Setting: Primary care based musculoskeletal service in UK. Participants: Men and women 40 years or older with unilateral shoulder pain with moderate or severe pain intensity on a 3-point scale, and with a non-capsular pattern of restriction. Key exclusion criteria were evidence of other pathological conditions in the shoulder and neck. Randomisation of 232 participants allocated 115 to the selleck inhibitor ‘injection plus exercise’ group and 117 to the ‘exercise only’ group. Interventions: Both groups received standard advice to avoid activities that caused or provoked pain. The physiotherapy program started one week after the subacromial injection or immediately in the exercise only arm. The
training sessions were individually adapted and comprised a selection of six mobilisation techniques and 23 progressive exercises. The patients attended as many sessions as deemed necessary by the treating physiotherapist. In addition, the intervention group received one injection of 20 mg triamcinolone acetonide mixed with 4.5 ml 1% lidocaine (lignocaine) at the midpoint of the acromion, which could be repeated after six weeks in patients with ongoing pain. Outcome measures: The primary outcome was the difference in improvement in the total shoulder pain and disability index (SPADI) at 12 weeks. The secondary outcome measure
was global assessment of selleck screening library change on a 5-point scale. Results: 193 of participants completed the study, 96 in the ‘injection plus exercise’ group and 97 to the ‘exercise only’ group. At Week 12 there was no significant difference between the groups in change in SPADI scores: the mean difference between change in groups was 3.3 (95% CI −0.8 to 7.3). Improvement was significantly greater in the injection plus exercise group at Week 1 (6.6, 95% CI 4.3 to 8.8) and Week 6 (7.4, 95% CI 4.3 to 10.4) for the SPADI, with no differences at Week 24 (−2.3, 95% CI −6.8 to 2.3). For the secondary
outcome a similar pattern was seen, with no significant differences at Weeks 12 and 24. For the secondary outcome a similar pattern was seen, with no significant Ribonucleotide reductase differences at Weeks 12 and 24. Conclusion: In the treatment of patients with subacromial impingement syndrome, injection plus exercise and exercise only are similarly effective at 12 weeks. This trial investigated whether reduced pain from a corticosteroid injection and lidocaine Modulators before starting an exercise therapy program would result in better outcome than exercise therapy only. Hence one cannot know whether it was the lidocaine or the steroid injection that gave pain relief. With this in mind, the title is somewhat misleading. The study is well conducted. The authors have performed Rasch transformation of the main outcome instrument, SPADI. As far as we know this has previously been applied only for the SPADI disability subscale (Cook et al 2001). The applied interventions are pertinent for this patient group (Green et al 2006).