***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: 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 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 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 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 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 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 Background Subacromial impingement syndrome ( SIS ) is the most frequently recorded shoulder disorder . When conservative treatment of SIS fails , a subacromial decompression is warranted . However , the best moment of referral for surgery is not well defined . Both early and late referrals have disadvantages – unnecessary operations and smaller improvements in shoulder function , respectively . This paper describes the design of a new interdisciplinary treatment strategy for SIS ( TRANSIT ) , which comprises rules to treat SIS in primary care and a well-defined moment of referral for surgery . Methods / Design The effectiveness of an arthroscopic subacromial decompression versus usual medical care will be evaluated in a r and omized controlled trial ( RCT ) . Patients are eligible for inclusion when experiencing a recurrence of SIS within one year after a first episode of SIS which was successfully treated with a subacromial corticosteroid injection . After inclusion they will receive injection treatment again by their general practitioner . When , after this treatment , there is a second recurrence within a year post-injection , the participants will be r and omized to either an arthroscopic subacromial decompression ( intervention group ) or continuation of usual medical care ( control group ) . The latter will be performed by a general practitioner according to the Dutch National Guidelines for Shoulder Problems . At inclusion , at r and omization and three , six and 12 months post-r and omization an outcome assessment will take place . The primary outcome measure is the patient-reported Shoulder Disability Question naire . The secondary outcome measures include both disease-specific and generic measures , and an economic evaluation . Treatment effects will be compared for all measurement points by using a GLM repeated measures analyses . Discussion The rationale and design of an RCT comparing arthroscopic subacromial decompression with usual medical care for subacromial impingement syndrome are presented . The results of this study will improve insight into the best moment of referral for surgery for SIS OBJECTIVE To assess the value of search ing for unpublished data by exploring the extent to which Cochrane review s include unpublished data and by evaluating the quality of unpublished trials . STUDY DESIGN AND SETTING We screened all 2,462 completed Cochrane review s published since 2000 in the Cochrane Data base of Systematic Review s Issue 3 , 2006 . In a r and om sample ( n=61 ) of 292 review s , including unpublished trials , we studied all 116 references . RESULTS Unpublished trials make up 8.8 % of all included trials in our sample . Thirty-eight percent of the " unpublished " trials have in fact been published . Allocation concealment was " unclear " or not adequate in 54.3 % and 61.3 % reported blinding . In 47.2 % reported withdrawal rates were > 20 % . Trials that were eventually published had larger mean population sizes ( P-value , 0.02 ) . Of the reported sponsors , 87.3 % were drug companies . Method ological quality and publication bias are mentioned in half of the review s and explored in a third . Quality ratings did not have consequences for pooling , because 82.8 % was included in the forest plots . CONCLUSIONS A minority of Cochrane review s include " unpublished trials " and many of these are eventually published . Truly unpublished studies have poor or unclear method ological quality . Therefore , it may be better to invest in regular updating of review s , rather than in extensive search ing for unpublished data 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 synd 
    Output:
    
SFA for RCSP confers benefit over generalised approaches up to six weeks but this benefit is not apparent by 3 months .
Early changes in pain are not clinical ly significant .