Effectiveness of Combined Program of Manual Therapy and Exercise Vs Exercise Only in Patients With Rotator Cuff-related Shoulder Pain: A Systematic Review and Meta-analysis

Context: Therapeutic exercise is considered the mainstay in the management of rotator cuff-related shoulder pain (RCRSP). Manual therapy (MT) interventions have also shown to be effective in RCRSP. However, the benefits of adding MT along with exercise interventions for the management of RCRSP remain unknown. Objective: To evaluate the additional benefits of MT with exercise compared with exercise in isolation for the management of RCRSP. Data Sources: A search of PubMed, Scopus, PEDro, and EBSCO from the inception date of each database through April 20, 2022, was conducted for randomized trials comparing the additional effects of MT in exercise interventions compared with exercise alone for pain management and function in patients with RCRSP. Standardized mean differences (SMDs) and 95% CIs were calculated using a random-effects inverse variance model according to the outcome of interest and comparison group. Methodological quality was assessed with PEDro and quality of evidence with the grading of recommendations assessment, development and evaluation approach. Study Design: Meta-analysis of randomized controlled trials. Results: Twelve articles were found eligible and 8 of them demonstrated high methodological quality. Eleven articles were included for quantitative analysis. Pain with movement was not significantly different between MT and exercise versus exercise alone (SMD [95% CI] = -0.15 [-0.41 to 0.12]; I-2 = 0%), whereas pain at rest was significantly improved in the groups that used exercise only with a moderate effect size (SMD [95% CI] = 0.47 [0.04 to 0.89]; I-2 = 75%). Furthermore, shoulder function was not significantly different between MT and exercise versus exercise alone in the short term (SMD [95% CI] = 0.23 [-0.22 to 0.69]; I-2 = 88%) or the long term (SMD [95% CI] = -0.02 [-0.21 to 0.16]; I-2 = 2%). Conclusion: Adding MT to exercise interventions for the management of RCRSP is not more effective than exercise alone for pain and function in adult patients.