***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: 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 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 OBJECTIVE The purpose of this study was to compare the efficacy of Mobilization with Movement ( MWM ) and kinesiotaping ( KT ) techniques with a supervised exercise program in participants with patients with shoulder pain . METHODS Twenty subjects with shoulder pain were included if subjects were diagnosed by the referring physician with either rotator cuff lesion with impingement syndrome or impingement shoulder syndrome . Participants were r and omly assigned to 1 of 2 groups after clinical and radiologic assessment : group 1 was treated with MWM and KT techniques , whereas group 2 was treated with a supervised exercise program . The main outcome measures were active pain-free shoulder abduction and flexion tested on days 0 , 5 , and 10 . RESULTS Improvement in active pain-free shoulder range of motion was significantly higher in the group treated with MWM and KT . Repeated- measures analysis of variance indicated significant effects of treatment , time , and treatment × time interaction . CONCLUSION This study suggests that MWM and KT may be an effective and useful treatment in range of motion augmentation of subjects with rotator cuff lesion and impingement syndrome or impingement shoulder syndrome 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 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 Abstract Background : There are no studies on economic issues concerning rehabilitation exercises for shoulder pain . Objective : The aim of the study was to investigate sick leave and the associated costs after a medical exercise therapy programme in patients with longst and ing subacromial pain/impingement . Methods : A r and omised controlled trial in which 61 patients were r and omly assigned either to a high-dosage medical exercise therapy group ( HD )  ( n=31 ) or to a low dosage exercise therapy group ( LD )  ( n=30 ) . Both groups were given three treatments a week over 3 months . The differences between the groups were number of repetitions , number of sets and time performing global aerobic exercises . Results : The outcome for the HD group was significantly ( p<0.05 ) better compared to the LD group . The reduction in costs for sick leave for the HD group was 59.1 % , whereas for the LD group , the reduction was only 42.3 % , which is a significant difference . Conclusion : In patients with longst and ing subacromial pain , HD medical exercise therapy might be an efficient treatment approach A systematic review of the literature was performed to evaluate the role of exercise in treating rotator cuff impingement and to synthesize a st and ard evidence -based rehabilitation protocol . Eleven r and omized , controlled trials ( level 1 and 2 ) evaluating the effect of exercise in the treatment of impingement were identified . Data regarding demographics , methodology , and outcomes of pain , range of motion , strength , and function were recorded . Individual components of each rehabilitation program were catalogued . Effectiveness was determined by statistical and clinical significance . Although many articles had method ologic concerns , the data demonstrate that exercise has statistically and clinical ly significant effects on pain reduction and improving function , but not on range of motion or strength .  Manual therapy augments the effects of exercise  , yet supervised exercise was not different than home exercise programs . Information regarding specific components of the exercise programs was synthesized into a gold st and ard rehabilitation protocol for future studies on the nonoperative treatment of rotator cuff impingement 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 Primary shoulder impingement syndrome is a common shoulder problem which , if treated ineffectively , can lead to more serious pathology and expensive treatment . This study examined whether subjects receiving joint mobilization and comprehensive treatment ( hot packs , active range of motion , physiologic stretching , muscle strengthening , soft tissue mobilization , and patient education ) would have improved pain , mobility , and function compared with similar patients receiving comprehensive treatment alone . Subjects were eight men and six women ( mean age = 52.9 years ) with primary shoulder impingement syndrome ( superolateral shoulder pain , decreased active humeral elevation , limited overhead function ) . Following r and om assignment to experimental ( N = 7 ) and control groups ( N = 7 ) , three blinded evaluators tested 24-hour pain ( visual analog scale ) , pain with subacromial compression test ( visual analog scale ) , active range of motion ( goniometry ) , and function ( reaching forward , behind the head , and across the body in an overhead position ) before and after nine treatments . One-tailed analyses of covariance ( baseline values as covariates ) showed that the experimental group had less 24-hour pain and pain with subacromial compression test but no differences in range of motion and function ( Mann-Whitney U ) compared with controls . The experimental group improved on all variables , while the control group improved only on mobility and function ( one-tailed , paired t tests ; Wilcoxon matched pairs ) . Age , side of dominance , duration of symptoms , treatment attendance , exercise quality , and adherence had no effect on the outcomes . Results may be affected by inadequate sample size , minimal capsular tightness , insensitive functional scale , nonspecific motion measurements , position at which mobilization treatment was given , or a strong effect of comprehensive treatment . Mobilization decreased 24-hour pain and pain with subacromial compression test in patients with primary shoulder impingement syndrome , but larger replication studies are needed to assess more clearly mobilization 's influence on motion and function The aim of the study was to identify the differences in functionality of the upper limb in subjects suffering from shoulder impingement syndrome after intervention by two manual therapy protocol s. R and omized , single-blind study with a sample of 22 subjects ( 58 ± 10.86 years old ) divided into two groups . The conventional-group ( n = 11 ) received mobilizations of 
    Output:
    
Based on qualitative analyses , it is unclear whether MT used alone or added to an exercise program improves function .
For patients with RC tendinopathy , based on low- to moderate- quality evidence , MT may decrease pain ; however , it is unclear whether it can improve function .