1. CDR Damien Avery PT, DPT, OCS

2. * Specificity of exercise including eccentric training has value for preventing surgical intervention in patients with a median duration of symptoms of 24 months (range 6-120 months) with a NNT of 3 (95%CI = 2 to 5). * Citation: Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomized controlled study. Holmgren, T. et. al. BMJ. 2012;344e787 doi

3. * Will a 43yo male with rotator cuff tendinopathy benefit from eccentric training? * Search Terms: Clinical Queries: Eccentric AND Rotator Cuff

4. * Participant and single assessor blinded, concealed, randomized controlled trial without intention-to-treat.

5. * Specific Exercise Group: 14 women/37men; age:52(SD:9); Duration of pain 24 months (6-120); Heavy Load occupation: 22 (43%); Light load: 29(57%); on sick-leave: 9(18%); RC: 33(65%)intact; 15(29%) partial tear; 3(6%) full thickness. * Non-specfic Exercise Group: 22 Women/24 men; age 52 (SD:8); Duration of pain: 12 months (6-156); Heavy Load occupation: 21 (46%); Light load 25(55%). RC: 34(74%)intact; 6(13%)partial tear; 6(13%) full thickness

6. * Non-specific exercise: (N = 46; 46 analyzed): Six unspecific movement exercises for neck and shoulder without external load (Shldr Horiz ABD; shldr elev; shldr retraction; upper-trap stretch and pec-major stretch). Completed 10 reps twice daily, and stretches 3 times/twice daily.

7. * (N = 51; 51 analyzed): Six different exercises (2 eccentric; 3 ecc/con; posterior shoulder stretch); 15 reps x 3 sets twice daily, and stretch 30-60 seconds 3x twice daily for eight weeks, and then once daily 8-12 weeks with resistance in pain monitoring model

8. Outcome Time to Outcome CEREERRRRARRNNT Surgery 12 Weeks0.5920.19667%0.3963 95% Confidence Intervals:37% to 97%0.220 to 0.5722 to 5 Measure Control GroupExperimental Group Difference95% CI MeanSDMeanSD DASH64143-8 -12.841 to - 3.159 Constant- Murley Score 94244.5158.5 to 20.6

9. * Patients were selected thru concealed randomization * Patients had similar prognostic factors with exception that the Specific Exercise group had a greater median duration of pain symptoms (24 months) than did the control group (12 months) * Patients and assessing clinician were blinded to group allocation, treating clinician was not.

10. * Study retention was good: lost total of 5 patients * ITT analysis not completed * Each group lost one patient 2/2 frozen shoulder * Control group lost 3 patients at beginning of study * NNT was able to be completed with ITT by this reviewer * Manual treatment (stretching post. Capsule & pec minor) completed “when necessary” * Follow-up period was only 12 weeks

11. * Event Defined as: opting for surgery by 12 weeks * Non-specific Exercise Group: 29/49 * Specific Exercise Group: 10/51 * NNT: 3 (95%CI: 2-5) * Dash: 8 (95%CI: 2.3 to 13.7) MCID: 13 * Constant-Murley Shoulder Score: 15 (95%CI: 8.5 to 20.6) MCID: assumed at 15%

12. * Patient’s ages ranged from 30-65 * Diagnosed with subacromial impingement * On waiting list for subacromial decompression * Similar to my patient population * Treatments are low cost, low risk justify use * Limited generalizability for sustained improvement over time