Comparative effectiveness of physical therapy interventions in adults with rotator cuff tendinopathy: a systematic review and network meta-analysis

Objective: To compare the effects of different physical therapy interventions and identify the most effective intervention on pain, function, quality of life (QoL) and adverse events (AEs) in adults with rotator cuff (RC) tendinopathy. Design: Systematic review and network meta-analysis (NMA) of randomised clinical trials (RCTs). Data sources: Seven databases and two trial registries were searched up to March 2024. Eligibility criteria for selecting studies: RCTs comparing physical therapy interventions to any other physical therapy intervention, sham, placebo, waiting list or no treatment on pain, function, QoL and AEs in adults with RC tendinopathy. Data synthesis: A frequentist NMA using a random-effects model was performed. Risk of bias and certainty of the evidence were assessed using the revised Cochrane risk-of-bias tool and the Grading of Recommendations, Assessment, Development and Evaluation approach, respectively. Results: 89 RCTs (5532 participants) were included. Exercises targeting the shoulder muscles may reduce pain (standardised mean difference (SMD) −0.79, 95% CI −1.33 to −0.26) and improve function (SMD 0.74, 95% CI 0.34 to 1.14) compared with no treatment but the evidence is very uncertain. Exercises targeting shoulder and scapular muscles in addition to percutaneous electrolysis (SMD −1.58, 95% CI −2.68 to −0.48) and to trigger point dry needling (SMD 3.10, 95% CI 1.99 to 4.22) seem to be the most effective interventions on pain and function at the end of treatment, respectively. Conclusion: Most of the interventions identified may not be superior to isolated shoulder exercises alone, which might be considered a reasonable first-line approach, but the evidence is very uncertain and most interventions are informed by limited data. High-quality research is needed to improve evidence of physical therapy interventions in adults with RC tendinopathy.