires further examined in a r and omized control trial Objective To explore the effects of contralateral manual acupuncture ( MA ) on patients with chronic shoulder pain . Methods Eighty patients with chronic shoulder pain were r and omly allocated to receive contralateral MA ( n=38 ) for 4 weeks or to remain on a waiting list while receiving conventional orthopaedic therapy ( n=42 ) . Visual analogue scale ( VAS ) scores were taken as the primary outcome measure and used for a priori power calculation . Secondary outcome measures for the assessment of shoulder mobility and quality of life included the Jobe test , the Constant-Murley ( CM ) score , the Disabilities of the Arm , Shoulder and H and ( DASH ) score , and the 36 item Short Form Health Survey ( SF-36 ) . Results Intention-to-treat ( ITT ) analysis demonstrated significant pain relief with contralateral acupuncture , with mean differences in VAS scores compared to the waiting list group of −19.4 ( −28.0 to −10.8 ) at 2 weeks , −40.4 ( −49.0 to −31.8 ) at 4 weeks , −41.1 ( −49.7 to −32.5 ) at 8 weeks , and −40.9 ( −49.5 to −32.3 ) at 16 weeks . CM and DASH scores were also improved at all time points ( p<0.01 ) . Shoulder mobility , physical functioning , social functioning and mental health components of the SF-36 were also improved by contralateral acupuncture at 8 weeks . No significant adverse effects were observed . Conclusions These results demonstrate beneficial effects of contralateral acupuncture in the treatment of chronic shoulder pain , both in terms of pain and function . Future research is required to compare directly the effects of local and contralateral acupuncture and to quantify the specific and non-specific effects . Trial Registration Number NCT01733914 Purpose To investigate superior value of adding heavy load eccentric training to conservative treatment in patients with subacromial impingement . Methods Sixty-one patients with subacromial impingement were included and r and omly allocated to the traditional rotator cuff training ( TT ) group ( n = 30 , mean age = 39.4 ± 13.1 years ) or traditional rotator training combined with heavy load eccentric training ( TT + ET ) group ( n = 31 , mean age = 40.2 ± 12.9 years ) . Isometric strength was measured to abduction at 0 ° , 45 ° and 90 ° of scapular abduction and to internal and external rotation . The SPADI question naire was used to measure shoulder pain and function . Patients rated subjective perception of improvement . Outcome was assessed at baseline , at 6 and 12 weeks after start of the intervention . Both groups received 9 physiotherapy treatments over 12 weeks . At home , the TT group performed traditional rotator cuff strengthening exercises 1x/day . The TT + ET group performed the same exercises 1x/day and a heavy load eccentric exercise 2x/day . Results After treatment , isometric strength had significantly increased in all directions , and SPADI score had significantly decreased . The TT + ET group showed a 15 % higher gain in abduction strength at 90 ° of scapular abduction . Chi-square tests showed patients ’ self-rated perception of improvement was similar in both groups . Conclusion Adding heavy load eccentric training result ed in a higher gain in isometric strength at 90 ° of scapular abduction , but was not superior for decreasing pain and improving shoulder function . This study showed that the combination of a limited amount of physiotherapy sessions combined with a daily home exercise programme is highly effective in patients with impingement . Level of evidence II Background Evidence from a recent r and omized controlled trial indicated that supervised exercises ( SE ) were more effective than radial extracorporeal shock-wave therapy ( rESWT ) for the treatment of subacromial shoulder pain in the short to medium term . Little knowledge exists about the long-term results of rESWT for subacromial pain . Objective The aim of this study was to evaluate the results of rESWT and SE provided to patients with subacromial shoulder pain after 1 year . Design This was a single-blind r and omized controlled trial . Setting The study was conducted in the outpatient clinic of the Physical Medicine and Rehabilitation Department at Oslo University Hospital , Ullevaal , Norway . Patients One hundred four patients with subacromial shoulder pain lasting at least 3 months participated . Patients were r and omly assigned to either an rESWT group ( n=52 ) or an SE group ( n=52 ) . Intervention The rESWT intervention consisted of one session weekly for 4 to 6 weeks . The SE intervention consisted of two 45-minute sessions per week for up to 12 weeks . Measurements The primary outcome measure was the Shoulder Pain and Disability Index . Secondary outcome measures were questions regarding pain and function and work status . Results After 1 year , an intention-to-treat analysis showed no significant differences between the 2 groups for the primary outcome measure ( −7.6 points , 95 % confidence interval=−16.6 to 0.5 ) and pain , function , and medication use . Twenty-nine participants ( 60 % ) in the SE group versus 24 participants ( 52 % ) in the rESWT group were categorized as clinical ly improved . Thirty-eight participants in the SE group were at work compared with 30 participants in the rESWT group ( odds ratio=1.1 , 95 % confidence interval=1.0 to 1.2 ) . Fewer patients in the SE group had received additional treatments between 18 weeks and 1 year . Limitations The lack of a placebo control group , the lack of a cost-benefit analysis , and the small sample size were limitations of the study . Conclusion No significant difference was found between the SE and rESWT groups at the 1-year follow-up . More participants in the SE group had returned to work Background Passive mobilization of shoulder region joints , often in conjunction with other treatment modalities , is used for the treatment of people with shoulder pain and minimal movement restriction . However , there is only limited evidence supporting the efficacy of this treatment modality . Objective The purpose of this study was to determine whether passive mobilization of shoulder region joints adds treatment benefit over exercise and advice alone for people with shoulder pain and minimal movement restriction . Design This was a r and omized controlled clinical trial with short- , medium- and longer-term follow-up . Setting The study was conducted in a metropolitan teaching hospital . Patients Ninety-eight patients with shoulder pain of local mechanical origin and minimal shoulder movement restriction were r and omly allocated to either a control group ( n=51 ) or an experimental group ( n=47 ) . Intervention Participants in both groups received advice and exercises design ed to restore neuromuscular control at the shoulder . In addition , participants in the experimental group received passive mobilization specifically applied to shoulder region joints . Measurements Outcome measurements of shoulder pain and functional impairment , self-rated change in symptoms , and painful shoulder range of motion were obtained at 1 , 3 , and 6 months after entry into the trial . All data were analyzed using the intention-to-treat principle by repeated- measures analyses of covariance . Results No statistically significant differences were detected in any of the outcome measurements between the control and experimental groups at short- , medium- , or longer-term follow-up . Limitations Therapists and participants were not blinded to the treatment allocation . Conclusion This r and omized controlled clinical trial does not provide evidence that the addition of passive mobilization , applied to shoulder region joints , to exercise and advice is more effective than exercise and advice alone in the treatment of people with shoulder pain and minimal movement restriction Abstract Purpose : Motor imagery ( MI ) has been used as a complementary therapeutic tool for motor recovery after central nervous system disease and peripheral injuries . However , it has never been used as a preventive tool . We investigated the use of MI in the rehabilitation of stage II shoulder impingement syndrome . For the first time , MI is used before surgery . Method : Sixteen participants were r and omly assigned to either a MI or control group .  Shoulder functional assessment ( Constant score ) , range of motion and pain were measured before and after intervention . Results : Higher Constant score was observed in the MI than in the control group ( p = 0.04 ) . Participants in the MI group further displayed greater movement amplitude ( extension ( p < 0.001 ) ; flexion ( p = 0.025 ) ; lateral rotation ( p < 0.001 ) . Finally , the MI group showed greater pain decrease ( p = 0.01 ) . Conclusion : MI intervention seems to alleviate pain and enhance mobility , this is probably due to changes in muscle control and consequently in joint amplitude . MI might contribute to postpone or even protect from passing to stage III that may require surgery . Implication s for Rehabilitation Adding motor imagery training to classical physical therapy in a stage II impingement syndrome : Helps in alleviating pain Enhances shoulder mobility  Motor imagery is a valuable technique that can be used as a preventive tool before the stage III of the impingement syndrome
target: In many instances , no or minimal attempts to screen were undertaken or reported .
background: Background Subacromial shoulder pain is a common clinical presentation with much diagnostic uncertainty .
  Some of this uncertainty relates to the involvement of the cervical spine as a source or contribution to subacromial shoulder pain .
  Currently , there is no accepted method of screening of the cervical spine in the presence of subacromial shoulder pain , which risks patients receiving misguided and /or ineffective interventions .
  Objective To evaluate approaches used to screen the cervical spine in patients with subacromial shoulder pain .