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strate that the control and intervention sites are notcomparable with respect to the methodologicalcriteria specified by Cochrane EPOC group. Thecombined effect of these factors resulted in the com-parability between intervention and control groupsbeing very weak. For example, there were differencesin the services provided in the intervention andcontrol arms, due possibly to differences in dominantremuneration systems, nature of the rehabilitationtransformation, patient characteristics, skill mix andacademic status of the care environment.

Contact address

Derek Ward, Clinical Research Fellow, Portsmouth Institute of Medicine, Health and Social Care,University of Portsmouth, St Georges Building, 141 High Street, Portsmouth, Hampshire, PO1 2HY.

Telephone 023 92 845245 Fax 023 92 845200 E-mail derek.ward@port.ac.uk

Background The prevalence of shoulder disordershas been reported to range from seven to 36% of thepopulation accounting for 1.2% of all generalpractitioner encounters in Australia. Substantialdisability and significant morbidity can result fromshoulder disorders. While many treatments have beenemployed in the treatment of shoulder disorders, fewhave been proven in randomised controlled trials.Physiotherapy is often the first line of managementfor shoulder pain and to date its efficacy has not beenestablished. This review is one in a series looking atvarying interventions for shoulder disorders, updatedfrom an earlier Cochrane review of all interventionsfor shoulder disorder.

Objectives To determine the efficacy of physio-therapy for disorders resulting in pain, stiffnessand/or disability of the shoulder.

Search strategy Medline, Embase, the CochraneClinical Trials Register and Cinahl were searched1966 to June 2002. The Cochrane MusculoskeletalReview Group's search strategy was used and keywords gained from previous reviews and all relevantarticles were used as text terms in the search.

Selection criteria Each identified study was assessedfor possible inclusion by two independent reviewers.The determinants for inclusion were that the trial beof an intervention generally delivered by a physio-therapist, that treatment allocation was randomised;and that the study population be suffering from ashoulder disorder, excluding trauma and systemicinflammatory diseases such as rheumatoid arthritis.

Data collection and analysis The methodologicalquality of the included trials was assessed by

two independent reviewers according to a list ofpredetermined criteria, which were based on thePEDro scale specifically designed for the assessmentof validity of trials of physiotherapy interventions.Outcome data were extracted and entered intoRevman 4.1. Means and standard deviations forcontinuous outcomes and number of events forbinary outcomes were extracted where available fromthe published reports. All standard errors of themean were converted to standard deviations. Fortrials where the required data were not reported ornot able to be calculated, further details wererequested from first authors. If no further detailswere provided, the trial was included in the reviewand fully described, but not included in the meta-analysis. Results were presented for each diagnosticsub-group (rotator cuff disease, adhesive capsulitis,etc) and where possible combined in meta-analysis togive a treatment effect across all trials.

Main results Twenty-six trials met the inclusioncriteria. Methodological quality was variable and trialpopulations were generally small (median sample size= 48, range 14 to 180). Exercise was demonstrated tobe effective in terms of short-term recovery in rotatorcuff disease (relative risk 7.74 (1.97, 30.32)), andlonger-term benefit with respect to function (relativerisk 2.45 (1.24, 4.86)). Combining mobilisation with exercise resulted in additional benefit whencompared to exercise alone for rotator cuff disease.Laser therapy was demonstrated to be more effectivethan placebo (relative risk 3.71 (1.89, 7.28)) foradhesive capsulitis but not for rotator cuff tendinitis.Both ultrasound and pulsed electromagnetic fieldtherapy resulted in improvement compared toplacebo in pain in calcific tendinitis (relative risk 1.81(1.26, 2.60) and relative risk 19 (1.16, 12.43)respectively). There is no evidence of the effect ofultrasound in shoulder pain (mixed diagnosis),adhesive capsulitis or rotator cuff tendinitis. Whencompared to exercises, ultrasound is of no additional

S Green, R Buchbinder, S Hetrick

Green, S, Buchbinder, R and Hetrick S (2003).'Physiotherapy interventions for shoulder pain', TheCochrane Library, 2, Update Software, Oxford.

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benefit over and above exercise alone. There is someevidence that for rotator cuff disease, corticosteroidinjections are superior to physiotherapy and noevidence that physiotherapy alone is of benefit foradhesive capsulitis.

Reviewers’ conclusions The small sample sizes,variable methodological quality and heterogeneity interms of population studied, physiotherapy employedand length of follow-up of randomised controlledtrials of physiotherapy interventions results in littleoverall evidence to guide treatment.

There is evidence to support the use of some inter-ventions in specific and circumscribed cases.

There is a need for trials of physiotherapy forspecific clinical conditions associated with shoulder

pain, for shoulder pain where combinations ofphysiotherapy interventions, and physiotherapy as anadjunct to non-physiotherapy interventions arecompared. This is more reflective of current clinicalpractice. Trials should be adequately powered andaddress key methodological criteria such as allocationconcealment and blinding of outcome assessor.

Contact address

Associate Professor Sally Green, Director, Australasian Cochrane Centre, Monash University,Australasian Cochrane Centre, Locked Bag 29, Clayton 3168, Victoria, Australia.

Telephone +61 3 9594 7531 Fax +61 3 9594 7554E-mail sally.green@med.monash.edu.au

A Pollock, G Baer, V Pomeroy, P Langhorne

Physiotherapy treatment approaches for the recovery ofpostural control and lower limb function following stroke

Background There are a number of different app-roaches to physiotherapy following stroke. Central tothese are approaches based on neurophysiological,motor learning and orthopaedic principles.

Objectives To determine whether there is a differ-ence in the recovery of postural control and lowerlimb function in patients with stroke if physiotherapyis based on orthopaedic or neurophysiological ormotor learning principles, or on a mixture of these.

Search strategy This review drew on the searchstrategy developed by the Stroke Group as a whole.Relevant trials were identified in the Stroke GroupTrials Register of Controlled Trials which was lastsearched in May 2001. We also searched theCochrane Controlled Trials Register (CochraneLibrary, 4, 1999), Medline (1966-1999), Embase(1980-1999) and Cinahl (1982-1999) and contactedexperts and researchers with an interest in stroke.

Selection criteria Studies – randomised or quasi-randomised controlled trials. Participants – adultswith a clinical diagnosis of stroke. Interventions –physiotherapy treatment approaches aimed atpromoting the recovery of postural control and lowerlimb function. Outcomes – measures of disability,motor impairment or participation.

Data collection and analysis Two independentreviewers categorised the identified trials according tothe inclusion/exclusion criteria, documented themethodological quality and extracted the data.

Main results Eleven trials were included in thereview, three of which were included in two com-parisons. Four trials compared a neurophysiolog-ical approach with another approach; four trialscompared a motor learning approach with anotherapproach; four studies compared a mixed approachwith another approach, two trials reported compar-isons of sub-groups of the same approach. A largenumber of heterogeneous outcome measures wereused, limiting the comparison of trial results. No onetype of approach had a significantly better outcomethan any other.

Reviewers' conclusions There is not enoughevidence to conclude that any one physiotherapyapproach is more effective than another in prom-oting the recovery of postural control or lower limbfunction.

Contact addressDr Alex Pollock, Research Therapist, Stroke Therapy Evaluation Programme, Academic Department of Geriatric Medicine, University of Glasgow, Level 3, Centre Block, Glasgow Royal Infirmary, Glasgow G4 OSF.

Telephone 0141 211 4953 Fax 0141 211 4944 E-mail pollock@middleton4.freeserve.co.uk

Pollock, A, Baer, G, Pomeroy, V and Langhorne, P (2003).'Physiotherapy treatment approaches for the recovery ofpostural control and lower limb function following stroke',The Cochrane Library, 2, Update Software, Oxford.