Manual Therapy
journal homepage: www.elsevier.com/math
Original article
a r t i c l e i n f o a b s t r a c t
Article history:
Background: Exercise is a key component of rehabilitation for soft tissue injuries of the shoulder;
Received 5 September 2014
however its effectiveness remains unclear.
Received in revised form
5 March 2015 Objective: Determine the effectiveness of exercise for shoulder pain.
Accepted 18 March 2015 Methods: We searched seven databases from 1990 to 2015 for randomized controlled trials (RCTs),
cohort and case control studies comparing exercise to other interventions for shoulder pain. We critically
Keywords: appraised eligible studies using the Scottish Intercollegiate Guidelines Network (SIGN) criteria. We
Shoulder pain synthesized findings from scientifically admissible studies using best-evidence synthesis methodology.
Subacromial impingement syndrome Results: We retrieved 4853 articles. Eleven RCTs were appraised and five had a low risk of bias. Four
Exercise studies addressed subacromial impingement syndrome. One study addressed nonspecific shoulder pain.
Systematic review 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.
* Corresponding author. Rebecca MacDonald Centre, Department of Medicine, Division of Rheumatology, Mount Sinai Hospital, 60 Murray Street, Toronto, ON, Canada, M5T
3L9. Tel: þ1 416 586 4800x6449.
E-mail address: dsoutherst@mtsinai.on.ca (D. Southerst).
http://dx.doi.org/10.1016/j.math.2015.03.013
1356-689X/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Abdulla SY, et al., Is exercise effective for the management of subacromial impingement syndrome and other
soft tissue injuries of the shoulder? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration, Manual
Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.03.013
2 S.Y. Abdulla et al. / Manual Therapy xxx (2015) 1e11
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.
Systematic review registration number: CRD42013003928.
© 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Abdulla SY, et al., Is exercise effective for the management of subacromial impingement syndrome and other
soft tissue injuries of the shoulder? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration, Manual
Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.03.013
S.Y. Abdulla et al. / Manual Therapy xxx (2015) 1e11 3
2.4. Study selection We computed agreements between reviewers for the screening
of articles and reported the kappa statistic (k) and 95% confidence
We used a two-phase screening process to select eligible interval (CI) (Cohen, 1960). When available, we used data provided
studies. In phase one, random pairs of independent reviewers in the admissible articles to measure the association between the
screened citation titles and abstracts to determine eligibility. Phase tested interventions and the outcomes by computing the relative
I screening resulted in studies being classified as relevant, possibly risk (RR) and its 95% CI. Similarly, we computed differences in mean
relevant, and irrelevant. In phase II, the same pairs of reviewers changes between groups and 95% CI to quantify the effectiveness of
independently screened possibly relevant articles to determine interventions. The computation of 95% CIs was based on the
eligibility. Reviewers met to resolve disagreements and reach assumption that baseline and follow-up outcomes were highly
consensus on the eligibility of studies. We involved a third reviewer correlated (r ¼ 0.80) (Follmann et al., 1992; Abrams et al., 2005). We
if consensus could not be reached. excluded findings based on outcome measures that had not been
Please cite this article in press as: Abdulla SY, et al., Is exercise effective for the management of subacromial impingement syndrome and other
soft tissue injuries of the shoulder? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration, Manual
Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.03.013
4 S.Y. Abdulla et al. / Manual Therapy xxx (2015) 1e11
2.7. Reporting
3. Results
Our search retrieved 4853 articles. We removed 1516 duplicates Fig. 1. Identification and selection of articles.
and screened the eligibility of 3337 articles (Fig. 1). Primary reasons
for exclusion of articles in full text screening are listed in Appendix
II. Twelve articles were critically appraised (Melegati et al., 2000; baseline was lower than 3/10 cm on the VAS; therefore, we have
Ludewig and Borstad, 2003; Ginn and Cohen, 2005; Andersen categorized this study population as low-grade nonspecific shoul-
et al., 2008; Lombardi et al., 2008; Osteras et al., 2010; Osteras der pain.
and Torstensen, 2010; Sandsjo et al., 2010; Beaudreuil et al., All exercise programs aimed to strengthen the rotator cuff
2011). Of these, five studies (reported in six articles) had a low (Ludewig and Borstad, 2003; Ginn and Cohen, 2005; Lombardi
risk of bias and were included in our synthesis (Ludewig and et al., 2008; Ketola et al., 2009, 2013; Maenhout et al., 2013);
Borstad, 2003; Ginn and Cohen, 2005; Lombardi et al., 2008). three also aimed to strengthen the scapular stabilizing musculature
Two of the articles with a low risk of bias reported outcomes from (Ludewig and Borstad, 2003; Ginn and Cohen, 2005; Ketola et al.,
different follow-up periods from one RCT (Ketola et al., 2009, 2013). 2009, 2013), and two included stretching exercises (Ludewig and
The inter-rater agreement for the screening of articles was k ¼ 0.75 Borstad, 2003; Ginn and Cohen, 2005). The duration of exercise
(95% CI 0.64e0.86). The percent agreement for the critical appraisal programs were five (Ginn and Cohen, 2005), eight (Ludewig and
of studies was 82% (9/11 studies). Disagreement was resolved Borstad, 2003; Lombardi et al., 2008), 12 weeks (Maenhout et al.,
through consensus for two studies. During critical appraisal, we 2013), or individually planned (Ketola et al., 2009, 2013). The
contacted the authors of four studies (3/4 responded). The data level of supervision varied between exercise programs: one pro-
from reviewed studies did not allow meta-analysis, so we con- gram was only performed at home (Maenhout et al., 2013); one
ducted a best evidence synthesis. program involved minimal supervision by a physical therapist (one
instructional session and one to two follow-up visits) (Ludewig and
3.2. Study characteristics Borstad, 2003); one involved biweekly supervised visits (Lombardi
et al., 2008); one involved weekly supervised visits (Ginn and
All five studies with a low risk of bias were RCTs. Four RCTs Cohen, 2005); and one with individualized number of visits (su-
assessed the effectiveness of exercise for the management of pervised and at home) (Ketola et al., 2009, 2013). Three studies
shoulder impingement syndrome (two targeting persistent dura- incorporated home-based exercises into supervised exercises
tion (Melegati et al., 2000; Ludewig and Borstad, 2003; Maenhout (Ludewig and Borstad, 2003; Ginn and Cohen, 2005; Ketola et al.,
et al., 2013) and two targeting variable duration (Ludewig and 2009, 2013). The exercise programs were added to physiotherapy
Borstad, 2003; Lombardi et al., 2008)). One RCT studied exercise and another exercise program (Maenhout et al., 2013) or compared
for the management of nonspecific shoulder pain lasting more than to surgery (Ketola et al., 2009, 2013), no intervention (Ludewig and
one-month (Ginn and Cohen, 2005). The median pain intensity at Borstad, 2003; Lombardi et al., 2008), corticosteroid injections
Please cite this article in press as: Abdulla SY, et al., Is exercise effective for the management of subacromial impingement syndrome and other
soft tissue injuries of the shoulder? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration, Manual
Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.03.013
S.Y. Abdulla et al. / Manual Therapy xxx (2015) 1e11 5
(Ginn and Cohen, 2005), or multimodal care (electrophysical mo- assessor (4/6) (Melegati et al., 2000; Osteras et al., 2010; Osteras
dalities, passive joint mobilization and ROM (range of motion) ex- and Torstensen, 2010; Sandsjo et al., 2010). Clinically important
ercises) (Ginn and Cohen, 2005). Overall, the exercise interventions differences in baseline characteristics between groups were re-
were described in sufficient detail for replication in further studies ported in 4/6 RCTs (Osteras et al., 2010; Osteras and Torstensen,
or for implementation into practice (Appendix III). 2010; Sandsjo et al., 2010; Beaudreuil et al., 2011) and one study
did not describe the baseline characteristics of participants
3.3. Risk of bias within studies (Melegati et al., 2000). All studies with high risk of bias did not
describe or properly account for co-interventions (Melegati et al.,
Four studies with a low risk of bias used appropriate 2000; Andersen et al., 2008; Osteras et al., 2010; Osteras and
randomization and blinding methods, and all five studies per- Torstensen, 2010; Sandsjo et al., 2010; Beaudreuil et al., 2011).
formed an intention to treat analysis (Table 1A). Four RCTs had Two trials reported drop-outs of greater than 30% (Sandsjo et al.,
follow-up rates greater than 85%. Nevertheless, these studies had 2010; Beaudreuil et al., 2011) one trial had large differences in
limitations: one study did not describe the method of randomi- the number of drop-outs between treatment arms (Andersen
zation and blinding (Maenhout et al., 2013); three studies did not et al., 2008), and one did not report on attrition (Melegati et al.,
describe the method used to conceal treatment allocation 2000).
(Ludewig and Borstad, 2003; Ginn and Cohen, 2005); all five
studies did not describe co-interventions or reported unbalanced 3.4. Summary of evidence
co-interventions between groups. The participants and treatment
providers of all studies were not blinded due to the nature of the 3.4.1. Low-grade nonspecific shoulder pain of variable duration
intervention. Two studies used outcome measures that have not (excluding major pathology)
been validated or were administered in a non-standardized Evidence from one RCT suggests that supervised strengthening
manner (i.e., a functional limitation score developed by the au- and stretching exercises, a single corticosteroid injection, and a
thors; VAS administered while participants were lifting weights in multimodal program of care lead to similar short-term outcomes
a non-standardized manner; SPADI with modified occupational for the management of low-grade nonspecific shoulder pain (Ginn
pain and disability questions i.e., modified version had not been and Cohen, 2005). Ginn and Cohen randomized patients with
tested for its validity (Ludewig and Borstad, 2003; Ginn and mechanical shoulder pain of more than one month duration
Cohen, 2005)). Findings using these outcome measures were (mean ¼ 7.3 months) to: 1) five weeks of individualized home-
excluded from our synthesis and conclusions are based only on based exercises (strengthening and stretching of the rotator cuff
valid and reliable outcome measures. and scapulohumeral muscles) with weekly supervision by a
The six RCTs with high risk of bias had important limitations physical therapist; 2) a single subacromial corticosteroid injection;
(Table 1B) (Melegati et al., 2000; Andersen et al., 2008; Osteras or 3) five weeks of multimodal care by a physical therapist
et al., 2010; Osteras and Torstensen, 2010; Sandsjo et al., 2010; (electrophysical modalities, passive joint mobilization, daily range
Beaudreuil et al., 2011). These included: inadequate (Osteras of motion exercises). There were no statistically significant dif-
et al., 2010) or non-disclosed (Melegati et al., 2000; Osteras and ferences between groups in range of motion, strength or the self-
Torstensen, 2010; Sandsjo et al., 2010) methods of randomiza- reported improvement in symptoms immediately following the
tion (4/6) (Melegati et al., 2000; Osteras et al., 2010; Osteras and intervention (Table 2). As the study population had low-grade
Torstensen, 2010; Sandsjo et al., 2010); inadequate concealment shoulder pain at baseline, floor effects may have been respon-
of treatment allocation (3/6) (Melegati et al., 2000; Andersen sible for the lack of superior effectiveness of any one or all of the
et al., 2008; Sandsjo et al., 2010); and no blinding of outcome tested interventions.
Table 1A
Risk of bias for scientifically admissible randomized controlled trials based on the Scottish Intercollegiate Guidelines Network criteria.
Author, year Research Randomization Concealment Blinding Similarity Similarity Outcome Percent drop-outa Intention Comparable
question at baseline between measurement to treat results between
arms sites
Acronyms: CS e can't say; N e no; NA e not applicable; Y e yes; LLLT: low level laser therapy; MPM: multiple physical modalities; PRTP: progressive resistance training
program; TT: traditional rotator cuff strength training; TT þ ET: traditional rotator cuff strength training combined with heavy load eccentric training.
a
Percent drop-out incorporates both participant withdrawal and loss to follow-up.
Please cite this article in press as: Abdulla SY, et al., Is exercise effective for the management of subacromial impingement syndrome and other
soft tissue injuries of the shoulder? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration, Manual
Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.03.013
6 S.Y. Abdulla et al. / Manual Therapy xxx (2015) 1e11
Table 1B
Risk of bias for scientifically inadmissible randomized controlled trials based on the Scottish Intercollegiate Guidelines Network criteria.
Author, year Research Randomization Concealment Blinding Similarity at Similarity Outcome Percent drop-outa Intention Comparable
question baseline between measurement to treat results between
arms sites
Acronyms: CS e can't say; N e no; NA e not applicable; Y e yes; APE: all-round physical exercise; DHC: dynamic humeral centering; HD: high-dosage medical exercise
therapy; LD: low-dosage medical exercise therapy; REF: reference intervention; SRT: specific resistance training.
a
Percent drop-out incorporates both participant withdrawal and loss to follow-up.
3.4.2. Subacromial impingement syndrome of variable duration 3.4.3. Persistent subacromial impingement syndrome
Evidence from one RCT suggests that home-based stretching Evidence from one RCT suggests that supervised and home-
and strengthening exercises for the rotator cuff and scapular based strengthening exercise leads to similar outcomes as surgery
muscles are effective for the management of subacromial plus post-surgical rehabilitation for the management of persistent
impingement syndrome of varied duration (Ludewig and Borstad, subacromial impingement syndrome (Ketola et al., 2009, 2013).
2003). Ludewig and Borstad randomized construction workers Ketola et al. randomized patients with subacromial impingement
with subacromial impingement syndrome to: 1) eight weeks of syndrome (3 months) to: 1) individually planned and progressive
home exercise with two follow-up visits with an exercise therapist; supervised exercises in seven visits and a home-based exercise
or 2) no treatment (Ludewig and Borstad, 2003). The exercise program; or 2) arthroscopic decompression and post-surgical
program included daily stretching and resistance training for the rehabilitation. The exercise program included strengthening exer-
scapular stabilizer and rotator cuff muscles. Following the inter- cises using elasticated stretch bands and light weights. There were
vention, there were greater improvements in shoulder pain and no statistically significant differences between groups in pain,
disability (difference in mean change in SRQ from baseline: 11.4/ disability, working ability, shoulder disability, reported painful
100) and satisfaction (difference in mean change from baseline 1.5/ days, or proportion of pain-free patients at two and five year
10) in the exercise group than the group receiving no treatment follow-up. Although there were statistically significant differences
(Table 2). Although these results were statistically and clinically in days of absence from work at two years follow-up (but not five
significant, the precision of these estimates could not be calculated. year follow-up) favoring the surgery group, the difference (i.e., 3.7
Evidence from another RCT suggests that clinic-based progres- days over two years) was small and likely not clinically important.
sive shoulder strengthening exercises are effective for the man- Evidence from one RCT suggests that home-based heavy load
agement of subacromial impingement syndrome of varied duration eccentric loading training does not provide added benefits to
(Lombardi et al., 2008). In a trial by Lombardi et al., participants home-based traditional rotator cuff strength training for the man-
with subacromial impingement syndrome (mean duration ¼ 13.7 agement of persistent subacromial impingement syndrome
months) were randomized to: 1) eight weeks of progressive resis- (Maenhout et al., 2013). Maenhout et al. randomized adults with
tance exercises for the shoulder (flexion, extension, medial and subacromial impingement syndrome (3 months) to 12 weeks of
lateral rotation); or 2) wait list (Lombardi et al., 2008). Both groups home-based progressive: 1) traditional rotator cuff training (in-
used acetaminophen or diclofenac as required. Immediately post- ternal and external rotation resisted with an elastic band); or 2)
intervention, the exercise group reported clinically significant re- traditional rotator cuff training combined with heavy load eccentric
ductions favoring the exercise group in pain at rest (difference in training (full can abduction in the scapular plane with a dumbbell
mean change in VAS: 2.2/10 cm [95% CI 1.3; 3.1]), pain with weight). Both groups received nine sessions over 12 weeks of
movement (difference in mean change in VAS: 2.2/10 cm [95% CI identical physiotherapy (information, glenohumeral and scap-
1.4; 3.0]), disability (difference in mean change in DASH 2: 17.7/100 ulothoracic mobilization, scapula setting and posture correction).
[95% CI 2.9; 16.0]), and abduction ROM (difference in mean change: There was no statistically significant or clinically important differ-
22.6 [95% CI 13.0; 32.2]). Moreover, there were statistically ence in shoulder pain and disability between groups post-
significant improvements in health-related quality of life favoring intervention. Participants in both groups had a similar likelihood
the exercise group (mean difference in change in SF-36 domains of perceiving improvement in shoulder pain post-intervention.
from baseline: physical function: 8.9 [95% CI 2.2; 15.6]; bodily pain:
8.2 [95% CI 1.6; 14.8]; social function: 15.0 [95% CI 5.3; 24.7]; 3.5. Adverse events
emotional role limitation: 21.0 [95% CI 7.4; 34.8]) (Table 2). How-
ever, to our knowledge, the clinical importance of change on these None of the included studies commented on the frequency or
subscales of the SF-36 has not been established in the literature. nature of adverse events.
Please cite this article in press as: Abdulla SY, et al., Is exercise effective for the management of subacromial impingement syndrome and other
soft tissue injuries of the shoulder? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration, Manual
Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.03.013
Table 2
Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.03.013
soft tissue injuries of the shoulder? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration, Manual
Please cite this article in press as: Abdulla SY, et al., Is exercise effective for the management of subacromial impingement syndrome and other
Evidence table for accepted randomized controlled trials on exercise for soft tissue injuries of the shoulder.
Author(s), year Subjects and setting; number Interventions; number (n) of Comparisons; number (n) of Follow-up Outcomes Key findings
(n) enrolled subjects subjects
Ginn and Cohen, Patients > 18 y.o., with Exercise: individualized daily Corticosteroid injection: single Post- Hand-behind-back ROM: distance Exercise vs. corticosteroid injection:
2005 unilateral mechanical shoulder home-based exercises subacromial injection by intervention between T1 spinous process and the Difference in mean change (exercise e
pain of >1 month duration supervised by a physical rheumatologist; 40 mg radial styloid process; unaffected corticosteroid injection):
recruited from a metropolitan therapist 1/week/5 weeks; methylprednisone acetate; patient side e affected side; No significant difference between
public hospital in Australia l stretching, strengthening, encouraged to use affected upper Isometric strength (abduction): groups for hand-behind-back ROM,
(n ¼ 138) exercises; gradual increase in limb in a normal manner (n ¼ 48) hand-held dynamometer; strength, or proportion reporting
Case definition: pain over the intensity and complexity as Multiple physical modalities Self-rated improvement: 3-point improvement in symptoms)
shoulder joint and/or the indicated (n ¼ 48) (MPM): 2/week/5 weeks by a Likert scale Exercise vs. MPM:
proximal arm exacerbated by physical therapist; electrophysical No significant difference between
active shoulder movements modalities (interferential therapy, groups for hand-behind-back ROM,
ultrasound, hot packs, ice packs), strength, or proportion reporting
passive joint mobilization, daily improvement in symptoms.
ROM (n ¼ 42)
Ketola et al., 2009, Patients (18e60 y.o.) referred to Supervised and home Surgery þ post-surgical exercises: 2 and 5 years Primary outcome: pain (10 cm 2 years
2013 the Kantah€ ame Central or strengthening exercises arthroscopic decompressions by an after VAS); Difference in mean change (exercise e
Riihim€aki Regional Hospital, provided by physiotherapist: orthopedic surgeon; post-operative randomization Secondary outcomes: disability surgery)
Finland between June 2001 and individually planned and treatment: anti-inflammatory (10 cm VAS), pain at night (10 cm Pain (10 cm VAS): 0.2 (99% CI 1.61,
7
(continued on next page)
Table 2 (continued )
8
Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.03.013
soft tissue injuries of the shoulder? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration, Manual
Please cite this article in press as: Abdulla SY, et al., Is exercise effective for the management of subacromial impingement syndrome and other
Author(s), year Subjects and setting; number Interventions; number (n) of Comparisons; number (n) of Follow-up Outcomes Key findings
(n) enrolled subjects subjects
Case definition: positive Neer exercises using multi-pulley Function (DASH 2, DASH 3); 3.0)a
and Hawkin tests, and pain muscle-building equipment Quality of life (Brazilian SF-36); DASH 2 (0e100): 17.7 (95% CI 9.3;
rated between 3 and 8/10 using (flexion, extension, medial ROM (goniometer); Strength (peak 26.1)a
NRS. rotation, lateral rotation); 2 torque and total work) (Cybex DASH 3 (1e100): 9.4 (95% CI 2.9; 16.0)a
series of 8 repetitions (50% and 6000); Abduction (degrees): 22.6 (95%
70% of maximum weight for 6 Analgesic and NSAID use (self- CI 32.2; 13.0)a
repetition). report); Extension (degrees): 4.2 (95%
750 mg acetaminophen or Satisfaction (5 point Likert scale).CI 7.7; 0.7)a
50 mg diclofenac every 8 h as SF-36 physical function (0e100): 8.9
required (n ¼ 30) (95% CI 15.6; 2.2)a
SF-36 pain (0e100): 8.2 (95%
CI 14.8; 1.6)a
SF-36 social function (0e100): 15.0
(95% CI 24.7; 5.3)a
SF-36 emotional role limitation (0
e100): 21.0 (95% CI 34.8; 7.4)a
Total work (joules) e extension: 9.7
(95% CI 18.7; 0.7)a
4. Discussion
Questionnaire; SF-36: the Short Form (36) Health Survey; SRQ: Shoulder Rating Questionnaire; SPADI: Shoulder Pain and Disability Index; TT: traditional rotator cuff strength training; VAS: Visual Analog Scale; y.o: years old.
Acronyms: DASH: Disabilities of the Arm, Shoulder and Hand; ET: heavy load eccentric training; NRS: Numeric Rating Scale; NSAIDs: Non-steroidal Anti-inflammatory Drugs; ROM: Range of Motion; SDQ: Shoulder Disability
Between group difference in mean change and 95% confidence intervals calculated by authors based on the assumption that pre- and post-intervention outcomes were highly correlated (r ¼ 0.8) (Hayden et al., 2006, 2013).
large improvement): 1.24 (95% CI 0.86,
point scale, 0 ¼ no change, 5 ¼ very improvement (some, large and very
We found five RCTs with a low risk of bias that inform the
effectiveness of exercise for the management of soft tissue injuries
of the shoulder. The evidence suggests that supervised progressive
shoulder exercises alone or combined with home-based shoulder
exercises (strengthening with or without stretching) are effective
over the short-term for the management of subacromial impinge-
ment syndrome of variable duration (Ludewig and Borstad, 2003;
1.77)a
Results are not accepted because the outcome assessor was not blinded to this examination-based outcome measure.
rotation resisted with an elastic
band; load increased once pain
example, all three reviews included studies where exercise was one
increased with 0.5 kg; same
load increased once on pain
Please cite this article in press as: Abdulla SY, et al., Is exercise effective for the management of subacromial impingement syndrome and other
soft tissue injuries of the shoulder? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration, Manual
Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.03.013
10 S.Y. Abdulla et al. / Manual Therapy xxx (2015) 1e11
the management of clinically meaningful subgroups of shoulder Andersen LL, Jorgensen MB, Blangsted AK, Pedersen MT, Hansen EA, Sjogaard G.
A randomized controlled intervention trial to relieve and prevent neck/shoul-
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der pain. Med Sci Sports Exerc 2008;40(6):983e90.
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Methods for the best evidence synthesis on neck pain and its associated dis-
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of bias as the majority of trials are published in English. The
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to biased results in previous publications (Moher et al., 1996; Sutton 2014;95(3 Suppl.):S152e73.
^ te
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relevant studies despite our broad definition of soft tissue injuries Prognosis. Arch Phys Med Rehabil 2014;95(3 Suppl.):S132e51.
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Please cite this article in press as: Abdulla SY, et al., Is exercise effective for the management of subacromial impingement syndrome and other
soft tissue injuries of the shoulder? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration, Manual
Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.03.013