***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 Background Noninvasive physical management is often prescribed for  headache and neck pain .  Systematic review s , however , indicate that the evidence of its efficacy is limited . Our aim was to evaluate the effectiveness of a workplace educational and physical program in reducing  headache and neck/shoulder pain . Methodology /Principal Findings Cluster-r and omized controlled trial . All municipal workers of the City of Turin , Italy , were invited to participate . Those who agreed were r and omly assigned , according to their departments , to the intervention group ( IG ) or to the control group and were given diaries for the daily recording of pain episodes for 1 month ( baseline ) . Subsequently , only the IG ( 119 departments , 923 workers ) began the physical and educational program , whereas the control group ( 117 departments , 990 workers ) did not receive any intervention . All participants were again given diaries for the daily recording of pain episodes after 6 months of intervention . The primary outcome was the change in the frequency of headache ( expressed as the proportion of subjects with a ≥50 % reduction of frequency ; responder rate ) ; among the secondary outcomes there were the absolute reduction of the number of days per month with headache and neck/shoulder pain . Differences between the two groups were evaluated using mixed-effect regression models . The IG showed a higher responder rate [ risk ratio , 95 % confidence interval ( CI ) ] for headache ( 1.58 ; 1.28 to 1.92 ) and for neck/shoulder pain ( 1.53 ; 1.27 to 1.82 ) , and a larger reduction of the days per month ( 95 % CI ) with headache ( −1.72 ; −2.40 to −1.04 ) and with neck/shoulder pain ( −2.51 ; −3.56 to −1.47 ) . Conclusions The program effectively reduced headache and neck/shoulder pain in a large working community and appears to be easily transferable to primary -care setting s. Further trials are needed to investigate the program effectiveness in a clinical setting , for highly selected patients suffering from specific headache types . Trial Registration Clinical Trials.gov 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 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 We investigated the effectiveness and efficiency of a four-week myofeedback-based teletreatment service in subjects with non-specific neck and shoulder pain . Subjects were recruited in Belgium , Germany and the Netherl and s and r and omly allocated to the intervention or conventional care . Subjects in the intervention group received four weeks of myofeedback training .  Pain intensity and disability were evaluated by question naires at baseline , immediately after four weeks of treatment and at follow-up 3 months later . To investigate efficiency , the time-investment of both therapists and patients were assessed . Seventy-one subjects were included in the study ( 36 in the intervention group and 35 in the conventional care group ) . Myofeedback-based teletreatment was at least as effective clinical ly as conventional care .  Pain intensity and disability decreased after 4 weeks of treatment in both groups and part of the effect remained at 3 months ' follow-up . The teletreatment also increased efficiency for therapists by almost 20 % and patients experienced the benefits of less travel time and travel costs by remote consultation . Myofeedback-based teletreatment has the potential to ensure more efficient treatment for patients with non-specific neck and shoulder pain 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 Objective : To investigate whether an exercise intervention shown to increase aerobic capacity , would also lead to less musculoskeletal pain ; improved work ability , productivity , and perceived physical exertion ; and less sick leave . Methods : Sixty-seven construction workers were r and omized into an exercise group training 3 × 20 minutes per week and a control group . Question naires and text messages were completed before and after the 12-week intervention . Results : No significant changes were found in musculoskeletal pain , work ability , productivity , perceived physical exertion , and sick leave with the intervention . Question naires and text messages provided similar results of pain and work ability . Conclusions : Although the intervention improved aerobic capacity , it was not successful in improving musculoskeletal pain and other work-related factors . A detectable improvement presumably requires a more multifaceted intervention , larger sample size , or longer follow-up . Text messages may be a convenient data - collection method in future studies OBJECTIVE To compare the effectiveness of exercise therapy aim ed at restoring neuromuscular control mechanisms at the shoulder with other conservative interventions for the treatment of chronic shoulder pain with and without accompanying stiffness . DESIGN R and omized control trial 
    Output:
    
For variable duration subacromial impingement syndrome : 1 ) supervised strengthening leads to greater short-term improvement in pain and disability over wait listing ; and 2 ) supervised and home-based strengthening and stretching leads to greater short-term improvement in pain and disability compared to no treatment .
For persistent subacromial impingement syndrome : 1 ) supervised and home-based strengthening leads to similar outcomes as surgery ; and 2 ) home-based heavy load eccentric training does not add benefits to home-based rotator cuff strengthening and physiotherapy .
For variable duration low- grade nonspecific shoulder pain , supervised strengthening and stretching leads to similar short-term outcomes as corticosteroid injections or multimodal care .
CONCLUSION The evidence suggests that supervised and home-based progressive shoulder strengthening and stretching are effective for the management of subacromial impingement syndrome .
For low- grade nonspecific shoulder pain , supervised strengthening and stretching are equally effective to corticosteroid injections or multimodal care .