Despite identifying 60 eligible trials, only one trial compared a combination of manual therapy and exercise reflective of common current practice to placebo. We judged it to be of high quality and found no clinically important differences between groups in any outcome. Effects of manual therapy and exercise may be similar to those of glucocorticoid injection and arthroscopic subacromial decompression, but this is based on low quality evidence. Adverse events associated with manual therapy and exercise are relatively more frequent than placebo but mild in nature. Novel combinations of manual therapy and exercise should be compared with a realistic placebo in future trials. Further trials of manual therapy alone or exercise alone for rotator cuff disease should be based upon a strong rationale and consideration of whether or not they would alter the conclusions of this review.

Based on low quality evidence, therapeutic ultrasound may have short-term benefits over placebo in people with calcific tendinitis, and LLLT may have short-term benefits over placebo in people with rotator cuff disease. Further high quality placebo-controlled trials are needed to confirm these results. In contrast, based on low quality evidence, PEMF may not provide clinically relevant benefits over placebo, and therapeutic ultrasound, LLLT and PEMF may not provide additional benefits when combined with other physical therapy interventions. We are uncertain whether TENS is superior to placebo, and whether any electrotherapy modality provides benefits over other active interventions (e.g. glucocorticoid injection) because of the very low quality of the evidence. Practitioners should communicate the uncertainty of these effects and consider other approaches or combinations of treatment. Further trials of electrotherapy modalities for rotator cuff disease should be based upon a strong rationale and consideration of whether or not they would alter the conclusions of this review.

BackgroundInitial management of rotator cuff disease often includes manual therapy and exercise, usually delivered together as components of a physical therapy intervention. To best inform current practice, an up-to-date review which incorporates the most recently available evidence is needed.ObjectivesTo systematically identify and synthesise the available evidence regarding the benefits and harms of manual therapy and exercise, alone or in combination, for the treatment of rotator cuff disease.MethodsWe included randomised controlled trials, including adults with rotator cuff disease, and comparing any manual therapy or exercise intervention with placebo, no intervention, a different type of manual therapy or exercise or any other intervention. Interventions included mobilisation, manipulation and supervised or home exercises, delivered alone or in combination. Trials investigating the primary or add-on effect of manual therapy plus exercise were the main comparisons of interest. Main outcomes of interest were overall pain, function, pain on motion, patient-reported global assessment of treatment success, quality of life and the number of participants experiencing adverse events.We searched CENTRAL, MEDLINE, EMBASE, CINAHL Plus, ClinicalTrials.gov and the WHO ICTRP clinical trials registries up to March 2015, unrestricted by language. Two review authors independently selected trials for inclusion, extracted data, performed risk of bias assessment and assessed the quality of the body of evidence for the main outcomes using the GRADE approach.ResultsWe included 60 trials (3620 participants). Only one trial compared manual therapy plus exercise with placebo (inactive ultrasound therapy) (120 participants; high quality evidence). At 22 weeks, there were no between-group differences in mean change in overall pain (placebo: 17.3 points on a 100-point scale; manual therapy plus exercise: 24.1 points; adjusted mean difference (MD) 6.8 points, 95% CI -0.7 to 14.3 points) and similar findings for function, pain on motion, treatment success and quality of life. More participants reported adverse events with manual therapy plus exercise (17/55, 31%) versus placebo (5/61, 8%): RR 3.77 (95% CI 1.49 to 9.54)) but these were mild and short-lived (short-term pain following treatment).Five trials (low quality evidence) found no important differences between manual therapy plus exercise compared with glucocorticoid injection and one trial (low quality evidence) showed no important differences between manual therapy plus exercise and arthroscopic subacromial decompression.ConclusionsDespite identifying 60 eligible trials, only one trial has compared a combination of manual therapy and exercise reflective of common current practice to placebo. It was judged of high quality and found no clinically important differences between groups in any outcome. Effects of manual therapy plus exercise may be similar to those of other active interventions (e.g. glucocorticoid injecton, surgery), but this is based on low quality evidence.Disclosure...