MAPS: Maitland-Australian homecontact us
find us on facebook find us on linkedin

RESEARCH COMMENTARY
Robert J. Fluegel, PT, COMT
MAPS Faculty, Fellow in Training, MAPS Orthopedic Manual Therapy Fellowship

Chris R. Showalter, PT, OCS, COMT, FAAOMPT, Fellowship Program Director

Mobilization combined with Stabilization is SUPERIOR compared to Stabilization alone in Non-Specific Mechanical Neck Pain (NSMNP)


 
sign up for email updates from MAPS

 
Hip or Knee Osteoarthritis (OA): Manual Therapy Produces SUPERIOR OUTCOMES to Usual Medical Care, Exercise Therapy AND the Combination of Manual Therapy And Exercise

February 28, 2014

RESEARCH COMMENTARY

 

Chris Showalter PT, OCS, COMT, FAAOMPT

MAPS Clinical Director

 

 

Hip or Knee Osteoarthritis (OA):

Manual Therapy Produces SUPERIOR OUTCOMES to Usual Medical Care, Exercise Therapy AND the Combination of Manual Therapy And Exercise

 

Osteoarthritis (O/A) is a serious condition that primarily affects the large, weight bearing joints of the body. The management of the resultant pain, weakness and loss of function in Hip or Knee OA patients is often multimodal, and often the most significant responsibility falls upon the Physical Therapist. Interventions used to effectively treat OA should be of increasing interest to Physical Therapists, particularly as the "Baby Boomers" mature and live longer and lead increasingly more active lives in their later years.   

 

Various forms of exercise have been shown to be effective in reducing pain and increasing function in patients with Hip or Knee OA, but few studies have shown this effect up to or beyond one year (Zhang 2010, Pisters 2010).

 

Similarly, manual therapy has also demonstrated significant improvements in pain and function in this patient population. (Deyle 2005, Deyle 2000, Hoeksma 2004, MacDonald 2006)

 

A recent article (Abbott 2013) sought to determine the relative long term effectiveness (at one year) of various interventions including: manual therapy, exercise therapy, a combination of manual therapy AND exercise therapy, in addition to usual care.

 

The article Abstract and hyperlink are provided below for "Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee: a randomized controlled trial. 1: clinical effectiveness"

 

Participants

 

The above (Abbott 2013) study involved 206 patients (193 at follow-up) with a mean age of 66 years who met the American College of Rheumatology criteria for Hip or Knee OA.

 

Group Allocation

 

Patients were randomly allocated into four groups:

  1. Manual therapy plus usual care (n=54)

  2. Multi-modal exercise therapy plus usual care (n=51)

  3. Combined manual therapy and exercise therapy plus usual care (n= 50)

  4. Control group recieved usual medical care (no specific manual therapy or exercise intervention given) (n=51) (usual care was provided by the patient’s regular physician or health care provider)  

Outcome Measures

The primary outcome measure used was a change in the Western Ontario and McMaster Osteoarthritis Index (WOMAC). 

 

Secondary outcome measures included measures of physical function, including the timed sit up and go test, 30 second sit to stand test, and 40 minute self-paced walk test.

 

Measures were taken at baseline, 9 weeks, 6 months and 1 year.

 

Results

Mean baseline WOMAC scores were 100.8 (on a scale of 0-240), representing moderate to severe OA.

(Higher scores indicate worse pain, stiffness and physical limitations).

 

The results of the study found the following changes to WOMAC scores compared to the usual care Control Group:

 

  • Manual therapy, reduction of 28.5 ( 95% Confidence Interval (CI) (9.2-47.8))

  • Exercise therapy, reduction of 16.4 (-3.2 to 35.9)

Combined manual and exercise therapy, reduction of 14.5 (-5.2 to 34.1)

 

There was an antagonistic interaction between exercise therapy and manual therapy (p=0.027).

Physical performance test outcomes favored the exercise therapy group.

 

Conclusions 

  • Manual therapy provided benefits over usual care, and these benefits were sustained for one year.  These findings are consistent with prior research.

  • Exercise therapy also provided benefits over usual care, in the form of physical performance benefits.

  • Manual therapy was superior to exercise therapy and usual care for patients with OA.

  • There was no added benefit from a combination of manual therapy and exercise.

IMPORTANT TAKE-HOME MESSAGES  

1) MANUAL THERAPY, in addition to usual care, produced both clinically and statistically significant (P<0.001) improvements in WOMAC scores compared to usual care alone. This was seen at 9 weeks, 6 months and 1 year.  In other words...ONLY Manual therapy was clinically and statistically valuable in reducing WOMAC scores.

2) Exercise therapy, in addition to usual care, produced significant improvements (P=0.012) in all three physical performance outcome measures.  In other words...Exercise therapy produced statistical, improvements in secondary performance outcome measures.

3) The COMBINATION of both interventions (manual therapy and exercise) did not produce any additional benefit, in fact, it was antagonistic and produced lesser relief from OA than the two therapies did alone.  In other words...the combination was generally less effective, or at best no more effective, than either intervention alone.  

4) Due to the antagonistic effect of manual therapy and exercise the authors (Abbott 2103) recommend that the two interventions should not be given concurrently but that adequate time be allowed to deliver these interventions separately.  In other words...thoughtful treatment planning and delivery is required with this patient population.       



Cheers and Enjoy

Chris R. Showalter PT, OCS, COMT, FAAOMPT 


© Chris R. Showalter and Maitland Australian Physiotherapy Seminars

Not to be reproduced, copied or retransmitted in any manner without author's express written permission

Directing others to the MAPS website (www.ozpt.com) is permissible.



Main Article Follows

 



Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee: a randomized controlled trial. 1: clinical effectiveness

 http://www.oarsijournal.com/article/S1063-4584%2813%2900003-4/abstract

 

Abbott JH1, Robertson MC, Chapple C, Pinto D, Wright AA, Leon de la Barra S, Baxter GD, Theis JC, Campbell AJ; MOA Trial team.



Abstract

OBJECTIVE:

To evaluate the clinical effectiveness of manual physiotherapy and/or exercise physiotherapy in addition to usual care for patients with osteoarthritis (OA) of the hip or knee.

DESIGN:

In this 2 x 2 factorial randomized controlled trial, 206 adults (mean age 66 years) who met the American College of Rheumatology criteria for hip or knee OA were randomly allocated to receive manual physiotherapy (n = 54), multi-modal exercise physiotherapy (n = 51), combined exercise and manual physiotherapy (n = 50), or no trial physiotherapy (n = 51). The primary outcome was change in the Western Ontario and McMaster osteoarthritis index (WOMAC) after 1 year. Secondary outcomes included physical performance tests. Outcome assessors were blinded to group allocation.

RESULTS:

Of 206 participants recruited, 193 (93.2%) were retained at follow-up. Mean (SD) baseline WOMAC score was 100.8 (53.8) on a scale of 0-240. Intention to treat analysis showed adjusted reductions in WOMAC scores at 1 year compared with the usual care group of 28.5 (95% confidence interval (CI) 9.2-47.8) for usual care plus manual therapy, 16.4 (-3.2 to 35.9) for usual care plus exercise therapy, and 14.5 (-5.2 to 34.1) for usual care plus combined exercise therapy and manual therapy. There was an antagonistic interaction between exercise therapy and manual therapy (P = 0.027). Physical performance test outcomes favoured the exercise therapy group.

CONCLUSIONS:

Manual physiotherapy provided benefits over usual care, that were sustained to 1 year. Exercise physiotherapy also provided physical performance benefits over usual care. There was no added benefit from a combination of the two therapies.

TRIAL REGISTRATION NUMBER:

Australian New Zealand Clinical Trials Registry ACTRN12608000130369.

 

Where to find the Articles

 

http://www.ncbi.nlm.nih.gov/pubmed/20170770

Zhang W, Nuki G, Moskowitz RW, Abramson S, Altman RD, Arden NK, Bierma-Zeinstra S, Brandt KD, Croft P, Doherty M, Dougados M, Hochberg M, Hunter DJ, Kwoh K, Lohmander LS, Tugwell P.OARSI recommendations for the management of hip and knee osteoarthritis: part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage. 2010 Apr;18(4):476-99.

http://www.ncbi.nlm.nih.gov/pubmed/20488250

Pisters MF, Veenhof C, Schellevis FG, De Bakker DH, Dekker J. Long-term effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a randomized controlled trial comparing two different physical therapy interventions. Osteoarthritis Cartilage. 2010 Aug;18(8):1019-26.

http://www.ncbi.nlm.nih.gov/pubmed/16305269

Deyle GD, Allison SC, Matekel RL, Ryder MG, Stang JM, Gohdes DD, Hutton JP, Henderson NE, Garber MB. Physical therapy treatment effectiveness for osteoarthritis of the knee: a randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program. Phys Ther. 2005 Dec;85(12):1301-17.

http://www.ncbi.nlm.nih.gov/pubmed/10651597

Deyle GD1, Henderson NE, Matekel RL, Ryder MG, Garber MB, Allison SC Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial. Ann Intern Med. 2000 Feb 1;132(3):173-81.

http://www.ncbi.nlm.nih.gov/pubmed/15478147

Hoeksma HL, Dekker J, Ronday HK, Heering A, van der Lubbe N, Vel C, Breedveld FC, van den Ende CH Comparison of manual therapy and exercise therapy in osteoarthritis of the hip: a randomized clinical trial. Arthritis Rheum. 2004 Oct 15;51(5):722-9.

http://www.ncbi.nlm.nih.gov/pubmed/16915980

MacDonald CW1, Whitman JM, Cleland JA, Smith M, Hoeksma HL. Clinical outcomes following manual physical therapy and exercise for hip osteoarthritis: A case series. J Orthop Sports Phys Ther. 2006 Aug;36(8):588-99.



Back To Research Commentary History
Find a COMT Course Schedule Course Descriptions Register for Courses Faculty
Looking for a COMT? This list of Certified Orthopedic Manual Therapists (or COMTs) includes all COMT graduates worldwide, as well as MAPS faculty. We suggest that you visit this page often to check course confirmation status and to find new courses which are added frequently. Our seminars incorporate the teaching of Geoff Maitland and others who have contributed to what has become known as the "Maitland-Australian Approach". Registering for classes is easy. Submit full payment with the registration form. Reservations are limited and are on a first come, first serve basis. Come meet our world-class faculty. Each of our faculty has experience in a wide variety of manual therapy practices and specialty areas.

 

HOME | ABOUT US | COURSES | RESEARCH | CLINICAL SITES | CONTACT US | SIGN UP FOR MAPS EMAIL UPDATES
© 2007 OZPT.com. All rights reserved.