Author Names
Feng T, Wang X, Jin Z, Qin X, Sun C, Qi B, Zhang Y, Zhu L and Wei X
Reviewer Name
Rachel Jablonski, SPT
Reviewer Affiliation(s)
Duke University
Paper Abstract
Background: Manual therapy has been used as an alternative approach to treat knee osteoarthritis (KOA) for many years. Numerous systematic reviews (SRs) or meta-analyses (MAs) were published to evaluate its effectiveness and safety. Nevertheless, the conclusions of SRs/MAs are inconsistent, and the uneven quality needs to be critically appraised. Objectives: To conduct a comprehensive overview of the effectiveness and safety of manual therapy for KOA and the quality of relevant SRs/MAs, thus providing critical evidence and valuable direction for future researchers to promote the generation of advanced evidence. Methods: The pre-defined search strategies were applied to eight electronic databases from inception to September 2022. Suitable SRs/MAs were included in accordance with the inclusion and exclusion criteria. The methodological quality, risk of bias, reporting quality, and evidence quality were assessed by two independent reviewers who used respectively the A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR-2), the Risk of Bias in Systematic Reviews (ROBIS), the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 Version (PRISMA 2020), and Grades of Recommendations, Assessment, Development and Evaluation (GRADE) based on the method of narrative synthesis. We excluded the overlapping randomized controlled trials (RCTs) and performed a re-meta-analysis of the total effective rate. Results: A total of eleven relevant SRs/MAs were included: nine SRs/MAs were rated critically low quality, and two were rated low quality by AMSTAR-2. According to ROBIS, all SRs/MAs were rated low risk in Phase 1 (assessing relevance) and Domain 1 (study eligibility criteria) of Phase 2. Three SRs/MAs (27.27%) were rated low risk in Domain 2 (identification and selection of studies). Ten SRs/MAs (90.91%) were rated low risk in Domain 3 (data collection and study appraisal). Five SRs/MAs (45.45%) were rated low risk in Domain 4 (synthesis and findings). And five SRs/MAs (45.45%) were rated low risk in Phase 3 (risk of bias in the review). By PRISMA 2020, there were some reporting deficiencies in the aspects of abstract (2/11, 18.18%), search strategy (0/11, 0%), preprocessing of merging data (0/11, 0%), heterogeneity exploration (6/11, 54.55%), sensitivity analysis (4/11, 36.36%), publication bias (5/11, 45.45%), evidence quality (3/11, 27.27%), the list of excluded references (3/11, 27.27%), protocol and registration (1/11, 9.09%), funding (1/11, 9.09%), conflict of interest (3/11, 27.27%), and approach to relevant information (0/11, 0%). In GRADE, the evidence quality was defined as moderate quality (8 items, 21.05%), low quality (16 items, 42.11%), and critically low quality (14 items, 36.84%). Among the downgraded factors, risk of bias, inconsistency, imprecision, and publication bias were the main factors. A re-meta-analysis revealed that manual therapy can increase the total effective rate in KOA patients (risk ratio = 1.15, 95% confidence interval [1.12, 1.18], p < 0.00001; I2 = 0, p = 0.84). There are four reviews that narratively report adverse effects, and no severe adverse reactions occurred in the manual therapy group. Conclusions: Manual therapy may be clinically effective and safe for patients with KOA. However, this conclusion must be interpreted with caution because of the generally unsatisfactory study quality and inconsistent conclusions of the included SRs/MAs. Further rigorous and normative SRs/MAs are expected to be carried out to provide robust evidence for definitive conclusions.
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?
- Yes
- Were eligibility criteria for included and excluded studies predefined and specified?
- Yes
- Did the literature search strategy use a comprehensive, systematic approach?
- Yes
- Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
- Yes
- Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
- Yes
- Were the included studies listed along with important characteristics and results of each study?
- Yes
- Was publication bias assessed?
- Yes
- Was heterogeneity assessed? (This question applies only to meta-analyses.)
- Yes
Key Finding #1
The use of manual therapy to treat knee osteoarthritis was significantly superior to the control group in terms of the total effective rate.
Key Finding #2
In terms of the safety of manual therapy, they found no significant adverse reactions in the group receiving manual therapy.
Key Finding #3
There were inconsistent findings regarding the effectiveness of manual therapy on improving pain and function in patients with knee OA. This topic will require further exploration.
Please provide your summary of the paper
This article reviewed nine different systematic reviews and meta-analyses that explored the effectiveness of manual therapy for treating knee osteoarthritis. They used two independent reviewers to assess quality, risk of bias, reporting quality, and evidence quality of the studies. The results showed manual therapy can be used as an effective tool to combat pain and functional deficits originating from knee osteoarthritis. They also found reported adverse reactions were rare, supporting the motion that this technique is safe. However, many of the studies were rated as low quality and there is a need for further quality studies about manual therapy and knee OA.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
It is clear from this study that there is a need for higher quality studies of manual therapy and knee osteoarthritis. There is a surplus of published studies supporting manual therapy as a treatment for knee OA but it is not clear that many of them are low quality. The low quality could create confounding variables that impact the results of the studies. I believe the results of these studies are accurate and can be used in support of manual therapy but more studies with higher quality and less risk of bias need to be published. This will help with using manual therapy as evidence based practice.
