Author Names
Abbott JH, Robertson MC, Chapple C, Pinto D, Wright AA, Leon de la Barra S, Baxter GD, Theis JC, Campbell AJ
Reviewer Name
Ericka Boeger, SPT
Reviewer Affiliations
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper 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 2×2 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.
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?
- Yes
- 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?
- Yes
- 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
The manual therapy plus usual care group and exercise therapy plus usual care group produce significant improvements in symptoms and physical function (timed up and go, 30 second sit-to-stand, and 40m self-paced walk) for patients with moderate to severe hip and knee OA. These benefits, along with pain and disability, were demonstrated at 9 weeks and sustained through the one-year follow-up appointment.
Key Finding #2
For hip and knee OA, the manual physical therapy plus usual care group demonstrated greater reductions in the Western Ontario and McMaster Osteoarthritis index (WOMAC) scores than the exercise therapy plus usual care group.
Key Finding #3
The combination of usual care plus manual and exercise physical therapy was less effective and demonstrated lower mean gains than the only manual therapy or only exercise therapy groups.
Please provide your summary of the paper
This randomized controlled trial examines the effects that usual care only, usual care plus manual therapy, usual care plus exercise therapy, and usual care plus a combination of manual and exercise therapy have on WOMAC scores, pain, patient global assessment, and physical function measures for patients with knee and hip osteoarthritis. The physical function measures include the timed up and go, 30 second sit-to-stand, and 40m self-paced walk. The patients attend nine treatment sessions, in addition to home exercise programs to complete three times per week.
The results demonstrate that the usual care plus manual therapy group has the greatest improvements in the WOMAC score. The usual care plus exercise therapy group demonstrates improvements in all three physical performance outcome measures. The combination group (usual care plus manual and exercise therapy) is less effective because there is an antagonistic interaction. Authors hypothesize that this was due to patients spending less time on each intervention, decreasing the effectiveness of both modalities.
Limitations include a low patient compliance with returning logbooks reporting their home exercises. However, patients self-reported high compliance of doing their home program during session interviews. The authors advise caution in this interpretation of at home exercise compliance. They also report excluding 44 participants because they received a joint replacement during the experiment, which is an important confounding factor.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This article can be implemented in the clinic by allowing patient preference in the choice of therapy as manual therapy and exercise therapy appear to be effective. The manual therapy group has patient-reported benefits on the WOMAC, while the exercise therapy group demonstrates physical performance benefits. It is also important to consider patient characteristics when deciding which form of therapy to use. The authors mention that a patient with restricted AROM and PROM might benefit more from manual therapy, whereas a patient with lower extremity muscle atrophy and low aerobic fitness may benefit more from exercise therapy. Finally, the authors mention the importance of dedicating adequate time to the individual intervention that is chosen and avoid combining both exercise and manual therapy in one treatment session.
