This review concluded that exercise had statistically and clinically significant effects on pain reduction and improved function, but not on range of motion or strength. This review's lack of reporting, particularly of primary studies, made it difficult to interpret results and raised concerns about the reliability of conclusions and the appropriateness of developing a rehabilitation protocol.

To evaluate the role of exercise in treating rotator cuff impingement and to synthesise a standard evidence-based rehabilitation protocol.

PubMed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, American College of Physicians Journal Club and DARE were searched. The references of retrieved articles were searched for additional studies and search terms were reported.

Randomised controlled trials (RCTs) that compared physical therapy with other treatments or placebo in patients with rotator cuff impingement were eligible for inclusion. Studies were required to use outcome measures of pain, function or disability measured with validated assessment tools. To be included, patients required a diagnosis of impingement syndrome defined by the criteria of Neer or Hawkins or both.

Interventions included standard exercises, subacromial decompression, physiotherapy treatments and home exercise programs. Interventions were compared to other interventions or to placebo. In most trials, diagnosis of impingement was made by physical exam for impingement signs with or without an impingement test. Symptom duration ranged from approximately four months to four years. The average age of patients ranged from 42 to 58 years.

The author stated neither how the papers were selected for review nor how many reviewers performed the selection.

Methodological quality was assessed using a checklist by Spindler et al (2005) where randomisation and blinding were assessed. Follow up was also assessed, as was the use of an independent examiner. The author did not report how many reviewers assessed validity.

The author did not state how many reviewers performed the data extraction. Clinical significance was defined as statistical significance of p<0.05 and effect size or difference between treatments of 20% or more.

The studies were combined using a narrative synthesis supported by tables.

Ten RCTs (n=592) were included. The number of participants ranged from 14 to 125. Follow up ranged from three weeks to four years. Five of the 10 studies reported the method of randomisation and three reported blinding. Effect sizes and p-values were not reported for all included studies.

Supervised exercise, home exercise programs, exercise associated with manual therapy and exercise after subacromial decompressions showed improvement in pain in all but one study. Five of the six studies that reported statistical analyses showed significant reductions in pain. Four trials assessed strength, which was not shown to improve significantly for exercise alone (three trials) but improved when exercise was combined with manual therapy (one trial). Eight trials assessed function, which improved with exercise in most studies.

Manual therapy was shown to significantly improve pain relief in three trials, two of which were considered clinically significant. One study evaluated bracing without exercise and showed significant improvement, both statistically and clinically in strength, but showed no difference in pain compared to exercise groups. Acromioplasty plus exercise was compared to exercise alone in five trials that all showed no difference.

Exercise had statistically and clinically significant effects on pain reduction and improving function, but no effect on range of motion or strength.

This review addressed a clear question supported by appropriate inclusion criteria. Relevant medical databases were searched and search terms were reported. It appeared that no attempts were made to identify unpublished studies and it was unclear whether language limitations were applied. The risk that some relevant studies were not included and of publication and language biases was, therefore, unclear. It was unclear whether steps to reduce reviewer bias and error were undertaken for study selection, data extraction or validity.

The decision to present included studies narratively and not to pool studies in a meta-analysis was appropriate given the heterogeneity between studies. It was unclear whether the significance tests for individual studies were poorly reported or not done at all. The author appeared to calculate intra-group and between-group differences to derive the results. Intra-group differences appeared straightforward, but there were a number of units missing in the table, which made interpretation difficult. Between-group differences were less clear and there was insufficient explanation for how these were calculated. Again, in many cases there were no units were associated with the differences. The author distinguished between statistical and clinical significance, but the finding of clinical significance was said to be when statistical significance occured and the magnitude of difference was 20% or more; without further information on the meaning of magnitude of difference, the results were difficult to interpret.

Limited data available for analysis from the primary studies, small study sizes and poor reporting of key aspects, including statistical significance, raised concerns about the reliability of the authors' conclusions and the appropriateness of developing a rehabilitation protocol.

Practice: The author made several statements about practice and provided an exercise protocol for impingement syndrome.

Research: The author stated that the exercise protocol could serve as a gold standard to reduce variables in future cohort and comparative studies in patients with impingement syndrome.

Arthrex Corporation (unrestricted grant).

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.