Author Names

Beumer, L., Wong, J., Warden, S.J., Kemp, J.L., Foster, P., Crossley, K.M.

Reviewer Name

Natalia Engel, SPT

Reviewer Affiliations

Duke University School of Medicine, Physical Therapy Division

 

Paper Abstract

Aim: To explore the effects of exercise (water-based or land-based) and/or manual therapies on pain in adults with clinically and/or radiographically diagnosed hip osteoarthritis (OA). Methods: A systematic review and meta-analysis was performed, with patient reported pain assessed using a visual analogue scale (VAS) or the Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain subscale. Data were grouped by follow-up time (0–3 months=short term; 4–12 months=medium term and; >12 months=long term), and standardised mean differences (SMD) with 95% CIs were used to establish intervention effect sizes. Study quality was assessed using modified PEDro scores.  Results: 19 trials were included. Four studies showed short-term benefits favouring water-based exercise over minimal control using the WOMAC pain subscale (SMD −0.53, 95% CI −0.96 to −0.10). Six studies supported a short-term benefit of land-based exercise compared to minimal control on VAS assessed pain (SMD −0.49, 95% CI −0.70 to −0.29). There were no medium (SMD −0.23, 95% CI −0.48 to 0.03) or long (SMD −0.22, 95% CI −0.51 to 0.06) term benefits of exercise therapy, or benefit of combining exercise therapy with manual therapy (SMD −0.38, 95% CI −0.88 to 0.13) when compared to minimal control.  Conclusions: Best available evidence indicates that exercise therapy (whether land-based or water-based) is more effective than minimal control in managing pain associated with hip OA in the short term. Larger high- quality RCTs are needed to establish the effectiveness of exercise and manual therapies in the medium and long term.

 

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?

Was publication bias assessed?

  • Yes

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

  • Yes

 

Key Finding #1

Land-based and water-based exercise programs demonstrated benefits compared to control interventions for patients with hip OA, but effects on in improvement were small.

Key Finding #2

No medium- or long-term benefits were seen for land-based exercise programs for patients with hip OA.

Key Finding #3

Manual therapy did not demonstrate benefits when combined with exercise, or when performed in isolation

 

Please provide your summary of the paper

This systematic review and meta-analysis demonstrated that for patients with hip OA, employing a combination of aquatic and land-based therapies demonstrated effectiveness for short-term pain reduction compared to minimal intervention. However, exercise therapy did not demonstrate strong and lasting effects in medium- and long-term follow-ups. When assessing the effects of manual therapy with and without exercise, none of the cases studied demonstrated a positive benefit compared to exercise therapy or minimal intervention. The overall results of this systemic review and meta-analysis suggest that exercise therapy can produce positive short term benefits for pain associated with hip OA, while manual therapy does not appear to contribute to reduction of pain. The study also demonstrated the need for further investigation in medium and long term benefits of exercise therapy for hip OA.

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

This systematic review and meta-analysis could have the potential to contradict clinicians’ bias towards manual therapy for hip OA. Prior to reading the article, many clinicians may assume that manual therapy would be a great intervention to use to treat patients with hip OA who are experiencing pain. Instead, it demonstrated how important exercise therapy can be to reduce patients’ pain, and that manual therapy did not demonstrate any positive benefit. However, it is still not known what the medium and long term benefits of exercise are for pain related to hip OA. Regardless, when treating patients with hip OA, maintaining primary focus on exercise interventions for reducing pain and recommendations for implementation of aquatic therapy along with land-based therapy would be beneficial for pain reduction in this patient population.