The treatment effect significantly favoured the exercise group at 6, 12, and 18 weeks, with a difference of –8 units on the SPADI (95% CI –16 to –1) at 18 weeks. At 18 weeks a higher proportion of the exercise group improved by at least the smallest detectable PD0325901 price amount (19.6 units) on the SPADI (NNT 4, 95% CI

2 to 12). At 18 weeks a higher proportion of the exercise group had returned to work (NNT 4, 95% CI 2 to 19). The groups did not differ significantly on the remaining secondary outcomes. Conclusion: A physiotherapy program emphasising supervised exercises was more effective than extracorporeal shockwave treatment in reducing pain and disability in patients with subacromial pain in the shoulder. [NNTs calculated by the CAP Editor.] This single blind randomised study suggests that supervised exercises combined with some manual therapy techniques for shoulder pain (Bohmer et al 1998, Baltaci 2003) are superior to extracorporeal shockwave treatment for decreasing shoulder pain and disability. There is recent evidence that extracorporeal shockwave treatment when compared to sham treatment can be effective in reducing pain and restoring function for patients

with calcific tendinitis with negligible complications (Hsu et al 2008). One possible limitation of the Engebretsen et al (2009) trial is that we do not know click here what proportion of their participants had the diagnosis of calcific tendinitis; the participants who would be expected to be most responsive to shockwave therapy. However, the trial did include similar numbers of participants in both groups with symptoms of greater than 6 months, Ketanserin which has been associated with the development of calcific tendinitis (Green et al 1998). Although the authors emphasised the supervised exercise component of their intervention, the manual therapy component was not well described. There is other evidence supporting the combined use of manual therapy and exercise in the treatment of

shoulder impingement syndrome (Suronkok et al 2009, Senbursa et al 2007). Because patients need support on how to deal with pain and dysfunction in the early rehabilitation phase, scapular mobilisation is a useful manual therapy technique to apply to patients to gain an initial improvement in shoulder range of motion and function (Suronkok et al 2009). In a randomised clinical trial by Senbursa et al (2007), patients treated with manual physical therapy applied by experienced physical therapists combined with supervised exercise showed improvement including increasing strength, decreasing pain, and improving function compared to treatment with an exercise program alone. Based on the positive results of the Engebretsen trial and other recent literature, future research should attempt to discern the relative contributions of manual therapy and supervised exercises to improvements in patients presenting with shoulder pain.