***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 
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    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 This paper provides an up-to- date overview of the occurrence , diagnosis , risk factors , prognostic indicators and outcome of shoulder disorder ( SD ) , and of the validity and reproducibility of diagnostic classifications and diagnostic imaging techniques for SD . Furthermore , the available evidence on the effectiveness of non-steroidal anti-inflammatory drugs ( NSAIDs ) , corticosteroid injections and physiotherapy for SD is summarized on the basis of r and omized controlled trials with an acceptable quality of their methods . The annual incidence of SD is estimated at about 7 % , its 1-year period prevalence at about 51 % and its lifetime prevalence at about 10 % . While approximately 50 % of all patients with SD seek medical care , about 95 % are treated in primary health care . Of all new episodes of SD presenting to primary care , approximately 50 % seem to resolve within 6 months , while about 40 % seem to persist for up to 12 months . Several prognostic indicators for a favourable or a poor outcome of SD have been identified , but a comprehensive prognostic model is not available . While evidence for the prognostic validity of popular diagnostic classifications of SD is lacking , their reproducibility has been shown to be poor . The accuracy and clinical usefulness of diagnostic imaging techniques appear to be sufficiently verified for SD in secondary care , while their clinical usefulness in primary care and prognostic validity are not . NSAIDs and steroid injections for SD have been shown to be effective within 6 weeks , but their effect on long-term outcome remains unclear . There is very limited evidence for the effectiveness in SD of physiotherapy , including exercise therapy , ultrasound , electrotherapy , laser , mobilization and manipulation This paper reports a prospect i ve study of 72 consecutive patients with fractures or fracture-dislocations of the upper end of the humerus , treated during 1981 . Most were elderly and treatment was conservative . Of the 72 patients 64 were followed up for a period of six months . Observations were made on the type of fracture , the speed and pattern of recovery of shoulder movements , on the time of commencement of physiotherapy , and on its duration . We found that with conservative treatment alone , 94 % of our patients had good or satisfactory results at six months from injury . The criteria for manipulation are discussed and the literature is review ed Current knowledge of the clinical course and efficacy of treatment for shoulder pain comes mainly from studies of hospital patients . However , only a few patients experiencing such pain require referral to a specialist . Although shoulder pain is common in the general population , the outcome of patients presenting in general practice is unknown.1 We conducted a prospect i ve cohort study to determine the outcome of shoulder pain in primary care . Twelve general practitioners recruited 166 patients who consulted with a new episode of shoulder pain during one year . They recorded demographic information , diagnosis , management , and an assessment of passive elevation of the shoulder ;  patients assessed the disability associated with their symptoms with a vali date d 22 item disability question naire.2 To assess outcome , identical disability question naires were sent to patients six and 18 months after consultation , together with a question measuring self assessed change in symptoms 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 OBJECTIVE To determine the natural history of shoulder pain in the population , and predictors of outcome on the basis of clinical and individual factors . In addition , to determine whether outcome is influenced by the definition of shoulder pain used . METHODS A prospect i ve cohort study , over a 3 year period , of subjects recruited from a cross sectional population screening study of shoulder pain , conducted in the Greater Manchester area of the UK . RESULTS Of 92 subjects classified as having shoulder pain in the cross sectional study , 50 ( 54 % ) reported shoulder pain at followup about 3 years later . In 90 % of cases this was accompanied by some disability specifically relating to the symptoms . Baseline factors that predicted symptoms at followup were : pain ( indicated on a manikin ) within a more narrowly defined shoulder region , shoulder pain related disability , pain on the day of examination , symptoms lasting more than one year , and a high score on the General Health Question naire , a measure of psychological distress . CONCLUSION Shoulder pain in the population is a longterm disabling symptom , although many subjects do not seek early medical consultation . Disability ( independent of whether there was restriction of movement on examination ) is a strong predictor of continuing symptoms . The outcome observed in epidemiological studies of shoulder pain will be influenced by the initial definition of symptoms Abstract Relatively little is known about outcomes following clinical osteoporotic fractures at nonhip , nonvertebral skeletal sites . To address this issue , we prospect ively assessed post-fracture disability at multiple skeletal sites in a population of 909 older ( aged 55–81 years ) , community-dwelling women with low femoral neck bone mineral density who had experienced a fracture while enrolled in the Fracture Intervention Trial ( FIT ) . FIT is a r and omized , double-masked , placebo-controlled trial that was design ed to determine the effect of alendronate on fracture incidence , and the current study was conducted as a secondary analysis of FIT data . Following incident clinical fractures , FIT participants were followed prospect ively for assessment of site-specific , fracture-related disability . Measures of disability were self-reported days hospitalized or confined to bed because of the fracture ( ` bed days ' ) and days of reduced usual activities because of the fracture ( ` limited activity days ' ) . Of fracture types evaluated , those of the hip result ed in the highest percentage of subjects with any bed days or limited activity days after fracture ( 94 % with any bed days and 100 % with any limited activity days ) , though the mean number of bed days and limited activity days appeared highest after lumbar vertebral fractures ( 25.8 mean bed days and 158.5 mean limited activity days ) . Substantial disability also was reported after fractures of thoracic vertebrae , humerus , distal forearm , ankle and foot . Within fracture types , post-fracture disability was highly variable , ranging from none to more than 6 months BACKGROUND AND PURPOSE The aim of this study was to evaluate the efficacy of a physical therapy approach to the treatment of  shoulder pain .  Subjects . Sixty-six volunteers with shoulder pain believed to be of local mechanical origin were r and omly allocated to either a treatment group or a control group . METHODS Subjects in the treatment group received 1 month of physical therapy aim ed at restoring function of their shoulder muscles . Subjects in the control group received no treatment . Outcome measurements of pain intensity , range of motion ( ROM ) , isometric muscle force , functional impairment , and self-perception of improvement were obtained by blinded assessment . RESULTS Subjects in the treatment group showed improvement in pain-free abduction and flexion ROM , functional impairment , and self-perception of improvement . The control group deteriorated slightly over the experimental period in ROM and functional impairment measures . CONCLUSION AND DISCUSSION These results suggest that the physical therapy approach used in this study is effective in improving shoulder function in subjects experiencing pain of mechanical origin . The results also provide little evidence of spontaneous recovery over a 1-month period The effectiveness of arthroscopic surgery , supervised exercises , and placebo was compared in 125 patients with rotator cuff disease ( impingement syndrome stage II ) in a r and omized clinical trial . The median age was 48 years , and the median duration of complications was 1 to 2 years . The treatments were arthroscopic subacromial decompression performed by 2 experienced surgeons , an exercise regimen supervised for 3 to 6 months by 1 experienced physiotherapist , or 12 sessions of detuned soft laser ( placebo ) for 6 weeks . The criterion for success was a Neer shoulder score > 80 . Fifteen ( 50 % ) and 11 ( 22 % ) of the patients r and omized to placebo and exercises , respectively , had surgery during the 2 1/2-year follow-up period and were classified as having failure with the treatments . The success rate was higher ( P < .01 ) for patients r and omized to surgery ( 26 of 38 ) and exercises ( 27 of 44 ) compared with the placebo group ( 7 of 28 ) . The odds ratio for success after surgery compared with exercises was 1.5 ( 95 % confidence interval 0.6 to 3.7 ; P = .49 ) . Including all patients who underwent operation , the success rate in those not on sick leave ( 19 of 21 ) before surgery was higher compared with those on sick leave ( 18 of 36 ) ( adjusted odds ratio 5.6 [ 1.2 to 29.2 ] ) . Similar results were observed for patients not receiving versus those receiving regular pain medication before surgery ( adjusted odds ratio 4.2 [ 1.2 to 15.8 ] ) A poor outcome arising from a minimally displaced fracture of the neck of the humerus may be the result of a contracture of the capsule of the glenohumoral joint . Pulsed high frequency electromagnetic energy ( PHFE ) is an electrotherapy to reduce pain and swelling and to enhance healing . If PHFE is effective , early mobilization of the injured shoulder will be possible , reducing the risk of joint capsule contracture . We therefore conducted a double-blind trial of PHFE in minimally displaced fractures of the neck of the humerus . Early physiotherapy produced an excellent outcome in all cases . The functional outcome depended on age rather than time of starting treatment , although a relationship was found between the time of starting treatment and the duration of therapy required . The use of PHFE did not improve the result further We undertook a prospect i ve , controlled trial which compared two rehabilitation programmes for 86 patients who sustained two-part fractures of the proximal humerus . Patients were r and omised either to receive immediate physiotherapy within one week ( group A ) or delayed physiotherapy after three 
    Output:
    
Electrotherapy or hydrotherapy does not enhance recovery and joint mobilization has limited evidence of its efficacy .
The best available evidence for shoulder rehabilitation emphasizes using advice , exercise , and mobilization of limited joints to restore upper limb function .
Placing controlled stresses throughout the fracture site at an early stage will optimize bone repair without increasing complication rates .
This approach requires cooperation between the referring surgeon and therapist and will optimize the patient 's shoulder function and maintain their functional independence .