Abdulla SY, Southerst D, Cote P, Shearer HM, Sutton D, Randhawa K, Varatharajan S, Wong JJ, Yu H, Marchand A-A, Chrobak K, Woitzik E, Shergill Y, Ferguson B, Stupar M, Nordin M, Jacobs C, Mior S, Carroll LJ, van der Velde G, Taylor-Vaisey A
Manual Therapy 2015 Oct;20(5):646-656
systematic review
​
BACKGROUND: Exercise is a key component of rehabilitation for soft tissue injuries of the shoulder; however its effectiveness remains unclear. OBJECTIVE: Determine the effectiveness of exercise for shoulder pain.
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 appraised eligible studies using the Scottish Intercollegiate Guidelines Network (SIGN) criteria. We synthesized findings from scientifically admissible studies using best-evidence synthesis methodology.
RESULTS: We retrieved 4,853 articles. Eleven RCTs were appraised and five had a low risk of bias. Four studies addressed subacromial impingement syndrome. One study addressed nonspecific shoulder pain.
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.

Diercks R, Bron C, Dorrestijn O, Meskers C, Naber R, de Ruiter T, Willems J, Winters J, van der Woude HJ [Netherlands Orthopedic Society, Koninklijk Nederlands Genootschap voor Fysiotherapie, Netherlands Association of General Practitioners, Netherlands Society of Rehabilitation Medicine, Netherlands Association of Occupational Medicine, Netherlands Society of Radiology]
Acta Orthopaedica 2014;85(3):314-322
practice guideline
Treatment of "subacromial impingement syndrome" of the shoulder has changed drastically in the past decade. The anatomical explanation as "impingement" of the rotator cuff is not sufficient to cover the pathology. "Subacromial pain syndrome", SAPS, describes the condition better. A working group formed from a number of Dutch specialist societies, joined by the Dutch Orthopedic Association, has produced a guideline based on the available scientific evidence. This resulted in a new outlook for the treatment of subacromial pain syndrome. The important conclusions and advice from this work are as follows:
(1) the diagnosis SAPS can only be made using a combination of clinical tests.
(2) SAPS should preferably be treated non-operatively.
(3) Acute pain should be treated with analgetics if necessary.
(4) Subacromial injection with corticosteroids is indicated for persistent or recurrent symptoms.
(5) Diagnostic imaging is useful after 6 weeks of symptoms. Ultrasound examination is the recommended imaging, to exclude a rotator cuff rupture.
(6) Occupational interventions are useful when complaints persist for longer than 6 weeks.
(7) Exercise therapy should be specific and should be of low intensity and high frequency, combining eccentric training, attention to relaxation and posture, and treatment of myofascial trigger points (including stretching of the muscles) may be considered.
8) Strict immobilization and mobilization techniques are not recommended.
(9) Tendinosis calcarea can be treated by shockwave (ESWT) or needling under ultrasound guidance (barbotage).
(10) Rehabilitation in a specialized unit can be considered in chronic, treatment resistant SAPS, with pain perpetuating behavior.
(11) There is no convincing evidence that surgical treatment for SAPS is more effective than conservature management.
(12) There is no indication for the surgical treatment of asymptomatic rotator cuff tears. 

de Vries JS, Krips R, Sierevelt IN, Blankevoort L, van Dijk CN
Cochrane Database of Systematic Reviews 2011;Issue 8
systematic review

BACKGROUND:
Chronic lateral ankle instability occurs in 10% to 20% of people after an acute ankle sprain. Initial treatment is conservative but if this fails and ligament laxity is present, surgical intervention is considered.
OBJECTIVES:
To compare different treatments, conservative or surgical, for chronic lateral ankle instability.
SEARCH STRATEGY:
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, Medline, Embase, CINAHL and reference lists of articles, all to February 2010.
SELECTION CRITERIA:
All identified randomised and quasi-randomised controlled trials of interventions for chronic lateral ankle instability were included.
DATA COLLECTION AND ANALYSIS:
Two review authors independently assessed risk of bias and extracted data from each study. Where appropriate, results of comparable studies were pooled.
MAIN RESULTS:
Ten randomised controlled trials were included. Limitations in the design, conduct and reporting of these trials resulted in unclear or high risk of bias assessments relating to allocation concealment, assessor blinding, incomplete and selective outcome reporting. Only limited pooling of the data was possible. Neuromuscular training was the basis of conservative treatment evaluated in four trials. Neuromuscular training compared with no training resulted in better ankle function scores at the end of four weeks training (Ankle Joint Functional Assessment Tool (AJFAT): mean difference (MD) 3.00, 95% CI 0.3 to 5.70; 1 trial, 19 participants; Foot and Ankle Disability Index (FADI) data: MD 8.83, 95% CI 4.46 to 13.20; 2 trials, 56 participants). The fourth trial (19 participants) found no significant difference in the functional outcome after six weeks training programme on a cyclo-ergometer with a bi-directional compared with a traditional uni-directional pedal. Longer-term follow-up data were not available for these four trials. Four studies compared surgical procedures for chronic ankle instability. One trial (40 participants) found more nerve injuries after tenodesis than anatomical reconstruction (risk ratio (RR) 5.50, 95% CI 1.39 to 21.71). One trial (99 participants) comparing dynamic versus static tenodesis excluded 17 patients allocated dynamic tenodesis because their tendons were too thin. The same trial found that dynamic tenodesis resulted in higher numbers of people with unsatisfactory function (RR 8.62, 95% CI 1.97 to 37.77, 82 participants). One trial comparing techniques of lateral ankle ligament reconstruction (60 participants) found that operating time was shorter using the reinsertion technique than the imbrication method (MD -9.00 minutes, 95% CI -13.48 to -4.52). Two trials (70 participants) compared functional mobilisation with immobilisation after surgery. These found early mobilisation led to earlier return to work (MD -2.00 weeks, 95% CI -3.06 to -0.94; 1 trial) and to sports (MD -3.00 weeks, 95% CI -4.49 to -1.51; 1 trial).
AUTHORS' CONCLUSIONS:
Neuromuscular training alone appears effective in the short term but whether this advantage would persist on longer-term follow-up is not known. While there is insufficient evidence to support any one surgical intervention over another surgical intervention for chronic ankle instability, it is likely that there are limitations to the use of dynamic tenodesis. After surgical reconstruction, early functional rehabilitation appears to be superior to six weeks immobilisation in restoring early function. 

Carcia CR, Martin RL, Houck J, Wukich DK [Orthopaedic Section of the American Physical Therapy Association]
The Journal of Orthopaedic and Sports Physical Therapy 2010 Sep;40(9):A1-A26
practice guideline
RECOMMENDATIONS:
RISK FACTORS: For specific groups of individuals, clinicians should consider abnormal ankle dorsiflexion range of motion, abnormal subtalar joint range of motion, decreased ankle plantar flexion strength,increased foot pronation, and abnormal tendon structure as intrinsic risk factors associated with Achilles tendinopathy. Obesity, hypertension, hyperlipidemia, and diabetes are medical conditions associated with Achilles tendinopathy. Clinicians should also consider training errors, environmental factors, and faulty equipment as extrinsic risk factors associated with Achilles tendinopathy. (Recommendation based on moderate evidence).
DIAGNOSIS/CLASSIFICATION: Self-reported localized pain and perceived stiffness in the Achilles tendon following a period of inactivity (ie, sleep, prolonged sitting), lessens with an acute bout of activity and may increase after the activity. Symptoms are frequently accompanied with Achilles tendon tenderness, a positive arc sign, and positive findings on the Royal London Hospital test. These signs and symptoms are useful clinical findings for classifying a patient with ankle pain into the ICD category of Achilles bursitis or tendinitis and the associated ICF impairment-based category of Achilles pain (b28015 Pain in lower limb), stiffness (b7800 Sensation of muscle stiffness), and muscle power deficits (b7301 Power of muscles of lower limb). (Recommendation based on weak evidence).
DIFFERENTIAL DIAGNOSIS: Clinicians should consider diagnostic classifications other than Achilles tendinopathy when the patient's reported activity limitations or impairments of body function and structure are not consistent with those presented in the diagnosis/classification section of this guideline, or,when the patient's symptoms are not resolving with interventions aimed at normalization of the patient's impairments of body function. (Recommendation based on expert opinion).
EXAMINATION -- OUTCOME MEASURES: Clinicians should incorporate validated functional outcome measures, such as the Victorian Institute of Sport Assessment and the Foot and Ankle Ability Measure. These should be utilized before and after interventions intended to alleviate the impairments of body function and structure, activity limitations, and participation restrictions associated with Achilles tendinopathy. (Recommendation based on strong evidence).
EXAMINATION -- ACTIVITY LIMITATION AND PARTICIPATION RESTRICTION MEASURES: When evaluating functional limitations over an episode of care for those with Achilles tendinopathy, measures of activity limitation and participation restriction can include objective and reproducible assessment of the ability to walk, descend stairs, perform unilateral heel raises and single-limb hop, and participate in recreational activity. (Recommendation based on moderate evidence).
EXAMINATION -- PHYSICAL IMPAIRMENT MEASURES: When evaluating physical impairment over an episode of care for those with Achilles tendinopathy, one should consider measuring dorsiflexion range of motion, subtalar joint range of motion, plantar flexion strength and endurance, static arch height, forefoot alignment, and pain with palpation. (Recommendations based on moderate evidence).
INTERVENTIONS -- ECCENTRIC LOADING: Clinicians should consider implementing an eccentric loading program to decrease pain and improve function in patients with midportion Achilles tendinopathy. (Recommendation based on strong evidence).
INTERVENTIONS -- LOW-LEVEL LASER THERAPY: Clinicians should consider the use of low-level laser therapy to decrease pain and stiffness in patients with Achilles tendinopathy. (Recommendation based on moderate evidence).
INTERVENTIONS -- IONTOPHORESIS: Clinicians should consider the use of iontophoresis with dexamethasone to decrease pain and improve function in patients with Achilles tendinopathy. (Recommendation based on moderate evidence).
INTERVENTIONS -- STRETCHING: Stretching exercises can be used to reduce pain and improve function in patients who exhibit limited dorsiflexion range of motion with Achilles tendinopathy. (Recommendation based on weak evidence).
INTERVENTIONS -- FOOT ORTHOSES: A foot orthosis can be used to reduce pain and alter ankle and foot kinematics while running in patients with Achilles tendinopathy. (Recommendation based on weak evidence).
INTERVENTIONS -- MANUAL THERAPY: Soft tissue mobilization can be used to reduce pain and improve mobility and function in patients with Achilles tendinopathy. (Recommendation based on expert opinion).
INTERVENTIONS -- TAPING: Taping may be used in an attempt to decrease strain on the Achilles tendon in patients with Achilles tendinopathy. (Recommendation based on expert opinion).
INTERVENTIONS -- HEEL LIFT: Contradictory evidence exists for the use of heel lifts in patients with Achilles tendinopathy. (Recommendation based on conflicting evidence).
INTERVENTIONS -- NIGHT SPLINT: Night splints are not beneficial in reducing pain when compared to eccentric exercise for patients with Achilles tendinopathy. (Recommendation based on weak evidence). 

 Nelson B. Watts Robert A. Adler John P. Bilezikian Matthew T. Drake Richard EastellEric S. Orwoll Joel S. Finkelstein
The Journal of Clinical Endocrinology & Metabolism, Volume 97, Issue 6, 1 June 2012, Pages 1802–1822, https://doi.org/10.1210/jc.2011-3045
Published:
 
01 June 2012

Objective:
The aim was to formulate practice guidelines for management of osteoporosis in men.

Evidence:
We used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe the strength of recommendations and evidence quality.

Consensus Process:
Consensus was guided by systematic evidence reviews, one in-person meeting, and multiple conference calls and e-mails. Task Force drafts were reviewed successively by The Endocrine Society's Clinical Guidelines Subcommittee and Clinical Affairs Core Committee; representatives of ASBMR, ECTS, ESE, ISCD; and members at large. At each stage, the Task Force received written comments and incorporated needed changes. The reviewed document was approved by The Endocrine Society Council before submission for peer review.

Conclusions:
Osteoporosis in men causes significant morbidity and mortality. We recommend testing higher risk men [aged ≥70 and men aged 50–69 who have risk factors (e.g. low body weight, prior fracture as an adult, smoking, etc.)] using central dual-energy x-ray absorptiometry. Laboratory testing should be done to detect contributing causes. Adequate calcium and vitamin D and weight-bearing exercise should be encouraged; smoking and excessive alcohol should be avoided. Pharmacological treatment is recommended for men aged 50 or older who have had spine or hip fractures, those with T-scores of −2.5 or below, and men at high risk of fracture based on low bone mineral density and/or clinical risk factors. Treatment should be monitored with serial dual-energy x-ray absorptiometry testing.

Dagfinrud H, Kvien T K, Hagen K 
​
Cochrane Database of Systematic Reviews 2008;Issue 1
systematic review

BACKGROUND:
Ankylosing spondylitis (AS) is a chronic, inflammatory rheumatic disease. Physiotherapy is considered an important part of the overall management of AS.
OBJECTIVES:
To summarise the available scientific evidence on the effectiveness of physiotherapy interventions in the management of AS.
SEARCH STRATEGY:
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, AMED, CINAHL and PEDro up to January 2007 for all relevant publications, without any language restrictions. We checked the reference lists of relevant articles and contacted the authors of included articles.
SELECTION CRITERIA:
We included randomised and quasi-randomised studies with AS patients and where at least one of the comparison groups received physiotherapy. The main outcomes of interest were pain, stiffness, spinal mobility, physical function and patient global assessment.
DATA COLLECTION AND ANALYSIS:
Two reviewers independently selected trials for inclusion, extracted data and assessed trial quality. Investigators were contacted to obtain missing information.
MAIN RESULTS:
Eleven trials with a total of 763 participants were included in this updated review. Four trials compared individualised home exercise programs or a supervised exercise program with no intervention and reported low quality evidence for effects in spinal mobility (Relative percentage differences (RPDs) from 5 to 50%) and physical function (four points on a 33-point scale). Three trials compared supervised group physiotherapy with an individualised home-exercise program and reported moderate quality evidence for small differences in spinal mobility (RPDs 7.5-18%) and patient global assessment (1.46 cm) in favour of supervised group exercises. In one study, a three-week inpatient spa-exercise therapy followed by 37 weeks of weekly outpatient group physiotherapy (without spa) was compared with weekly outpatient group physiotherapy alone; there was moderate quality evidence for effects in pain (18%), physical function (24%) and patient global assessment (27%) in favour of the combined spa-exercise therapy. One study compared daily outpatient balneotherapy and an exercise program with only exercise program, and another study compared balneotherapy with fresh water therapy. None of these studies showed significant between-group differences. One study compared an experimental exercise program with a conventional program; statistically significant change scores were reported on nearly all spinal mobility measures and physical function in favour of the experimental program.
AUTHORS' CONCLUSIONS:
The results of this review suggest that an individual home-based or supervised exercise program is better than no intervention; that supervised group physiotherapy is better than home exercises; and that combined inpatient spa-exercise therapy followed by group physiotherapy is better than group physiotherapy alone. 

Reid SA, Rivett DA, Katekar MG, Callister R
Manual Therapy 2008 Aug;13(4):357-366

clinical trial
9/10 [Eligibility criteria: Yes; Random allocation: Yes; Concealed allocation: Yes; Baseline comparability: Yes; Blind subjects: Yes; Blind therapists: No; Blind assessors: Yes; Adequate follow-up: Yes; Intention-to-treat analysis: Yes; Between-group comparisons: Yes; Point estimates and variability: Yes. Note: Eligibility criteria item does not contribute to total score] *This score has been confirmed*
​
Cervicogenic dizziness is dizziness described as imbalance occurring together with cervical pain or headache. This study aimed to determine the efficacy of sustained natural apophyseal glides (SNAGs) in the treatment of this condition. A double-blind randomised controlled clinical trial was undertaken. Thirty-four participants with cervicogenic dizziness were randomised to receive four to six treatments of SNAGs (n = 17) or a placebo of detuned laser (n = 17). Participants were assessed by a blinded assistant before treatment, after the final treatment and at 6- and 12-week follow-ups. The primary outcome measures were severity of dizziness, disability, frequency of dizziness, severity of cervical pain, and global perceived effect; balance and cervical range of motion were secondary measures. At post-treatment, 6- and 12-week follow-ups compared to pre-treatment, the SNAG group had less (p < 0.05) dizziness, lower (p < 0.05) scores on the Dizziness Handicap Inventory (DHI), decreased (p < 0.05) frequency of dizziness, and less (p < 0.05) cervical pain. The placebo group had significant (p < 0.05) changes only at the 12-week follow-up in three outcome measures: severity of dizziness, DHI, and severity of cervical pain. Compared to the placebo group at post-treatment and 6-week follow-up, the SNAG group had less (p < 0.05) dizziness, lower (p <= 0.05) scores on DHI, and less (p < 0.05) cervical pain. Balance with the neck in extension improved (p <= 0.05) and extension range of motion increased (p < 0.05) in the SNAG group. No improvements in balance or range of motion were observed in the placebo group. The SNAG treatment had an immediate clinically and statistically significant sustained effect in reducing dizziness, cervical pain and disability caused by cervical dysfunction. 

Bussieres AE, Stewart G, al-Zoubi F, Decina P, Descarreaux M, Hayden J, Hendrickson B, Hincapie C, Page I, Passmore S, Srbely J, Stupar M, Weisberg J, Ornelas J [The Canadian Chiropractic Guideline Initiative]
Journal of Manipulative and Physiological Therapeutics 2016 Oct;39(8):523-564
practice guideline
OBJECTIVE:
The objective was to develop a clinical practice guideline on the management of neck pain-associated disorders (NADs) and whiplash-associated disorders (WADs). This guideline replaces 2 prior chiropractic guidelines on NADs and WADs.
METHODS:
Pertinent systematic reviews on 6 topic areas (education, multimodal care, exercise, work disability, manual therapy, passive modalities) were assessed using A Measurement Tool to Assess Systematic Reviews (AMSTAR) and data extracted from admissible randomized controlled trials. We incorporated risk of bias scores in the Grading of Recommendations Assessment, Development, and Evaluation. Evidence profiles were used to summarize judgments of the evidence quality, detail relative and absolute effects, and link recommendations to the supporting evidence. The guideline panel considered the balance of desirable and undesirable consequences. Consensus was achieved using a modified Delphi. The guideline was peer reviewed by a 10-member multidisciplinary (medical and chiropractic) external committee.
RESULTS:
For recent-onset (0 to 3 months) neck pain, we suggest offering multimodal care; manipulation or mobilization; range-of-motion home exercise, or multimodal manual therapy (for grades I to II NAD); supervised graded strengthening exercise (grade III NAD); and multimodal care (grade III WAD). For persistent (> 3 months) neck pain, we suggest offering multimodal care or stress self-management; manipulation with soft tissue therapy; high-dose massage; supervised group exercise; supervised yoga; supervised strengthening exercises or home exercises (grades I to II NAD); multimodal care or practitioner's advice (grades I to III NAD); and supervised exercise with advice or advice alone (grades I to II WAD). For workers with persistent neck and shoulder pain, evidence supports mixed supervised and unsupervised high-intensity strength training or advice alone (grades I to III NAD).
CONCLUSIONS:
A multimodal approach including manual therapy, self-management advice, and exercise is an effective treatment strategy for both recent-onset and persistent neck pain. 
Reprinted from the Journal of Manipulative and Physiological Therapeutics with copyright permission from the National University of Health Sciences.

Anwer S, Alghadir A, Abu Shaphe M, Anwar D

BioMed Research International 2015;(123848):Epub

systematic review

OBJECTIVES:
This systematic review was conducted to examine the effects of exercise on spinal deformities and quality of life in patients with adolescent idiopathic scoliosis (AIS).
DATA SOURCES:
Electronic databases, including PubMed, CINAHL, Embase, Scopus, Cochrane Register of Controlled Trials, PEDro, and Web of Science, were searched for research articles published from the earliest available dates up to May 31, 2015, using the key words "exercise", "postural correction", "posture", "postural curve", "Cobb's angle", "quality of life", and "spinal deformities", combined with the Medical Subject Heading "scoliosis".
STUDY SELECTION:
This systematic review was restricted to randomized and nonrandomized controlled trials on AIS published in English language. The quality of selected studies was assessed by the PEDro scale, the Cochrane Collaboration's tool, and the Grading of Recommendations Assessment, Development, and Evaluation System (GRADE). DATA EXTRACTION: Descriptive data were collected from each study. The outcome measures of interest were Cobb angle, trunk rotation, thoracic kyphosis, lumbar kyphosis, vertebral rotation, and quality of life.
DATA SYNTHESIS:
A total of 30 studies were assessed for eligibility. Six of the 9 selected studies reached high methodological quality on the PEDro scale. Meta-analysis revealed moderate-quality evidence that exercise interventions reduce the Cobb angle, angle of trunk rotation, thoracic kyphosis, and lumbar lordosis and low-quality evidence that exercise interventions reduce average lateral deviation. Meta-analysis revealed moderate-quality evidence that exercise interventions improve the quality of life.
CONCLUSIONS:
A supervised exercise program was superior to controls in reducing spinal deformities and improving the quality of life in patients with AIS. 

Otadi K, Hadian M-R, Olyaei G, Jalaie S
Journal of Back and Musculoskeletal Rehabilitation 2012;25(1):13-19
clinical trial
8/10 [Eligibility criteria: Yes; Random allocation: Yes; Concealed allocation: Yes; Baseline comparability: Yes; Blind subjects: Yes; Blind therapists: No; Blind assessors: Yes; Adequate follow-up: Yes; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates and variability: Yes. Note: Eligibility criteria item does not contribute to total score] *This score has been confirmed*
OBJECTIVES: A randomized, double-blind, clinical trial study was conducted with the aim of determining the efficacy of adding laser (830 nm) to ultrasound (US) and exercise for the management of shoulder tendonitis.
METHODS: 42 subjects (n = 21, in adding laser group and n = 21, in US and exercise group) received a course of 10 sessions treatment over one month in the shoulder region. Outcome measures such as visual analogue scale (VAS), tenderness severity scale (TSS), Constant Murley Score (CMS) and manual muscle testing (MMT) were performed before treatment and at the end of 4 weeks treatment. In addition, follow up were performed 2 months after the end of treatment based on the degree of pain improvement.
RESULTS: VAS, TSS and CMS improved significantly (p = 0.001) in both groups, however the muscle strengths only improved significantly in adding laser group (p < 0.01).
CONCLUSION: It seems that both protocols of physical therapy interventions were effective in relieving the signs and symptoms of shoulder tendonitis. Furthermore, adding low level laser therapy (LLLT) to the US and exercise was more efficient in improving the muscle strength in patients with shoulder tendonitis over a period of three months. However, it should be emphasized that, the current results might be due to the effects of laser and exercise instead of laser, us and exercise (as we had no independent group for US).