Manual Therapy for Hip Osteoarthritis: A Systematic Review and Meta-analysis – Duke Center of Excellence in Manual and Manipulative Therapy

Author Names

Wang, Q; Wang, T; Qi, X; Yao, M; Cui, X; Wang, Y; Liang, Q

Reviewer Name

Kayla Berezne, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Hip osteoarthritis (HOA) is one of the major causes of disability in seniors and is costly to society. Manual therapy is one therapeutic approach to treating HOA.

Objectives: To assess the effect of manual therapy compared to the placebo or wait-list/no treatment or a minimal intervention control for HOA at post-treatment and short-, intermediate and long-term follow-ups.

Study Design: A systematic review and meta-analysis of randomized controlled trials (RCTs).

Setting: Hospital outpatient clinic in China.

Methods: We searched PubMed, EMBASE, the Cochrane Library, CINAHL, ISI web of knowledge, and Chinese databases from the inception to October 2014 without language restrictions. References of systematic reviews and other related reviews, files in our department, and conference proceedings as grey literature were also screened by hand. RCTs compared manual therapy to the placebo, wait-list/no treatment or a minimal intervention control with an appropriate and precise description of randomization. Two reviewers independently conducted the search results identification, data extraction, and methodological quality assessment. We calculated the risk difference (RD) for dichotomous data and the mean difference (MD) or standardized mean difference (SMD) for continuous data in a fixed or random effect model.

Outcome Measures: The primary outcomes were self-reported pain in the past week and physical function. The secondary outcomes were the quality of life, global perceived effect, patients’ satisfaction, cost, and adverse events.

Results: Six studies involving 515 HOA patients were included. Five of the 6 studies ranked as high quality in the methodological assessment. Immediately post-treatment, there was low quality evidence that manual therapy could not statistically significantly relieve pain (SMD: -0.07 [95%CI -0.38 to 0.24]); for physical function, a moderate quality of evidence showed that manual therapy could not improve the physical function significantly (SMD: 0.14 [95%CI -0.08 to 0.37]). We still found low-quality evidence that manual therapy did not benefit the patients in the global perceived effect (RD: 0.12 [95%CI -0.12 to 0.36]), and in terms of quality of life. In addition, the risks of patients in the manual therapy group was 0.13 times higher than that in the controls (RD: 0.13 [95%CI -0.05 to 0.31]) in the low-quality evidence studies. We could not find any evidence that manual therapy benefits the patients at short-, intermediate- or long-term follow-up. There were no studies reporting patients’ satisfaction or cost.

Limitations: The limitations of this systematic review include the paucity of literature and inevitable heterogeneity between included studies.

Conclusion: This review did not suggest there was enough evidence for manual therapy for the management of HOA. However, we are not confident in making such a conclusion due to the limitations listed above.

Key words: Manual therapy, hip osteoarthritis, efficacy, systematic review, meta-analysis

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

Is the review based on a focused question that is adequately formulated and described?

Were eligibility criteria for included and excluded studies predefined and specified?

Did the literature search strategy use a comprehensive, systematic approach?

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

Were the included studies listed along with important characteristics and results of each study?

Was publication bias assessed?

Was heterogeneity assessed? (This question applies only to meta-analyses.)

Key Finding #1

There is moderate quality evidence that manual therapy does not improve function in people with hip osteoarthritis.

Key Finding #2

There is low quality evidence that manual therapy does not improve pain in people with hip osteoarthritis.

Please provide your summary of the paper

This systematic review and meta-analysis concludes that manual therapy techniques (mobilizations, manipulations, and massage) do not improve pain or function in individuals with hip osteoarthritis (OA). They evaluated 6 RCTs comparing manual therapy techniques to sham, placebo, no treatment, or minimal treatment in individuals with hip OA only with varying frequency of treatment and outcome follow-up from immediately post-intervention up to 1 year. They outlined clear criteria for the search process, study selection, inclusion/exclusion, outcome measures, and assessment of bias and quality of evidence. The study limitations include inherent bias in study selection, heterogeneity, and publication bias. Additionally, it is worth noting that studies evaluating other musculoskeletal issues including knee OA were excluded which does increase the reliability of these results to hip OA, but does leave out a selective population that experiences combined OA with symptoms in the hip. Overall, this study suggests with clear evaluation of evidence that manual therapy techniques are not effective in treating hip OA, but the authors encourage further study with less heterogeneity in intervention dosage, duration, and form.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

The results of this study suggest that manual therapy techniques are not effective to use to treat pain and improve function or quality of life in patients with hip OA. Further research may examine specific manual therapy techniques with defined dosages, but this study combined multiple manual therapy forms, durations, and outcomes. A clinician’s clinical reasoning may determine that specific patients with hip OA could still benefit from manual therapy techniques to improve patient-provider relationships, other areas of the body or referred pain patterns, or possible short-term effects in combination with other therapy options to facilitate post-session and long-term pain or functional changes.