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Management of the Unilateral Shoulder Impingement Syndrome

IN RESPONSE: We thank Dr. Leib for his interest in our study and the list of factors that he feels may confound the direct comparison of the 2 treatments for the SIS: corticosteroid injection and MPT. We appreciate the opportunity to address each of these comments. First, as stated in our article, 1 limitation is the lack of consensus on diagnostic criteria for this condition. To study a homogeneous group of patients, we enrolled those with similar presentations and functional limitationsthus, the inclusion criteria. What Dr. Leib suggests for evaluation is exactly what was done. As part of the assessment during treatment, the treating physical therapists certainly addressed all of the factors that Dr. Leib mentioned (for example, stiffness and irritability to pressure). The assessment was not a pathoanatomical-directed evaluation or -intervention but rather an impairment-based model predicated on the previously stated criteria. Second, we agree that patient exposure is typically greater with a physical therapist based on the nature of the interactions. Third, we also agree that the goal of health care providers in general should be to get patients to a place of effective self-management. We imagine that this is true whether the issue is a musculoskeletal symptom or long-term management of diabetes or chronic obstructive pulmonary disease. Finally, we do not refute the potential synergistic value of these interventions. We do not disagree with any of Dr. Leib's statements. However, when evaluating the question driving this study, we do not feel that these factors complicate the comparison. Our goal with this pragmatic trial was to compare 2 intervention approaches for the management of SIS, not how 2 types of medical providers would approach the management of the same patient. The difference may seem subtle but is important in our minds. To answer our question, we needed to replicate usual practice as much as possible. Thorpe and colleagues (1) describe 10 domains to help evaluate the pragmatic nature of a trial. When establishing the comparison treatment, pragmatic trials should use usual practice, or the best alternative management strategy. Treweek and Zwarenstein (2) argue that clinical trials should be designed to produce results that are more widely applicable. We chose these 2 treatments because they represent 2 common options that patients are provided in usual practice.