Comparative Effectiveness of Combination Versus Single-Modality Physiotherapy for Rotator Cuff-Related Shoulder Pain: A Systematic Review and Network Meta-Analysis

Abstract

Background/Objective: The objective of this study is to compare the relative effectiveness of combination therapy (exercise plus manual therapy) versus single-modality physiotherapy interventions for improving pain and function in patients with rotator cuff-related shoulder pain (RCRSP), using a network meta-analysis (NMA) approach. Methods: We systematically searched five electronic databases from inception to October 2023 for randomized controlled trials (RCTs) evaluating non-invasive physiotherapy interventions in adults with RCRSP. Primary outcomes included pain intensity and shoulder function, assessed at 12 weeks. A frequentist NMA was conducted to estimate standardized mean differences (SMDs) with 95% confidence intervals (CIs). Risk of bias was assessed using the Cochrane RoB 2.0 tool. Results: Eleven RCTs (n = 548) were included. Combination therapy demonstrated the greatest improvement in function (SMD = −1.02; 95% CI: −2.59 to 0.56) and pain (SMD = −1.05; 95% CI: −2.41 to 0.30), although the wide confidence intervals crossing the null suggests statistical uncertainty. Exercise therapy alone showed moderate functional improvement (SMD = −0.41; 95% CI: −1.64 to 0.82), and Kinesio taping (KT) provided moderate pain relief (SMD = −0.53; 95% CI: −1.81 to 0.75). While these effects approached known minimal clinically important difference (MCID) thresholds (e.g., DASH: 10–15; VAS: 1.4–2.0), they did not reach statistical significance. Conclusions: Based on 11 RCTs, combination therapy (exercise plus manual therapy) appears to be the most effective non-invasive approach for improving pain and function in patients with RCRSP. However, the wide confidence intervals highlight uncertainty. Further large-scale and long-term trials are warranted to confirm its clinical utility and sustainability.