All three pain provocation tests proved to be of potential value in assessing chronic PHT in athletes. However, we recommend that they be used in conjunction with other objective measures, such as MRI.

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We have read with interest the paper by Itz et al., 1 focusing on a major issue for pain physicians involved in daily clinical practice. In their work, different Dutch scientific societies collaborated to make a declaration of intents and aims, taking into account diagnostic workup and therapeutic approaches adopted by healthcare professionals with different skills and knowledge in the pain field, leading to the development of shared guidelines for the invasive treatment of pain syndromes of the lumbosacral spine.Although the International Association for the Study of Pain already stated the importance of a multidisciplinary approach to pain disorders, 2 the common picture often shows the presence of uncoordinated clinicians from different medical disciplines. Several previous pain treatment guidelines hampered the agreement on a collaborative and shared approach, supported by health professionals with different background and scientific terminology. Pain physicians, physical therapists, neurologists, surgeons, and psychologists are actually still working apart, speaking their own languages, making their own diagnosis and treatment choices.This independent approach shows several pitfalls, especially if applied to pain of the spine, whose pathophysiology may involve mechanical, neurological as well as psychosocial factors, therefore requiring heterogeneous expertise in the pain management.3 Moreover, most of scientific literature is simply prone to compare physical therapy and psychosocial approach vs. surgery. 4 Progress in minimally invasive interventional and surgical techniques is encouraging, leading us to reconsider the term "multidisciplinarity" in its true meaning. 5 A shared approach to pain disorders should include common strategies for diagnosis and treatment. In this regard, we consider the scientific agreement between Dutch orthopedics, neurosurgeons, and anesthesiologists a significant step forward. To improve the chance of reaching the correct diagnosis and treatment, we recently promoted the development of a "Multidisciplinary Spine Center," where physicians expert in different specialties are encouraged to provide their knowledge toward this main goal. Clinical cases may be discussed within this pain community, exploiting the ability of each specialist and leading to improved results and better patient satisfaction. We used IASP and scientific society guidelines as a starting point for a diagnostic and therapeutic flow chart, taking into account expertise from pain medicine, neurophysiology, surgery, physical therapy, and psychology (Figure 1). The categorization of each patient's syndrome as acute, subacute, or chronic is not only related to temporal factors, but also to pathophysiological criteria. Moreover, the mutual relationship between specialists plays an extremely important role during the first approach as well as during the follow-up. Clinical guidelines should help physicians in characterizing pain syndromes, leading toward the correct treatment in agreement with pathophysiology, signs...

Context: The use of therapeutic exercise and manual therapy in rehabilitation of the unstable and conflicting shoulder (UCS) is widespread. In the literature, there are several electromyographical studies that have analysed the effect of specific physical exercises and clinical trials on the effectiveness of specific rehabilitative protocols. However, it has not been established yet what is the best intervention for these disorders. Objective: In order to establish general recommendations for the treatment of UCS, we have reviewed the results of some electromyographical studies to identify the best exercises to recruit specifically the shoulder girdle muscles and some clinical trials that have proposed the utilisation of therapeutic exercise and manual therapy for UCS. Methods: Review of the literature of the last 10 years. We have searched Pedro, Medline and the Cochrane Library for randomised clinical trials, systematic reviews and electromyographical studies on rehabilitative protocols based on therapeutic exercise and manual therapy. Outcomes: It is common practice for clinicians to consider the involvement of patients with shoulder instability or impingement in a programme of exercises, before proceeding to a surgical intervention. Our analysis of the literature provides evidence of the efficacy of manual therapy associated with therapeutic exercises for decrease in pain, recovery of patient's strength and restoration of abilities. Conclusions: While the analysed studies are inconclusive, on the basis of the available data, we suggest some general rehabilitative principles for the treatment of the unstable and conflicting shoulder.