Author Names
Nigam, A, Satpute, K, Hall, T
Reviewer Name
Andrew Erker, SPT, CSCS
Reviewer Affiliation(s)
Duke University Doctorate of Physical Therapy
Paper Abstract
Objectives: To evaluate the long term effect of mobilisation with movement on disability, pain and function in subjects with symptomatic knee osteoarthritis. Design: A randomised controlled trial. Setting: A general hospital. Subjects: Forty adults with knee osteoarthritis (grade 1-3 Kellgren-Lawrence scale). Interventions: The experimental group received mobilisation with movement and usual care (exercise and moist heat) while the control group received usual care alone in six sessions over two weeks. Main measures: The primary outcome was the Western Ontario McMaster University Osteoarthritis index, higher scores indicating greater disability. Pain intensity over 24 hours and during sit to stand were measured on a 10 centimetre visual analogue scale. Functional outcomes were the timed up and go test, the 12 step stair test, and knee range of motion. Patient satisfaction was measured on an 11 point numerical rating scale. Variables were evaluated blind pre- and post intervention, and at three and six months follow-up. Results: Thirty five participants completed the study. At each follow-up including six-months, significant differences were found between groups favouring those receiving mobilisation with movement for all variables except knee mobility. The primary outcome disability showed a mean difference of 7.4 points (95% confidence interval, 4.5 to 10.3) at six-months and a mean difference of 13.6 points (95% confidence interval, 9.3 to 17.9) at three-months follow-up. Conclusion: In patients with symptomatic knee osteoarthritis, the addition of mobilisation with movement provided clinically significant improvements in disability, pain, functional activities and patient satisfaction six months later. Keywords: Knee osteoarthritis; manual therapy; mobilisation with movement.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
- Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
- Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?
- Yes
- Were study participants and providers blinded to treatment group assignment?
- No
- Were the people assessing the outcomes blinded to the participants’ group assignments?
- Yes
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
- Yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
- Yes
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
- Yes
- Was there high adherence to the intervention protocols for each treatment group?
- Cannot Determine, Not Reported, or Not Applicable
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
- Yes
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
- Yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
- Yes
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
- Yes
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
- Yes
Key Finding #1
Subjects that received mobilization with movement, along with an exercise program and heat treatment sustained better outcomes (lower pain, higher self-reported function, and patient satisfaction) at 3 and 6 months compared to subjects who participated in an exercise program and heat treatment.
Key Finding #2
There were no differences in range of motion improvements between the experimental and control subjects at any point in the evaluation timeline.
Key Finding #3
The authors hypothesize that the reduction in pain in the subjects receiving mobilization with movement can be due to an alteration of nociceptive inputs.
Key Finding #4
All subjects were guided to continue exercise treatment at home, however this was never monitored. Therefore, adherence to a home exercise program is a variable that is not accounted for in the results.
Please provide your summary of the paper
This randomized clinical trial provided a new view on the effects of mobilization with movement by examining various outcomes both immediately and long-term (6 months). This study included 40 subjects with a similar age (50-70 y/o), pain intensity (4-8/10), functional status, lack of complex medical history, and Kellgren and Lawrence osteoarthritis scale score (1-3). The subjects were selected randomly to either receive exercise and moist heat with/without mobilization with movement. The mobilization with movement was provided at the tibia with stabilization of the femur in all directions during active range of motion knee flexion and extension. This program lasted two weeks, and the subjects all had six 45-minute treatment sessions. Pain, function, range of motion and patient satisfaction were all assessed by a blinded, qualified physical therapist at the conclusion of the two week program, as well as in re-evaluations at 3 months and 6 months. After the conclusion of the two weeks, all subjects were guided to continue their exercise program at home, and the experimental subjects were educated on how to self-mobilize. However, there was no documentation regarding adherence to the home program. There were improvements in pain, function, range of motion and patient satisfaction by both groups. There was a clinically significant improvement in pain, function and patient satisfaction in experimental subjects compared to their controlled counterparts. There was not a clinically significant difference in the range of motion between the experimental and control groups.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This study used a small sample size with adequate power. The results of the study are promising for the implementation of mobilization with movement techniques in clinical practice. However, the participants of this study were highly specific, therefore more research should be conducted to determine more universal guidelines for appropriateness. Furthermore, it is important to note that implementation of Mulligan manual therapy should be utilized in congruence with an adequate rehabilitative exercise program to achieve optimal outcomes.
