The efficacy of higher versus lower dose exercise in rotator cuff tendinopathy: A systematic review of randomised controlled trials

Aim: to compare the effectiveness and harms of higher exercise dose, including higher exercise load and/or higher volume, with lower exercise dose (lower load and/or lower volume) in people with rotator cuff tendinopathy Design: Systematic review (PROSPERO: CRD42017077478) Data sources: CENTRAL, MEDLINE, EMBASE, CINAHL from inception to March 2019. Eligibility criteria: Randomised controlled trials comparing higher versus lower dose exercise. Data extraction and risk of bias: Two authors independently determined eligibility, extracted data and assessed risk of bias using the Cochrane tool. Outcomes were function and pain (overall, activity, night), and proportion of participants with adverse events. The primary endpoint was >six weeks to three months (other endpoints included up to six weeks & beyond three months) and GRADE was used to assess evidence certainty. Results: Three trials (N=283), none at low risk of bias for all domains, were included. Low certainty evidence (1 trial, N=102) indicated improved function (20 points [95% CI 12 to 28 points] on 0-100 point scale) with higher load and volume exercise at three months, but little or no clinically important between-group difference in activity or night pain (overall pain not reported). Very low certainty evidence (1 trial, N=120) indicated higher load exercise conferred no function benefits over lower load exercise at six weeks. Very low certainty evidence (1 trial, N=61) indicated benefit of uncertain clinical importance in function with higher versus lower volume exercise at three months and clinically important benefit at >3 months (pain outcomes not reported). Risk of adverse events was uncertain. Conclusions: There are few studies that investigate higher dose exercise for rotator cuff tendinopathy. Low to very low certainty and conflicting evidence found about the value of higher versus lower dose exercise for people with rotator cuff tendinopathy