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Physiotherapy or corticosteroid injection for shoulder pain?
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  1. D A W M van der Windt,
  2. L M Bouter

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    The choice is not clear cut and patients’ expectations and preferences may affect the outcome

    In this issue Hay et al1 report the results of a randomised clinical trial evaluating the effectiveness of physiotherapy and corticosteroid injection for patients with unilateral shoulder pain. Shoulder pain is a common complaint; estimates of the annual incidence in general practice vary from 6.6 to 25 cases per 1000 patients.2–4 Most patients are treated in primary care. If treatment with analgesics or non-steroidal anti-inflammatory drugs (NSAIDs) is not successful, patients with persistent symptoms are often referred for physiotherapy or treated with local infiltration of a corticosteroid.4 Until recently, evidence on the effectiveness of these interventions was scarce, particularly for primary care patients. Over the past few years two randomised trials have been published that directly compared the effects of physiotherapy with corticosteroid injections.5,6 Both trials were carried out in Dutch general practice.

    The trial by Hay et al adds important and relevant information to this existing evidence. The trial is characterised by a thorough design, enrolled a relatively large number of patients, used relevant outcome measures, and achieved a nearly complete six months’ follow up of participants. When examining the results of these three primary care trials, three issues arise for discussion. Firstly, the short term findings are rather different, with the Dutch trials clearly showing better effects of corticosteroid injections, whereas the English trial reports similar outcomes for the two interventions. Secondly, all three trials show minor and non-significant differences at long term follow up.1,6,7 Thirdly, the somewhat ambiguous overall evidence may leave substantial room for considering patient preferences and expectations when applying the results in clinical practice.

    Inconsistent short term results: differences in study group, content of treatment, or outcome measures?

    Figure 1a shows the self reported change of symptoms at 5–7 weeks of follow up for …

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