Preprint / Version 1

Are patients satisfied?

A systematic review and meta-analysis of patient ratings in exercise therapy for the management of tendinopathy


  • Joanna Shim School of Health Sciences, Robert Gordon University, Aberdeen, UK
  • Anastasia Pavlova School of Health Sciences, Robert Gordon University, Aberdeen, UK
  • Rachel Moss School of Health Sciences, Robert Gordon University, Aberdeen, UK
  • C. MacLean Robert Gordon University
  • D. Brandie Sport Scotland, Inverness, UK
  • L. Mitchell NHS Grampian
  • L. Greig School of Health Sciences, Robert Gordon University, Aberdeen, UK
  • E. Parkinson School of Health Sciences, Robert Gordon University, Aberdeen, UK
  • Victoria Brown Institute of Population Health Sciences, Queen Mary University of London and East London Health and Care Partnership
  • Dylan Morrissey Centre for Sports & Exercise Medicine, Barts & the London School of Medicine & Dentistry
  • Lyndsay Alexander School of Health Sciences, Robert Gordon University, Aberdeen, UK
  • Kay Cooper School of Health Sciences, Robert Gordon University, Aberdeen, UK
  • Paul Swinton School of Health Sciences, Robert Gordon University, Aberdeen, UK



Exercise Therapy, RCRSP, Rotator cuff-related Shoulder Pain, Network meta-analysis, Patient rating of condition



Outcomes measuring patient rating of overall condition, including patient satisfaction, are associated with improved general health and higher quality of life. However, this outcome domain is under-explored in the management of tendinopathy. The purpose of this systematic review and meta-analysis was to synthesise intervention data investigating patient satisfaction and perceived improvement or deterioration following engagement in exercise therapy for the management of tendinopathy.

Materials and Methods:

A search of randomised controlled trials investigating exercise therapy interventions across all tendinopathies was conducted, extracting data assessing patient rating of overall condition. Outcomes were split into those measuring satisfaction (binary) and those measuring global rating of change (GROC). Bayesian hierarchical models were used to meta-analyse proportions and mean effect size (percentage of maximum) for the two outcome categories.


From a total of 124 exercise therapy studies, 34(Achilles: 41%, rotator cuff: 32%, patellar: 15%, elbow: 9% and gluteal: 3%) provided sufficient information to be meta-analysed. The data were obtained across 48 treatment arms and 1246 participants. The pooled estimate for proportion of satisfaction was 0.63 [95%CrI: 0.53 to 0.73], and the pooled estimate for percentage of maximum GROC was 53 [95%CrI: 38 to 69%]. Evidence was also obtained that proportion of patients reporting positive satisfaction and perception of change increased with longer durations relative to treatment onset.


Patient satisfaction is not commonly reported in tendinopathy research, and in those studies where it is reported, satisfaction and GROC appear similar and are ranked moderately high demonstrating that patients generally perceive exercise therapy for tendinopathy management positively.  Further research including greater consistency in measurement tools is required to explore, and where possible identify patient and exercise moderating factors that can be used to improve person-centred care.


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Fu FH, Wang J, Rothrauff BB. Best Practice Tendinopathy [Internet]. BMJ. 2019;2019.

Abat F, Alfredson H, Cucchiarini M, et al. Current trends in tendinopathy: consensus of the ESSKA basic science committee. Part I: biology, biomechanics, anatomy and an exercise-based approach. Journal of experimental orthopaedics. 2017;4(1):18.

Lim HY, Wong S. Effects of isometric, eccentric, or heavy slow resistance exercises on pain and function in individuals with patellar tendinopathy: A systematic review. Physiother Res Int. 2018;23(4):4.

Vincenzino B, de Vos RJ, Alfredson H, others. ICON 2019—International Scientific Tendinopathy Symposium Consensus: There are nine core health-related domains for tendinopathy (CORE DOMAINS): Delphi study of healthcare professionals and patients. Br J Sports Med. 2019;54(8):444-451.

Alexander LA, Harrison I, Moss RA, et al. Exercise therapy for tendinopathy: A scoping review mapping interventions and outcomes. SportRχiv. 2021.

Graham B. Defining and measuring patient satisfaction. J Hand Surg. 2016;41(9):929-931.

Department of Health. The NHS Plan: A Plan for Investment, A Plan for Reform. 2000.

Hush JM, Cameron K, Mackey M. Patient Satisfaction With Musculoskeletal Physical Therapy Care: A Systematic Review. Phys Ther. 2011;91(1):25-36. doi: 10.2522/ptj.20100061.

Smith MJ, Choma TJ. Patient satisfaction in musculoskeletal medicine. Current reviews in musculoskeletal medicine JID - 101317803 PMC - PMC5435634 OTO - NOTNLM. (1935-973).

Batbaatar E, Dorjdagva J, Luvsannyam A, Savino MM, Amenta P. Determinants of patient satisfaction: a systematic review. Perspectives in public health JID - 101499631.

Kamper SJ, Maher CG, Mackay G. Global rating of change scales: a review of strengths and weaknesses and considerations for design. J Man Manip Ther. 2009;17(3):163-170. doi: jmmt0017-0163 [pii].

Garrison C, Cook C. Clinimetrics corner: the Global Rating of Change Score (GRoC) poorly correlates with functional measures and is not temporally stable. 2012;20(4):178-181. doi: 10.1179/1066981712Z.00000000022.

Fischer D, Stewart AL, Bloch DA, Lorig K, Laurent D, Holman H. Capturing the patient's view of change as a clinical outcome measure. JAMA. 1999;282(12):1157-1162. doi: joc90009 [pii].

Kennedy GD, Tevis SE, Kent KC. Is there a relationship between patient satisfaction and favorable outcomes?. Ann Surg. 2014;260(4):592-8; discussion 598-600. doi: 10.1097/SLA.0000000000000932 [doi].

Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi: 10.1136/bmj.n71.

Swinton P.A, Shim JI, Pavlova A, et al. Empirically derived guidelines for interpreting the effectiveness of exercise therapy for tendinopathies: A protocol. SportRxiv PrePrint. 2021. doi: 10.31236/

Stevens M, Tan C. Effectiveness of the Alfredson protocol compared with a lower repetition-volume protocol for midportion Achilles tendinopathy: a randomized controlled trial. journal of orthopaedic & sports physical therapy. 2014;44(2):59-67.

Van Ark M, Cook JL, Docking SI, et al. Do isometric and isotonic exercise programs reduce pain in athletes with patellar tendinopathy in-season? A randomised clinical trial. Journal of science and medicine in sport. 2016;19(9):702-706.

Program U,Nations Development. Human Development Reports [Internet]. New York: United Nations;. 2020;2019.

Higgins JPT, Altman DG, Gøtzsche PC, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928. doi: 10.1136/bmj.d5928.

Challoumas D, Millar NL. Risk of bias in systematic reviews of tendinopathy management: Are we comparing apples with oranges?. Transl Sports Med. 2021;4(1):21-37. doi:

Marshall IJ, Kuiper J, Wallace BC. RobotReviewer: evaluation of a system for automatically assessing bias in clinical trials. Journal of the American Medical Informatics Association. 2016;23(1):193-201.

Wang N. How to Conduct a Meta-Analysis of Proportions in R: A Comprehensive Tutorial. ; 2018.

Morris SB, DeShon RP. Combining effect size estimates in meta-analysis with repeated measures and independent-groups designs. Psychol Methods. 2002;7(1):105.

Fernández-Castilla B, Jamshidi L, Declercq L, Beretvas SN, Onghena P, Van den Noortgate W. The application of meta-analytic (multi-level) models with multiple random effects: A systematic review. Behavior research methods. 2020;52(5).

Gelman A. Prior distributions for variance parameters in hierarchical models (comment on article by Browne and Draper). Bayesian analysis. 2006;1(3):515-534.

Bürkner P. brms: An R package for Bayesian multilevel models using Stan. Journal of statistical software. 2017;80(1):1-28.

Schünemann HJ, Mustafa RA, Brozek J, et al. GRADE guidelines: 21 part 1. Study design, risk of bias, and indirectness in rating the certainty across a body of evidence for test accuracy. Journal of clinical epidemiology JID - 8801383.

Schünemann HJ, Mustafa RA, Brozek J, et al. GRADE guidelines: 21 part 2. Test accuracy: inconsistency, imprecision, publication bias, and other domains for rating the certainty of evidence and presenting it in evidence profiles and summary of findings tables. Journal of clinical epidemiology JID - 8801383.

Challoumas D, Millar NL. Do we need to improve the reporting of evidence in tendinopathy management? A critical appraisal of systematic reviews with recommendations on strength of evidence assessment. BMJ OPEN SP EX MED. 2021;7(1):e000920. doi: 10.1136/bmjsem-2020-000920.

Bahr R, Fossan B, Løken S, Engebretsen L. Surgical treatment compared with eccentric training for patellar tendinopathy (jumper's knee): a randomized, controlled trial. JBJS. 2006;88(8):1689-1698.

Breda SJ, Oei EHG, Zwerver J, et al. Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial. Br J Sports Med. 2020.

Brox JI, Gjengedal E, Uppheim G, et al. Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease (stage II impingement syndrome): a prospective, randomized, controlled study in 125 patients with a 2 1/2-year follow-up. Journal of shoulder and elbow surgery. 1999;8(2):102-111.

Chaconas EJ, Kolber MJ, Hanney WJ, Daugherty ML, Wilson SH, Sheets C. SHOULDER EXTERNAL ROTATOR ECCENTRIC TRAINING VERSUS GENERAL SHOULDER EXERCISE FOR SUBACROMIAL PAIN SYNDROME: A RANDOMIZED CONTROLLED TRIAL. International Journal of Sports Physical Therapy. 2017;12(7):1121-1133. doi: 10.26603/ijspt20171121.

Tol Suzan de Jonge, Johannes,L., de Vos R, van Schie H,T.M., Verhaar JAN. midportion Achilles tendinopathy on added splinting to eccentric exercises in chronic One-year follow-up of a randomised controlled trial Rapid responses Downloaded from. bjsm bmj com. 2008. doi: 10.1136/bjsm.2008.052142.

De Vos RJ, Weir A, Visser R, de Winter T, Tol JL. The additional value of a night splint to eccentric exercises in chronic midportion Achilles tendinopathy: a randomised controlled trial. Br J Sports Med. 2007;41(7).

Gatz M, Betsch M, Dirrichs T, et al. Eccentric and Isometric Exercises in Achilles Tendinopathy Evaluated by the VISA-A Score and Shear Wave Elastography. Sports health. 2020:1941738119893996. doi: 10.1177/1941738119893996.

Granviken F, Vasseljen O. Home exercises and supervised exercises are similarly effective for people with subacromial impingement: a randomised trial. Journal of physiotherapy. 2015;61(3):135-141.

Hotta GH, Gomes de Assis Couto, Amanda, Cools AM, McQuade KJ, Siriani de Oliveira A. Effects of adding scapular stabilization exercises to a periscapular strengthening exercise program in patients with subacromial pain syndrome: A randomized controlled trial. Musculoskeletal Science and Practice. 2020;49. doi: 10.1016/j.msksp.2020.102171.

Johansson KM, Adolfsson LE, Foldevi MOM. Effects of acupuncture versus ultrasound in patients with impingement syndrome: randomized clinical trial. Phys Ther. 2005;85(6):490-501.

Jonsson P, Alfredson H. Superior results with eccentric compared to concentric quadriceps training in patients with jumper’s knee: a prospective randomised study. Br J Sports Med. 2005;39. doi: 10.1136/bjsm.2005.018630.

Knobloch K, Schreibmueller L, Longo UG, Vogt PM. Eccentric exercises for the management of tendinopathy of the main body of the Achilles tendon with or without the AirHeel Brace. A randomized controlled trial. A: effects on pain and microcirculation. Disabil Rehabil. 2008;30(20). doi: 10.1080/09638280701786658.

Kromer TO, de Bie R,A., Bastiaenen CHG. Physiotherapy in patients with clinical signs of shoulder impingement syndrome: a randomized controlled trial. J Rehabil Med. 2013;45(5):488-497. doi: 10.2340/16501977-1142.

Ludewig PM, Borstad JD. Effects of a home exercise programme on shoulder pain and functional status in construction workers. Occup Environ Med. 2003;60(11):841-849.

Marzetti E, Rabini A, Piccinini G, et al. Neurocognitive therapeutic exercise improves pain and function in patients with shoulder impingement syndrome: a single-blind randomized controlled clinical trial. European journal of physical and rehabilitation medicine. 2014;50(3):255-264.

McCormack JR, Underwood FB, Slaven EJ, Cappaert TA. Eccentric Exercise Versus Eccentric Exercise and Soft Tissue Treatment (Astym) in the Management of Insertional Achilles Tendinopathy. 2016;8(3). doi: 10.1177/1941738116631498.

Mulligan EP, Huang M, Dickson T, Khazzam M. The Effect of Axioscapular and Rotator Cuff Exercise Training Sequence in Patients with Subacromial Impingement Syndrome: a Randomized Crossover Trial. International Journal of Sports Physical Therapy. 2016;11(1):94-107.

Nishizuka T, Iwatsuki K, Kurimoto S, Yamamoto M, Hirata H. Efficacy of a forearm band in addition to exercises compared with exercises alone for lateral epicondylitis: A multicenter, randomized, controlled trial. Journal of Orthopaedic Science. 2017;22(2):289-294. doi:

Nørregaard J, Larsen CC, Bieler T, Langberg H. Eccentric exercise in treatment of Achilles tendinopathy. Scand J Med Sci Sports. 2007;17(2):133-138.

Østerås H, Torstensen TA, Haugerud L, Østerås BS. Dose-response effects of graded therapeutic exercises in patients with long-standing subacromial pain. Advances in Physiotherapy. 2009;11(4):199-209. doi: 10.3109/14038190802239729.

Paavola M, Malmivaara A, Taimela S, et al. Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial. BMJ. 2018;362. doi: 10.1136/bmj.k2860.

Reyhan AC, Sindel D, Dereli EE. The effects of Mulligan's mobilization with movement technique in patients with lateral epicondylitis. Journal of Back and Musculoskeletal Rehabilitation. 2020;33(1):99-107. doi:

Rompe JD, Nafe B, Furia JP, Maffulli N. Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial. Am J Sports Med. 2007;35(3):374-383.

Rompe JD, Furia J, Maffulli N. Eccentric loading versus eccentric loading plus shock-wave treatment for midportion achilles tendinopathy: a randomized controlled trial. Am J Sports Med. 2009;37(3):463-470.

Rompe JD, Segal NA, Cacchio A, Furia JP, Morral A, Maffulli N. Home training, local corticosteroid injection, or radial shock wave therapy for greater trochanter pain syndrome. Am J Sports Med. 2009;37(10):1981-1990. doi: 10.1177/0363546509334374.

Rompe JD, Furia J, Maffulli N. Eccentric loading compared with shock wave treatment for chronic insertional achilles tendinopathy: A randomized, controlled trial. Journal of Bone and Joint Surgery - Series A. 2008;90(1):52-61. doi: 10.2106/JBJS.F.01494.

Roos EM, Engstrom M, Lagerquist A, Soderberg B. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy -- a randomized trial with 1-year follow-up [with consumer summary]. Scandinavian Journal of Medicine & Science in Sports 2004 Oct;14(5):286-295. 2004.

Silbernagel KG, Thomeé R, Thomeé P, Karlsson J. Eccentric overload training for patients with chronic Achilles tendon pain--a randomised controlled study with reliability testing of the evaluation methods. Scand J Med Sci Sports. 2001;11(4):197-206.

Steunebrink M, Zwerver J, Brandsema R, Groenenboom P, van den Akker-Scheek I, Weir A. Topical glyceryl trinitrate treatment of chronic patellar tendinopathy: a randomised, double-blind, placebo-controlled clinical trial. Br J Sports Med. 2013;47(1):34-39.

VUVAN V, VICENZINO B, MELLOR R, HEALES LJ, COOMBES BK. Unsupervised Isometric Exercise versus Wait-and-See for Lateral Elbow Tendinopathy. Medicine & Science in Sports & Exercise. 2020;52(2):287-295. doi: 10.1249/MSS.0000000000002128.

Werner A, Walther M, Ilg A, Stahlschmidt T, Gohlke F. [Self-training versus conventional physiotherapy in subacromial impingement syndrome]. Z Orthop Ihre. 2002;140(4):375-380.

Yelland MJ, Sweeting KR, Lyftogt JA, Ng SK, Scuffham PA, Evans KA. Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial. Br J Sports Med. 2011;45(5). doi: 10.1136/bjsm.2009.057968.

Jaeschke R, Singer J, Guyatt GH. Measurement of health status. Ascertaining the minimal clinically important difference. Control Clin Trials. 1989;10(4):407-415. doi: 0197-2456(89)90005-6 [pii].

Ferguson L, Scheman J. Patient global impression of change scores within the context of a chronic pain rehabilitation program. The Journal of Pain. 2009;10(4):S73.

Busner J, Targum SD. The clinical global impressions scale: applying a research tool in clinical practice. Psychiatry (Edgmont). 2007;4(7):28-37.

Kamper SJ, Ostelo RW, Knol DL, Maher CG, de Vet HC, Hancock MJ. Global Perceived Effect scales provided reliable assessments of health transition in people with musculoskeletal disorders, but ratings are strongly influenced by current status. J Clin Epidemiol. 2010;63(7):760-766. e1.

Guyatt GH, Norman GR, Juniper EF, Griffith LE. A critical look at transition ratings. J Clin Epidemiol. 2002;55(9):900-908. doi: S0895435602004353 [pii].

Schmitt JS, Abbott JH. Patient Global Ratings of Change Did Not Adequately Reflect Change Over Time: A Clinical Cohort Study. Phys Ther. 2014;94(4):534-542. doi: 10.2522/ptj.20130162.

Wagner EH, Austin BT, Von Korff M. Improving outcomes in chronic illness. Manag Care Q. 1996;4(2):12-25.

Cleary PD, McNeil BJ. Patient satisfaction as an indicator of quality care. Inquiry. 1988;25(1):25-36.