Author Names

Mohammad Kashif Reza, Mohammad Abu Shaphe, Mohammed Qasheesh, Mudasir Nazar Shah, Ahmad H Alghadir, and Amir Iqbal

Reviewer Name

Megan Shoemaker, SPT

Reviewer Affiliation(s)

Duke University Doctor of Physical Therapy Department

 

Paper Abstract

Purpose The current study aimed to determine the efficacy of specified manual therapies in combination with a supervised exercise protocol for managing pain intensity and functional disability in patients with knee osteoarthritis.  Methods The study was based on a two-arm parallel-group randomized controlled trial design, including a total of 32 participants with knee osteoarthritis randomly divided into groups A and B. Group A received a supervised exercise protocol; however, group B received specified manual therapies in combination with a supervised exercise protocol. Pain and functional disability were measured with the numeric pain rating scale (NPRS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), respectively. Data were collected at baseline (pre-intervention), 2 weeks, and 4 weeks post-intervention. To evaluate the efficacy of specific manual therapies with supervised exercise compared to supervised exercise alone, an unpaired t-test and repeated measures ANOVA were used to analyze the data, keeping the level of significance at p<0.05.  Results A significant (p<0.05) mean difference (∆MD) was found within group A and group B for both outcomes when we compared their baseline scores with 2-week (group A, NPRS: ∆MD=−1.56 and WOMAC: ∆MD=14.94; group B, NPRS: ∆MD=2.06 and WOMAC: ∆MD=22.19) and 4-week post-intervention scores (group A, NPRS: ∆MD=0.62 and WOMAC: ∆MD=6.75; group B, NPRS: ∆MD=0.75 and WOMAC: ∆MD=11.12). In addition, significant mean differences (p<0.05) reported for both outcomes when we compared their scores between groups A and B at 2 weeks (∆MD: NPRS=0.69; WOMAC=10.87) and 4 weeks post-intervention (∆MD: NPRS=0.31; WOMAC=8.00). Furthermore, a post hoc Scheffe analysis for the outcomes NPRS and WOMAC revealed the superiority of group B over group A.  Conclusion The specified manual therapies, in combination with a supervised exercise protocol, were found to be more effective than a supervised exercise protocol alone for improving pain and functional disability in patients with knee osteoarthritis.

 

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

  1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT?
  • Yes
  1. Was the method of randomization adequate (i.e., use of randomly generated assignment)?
  • Yes
  1. Was the treatment allocation concealed (so that assignments could not be predicted)?
  • Yes
  1. Were study participants and providers blinded to treatment group assignment?
  • Cannot Determine, Not Reported, or Not Applicable
  1. Were the people assessing the outcomes blinded to the participants’ group assignments?
  • No
  1. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
  • Yes
  1. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
  • No
  1. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
  • Cannot Determine, Not Reported, or Not Applicable
  1. Was there high adherence to the intervention protocols for each treatment group?
  • Yes
  1. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
  • Yes
  1. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
  • Yes
  1. 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
  1. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
  • No
  1. 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

Combining LE strengthening exercises as well as manual therapy is the most effective in treating knee osteoarthritis pain and disability.

Key Finding #2

Although manual therapy and an exercise program reduce the most pain, the retention of decreased pain was no different in the combination group than the exercise-only group.

Key Finding #3

This study only reaccessed at weeks 2 and 4 so there is an unknown to effectiveness long-term.

Key Finding #4

The exercise program only included strengthening and stretching and the manual therapy only included the myofascial mobilization technique and the myofascial manipulation technique.

 

Please provide your summary of the paper

This randomized controlled trial observed the pain control benefits of a supervised exercise protocol vs the supervised exercise protocol in combination with manual therapy in patients with knee osteoarthritis. All patients had to be within 47-60 years of age, had morning stiffness for <30 min, experienced mild-moderate knee pain in one or both knees for 3 months, had a pain rating of 2-6/10, reported knee crepitus during knee movements, and diagnosed knee OA on radiographs. Results showed that after 2 weeks, the combination therapy group individuals self-reported less pain than the exercise-only group. Still, after 4 weeks there was no evidence of a strong retention of decreased pain in the combination therapy group. More research needs to be done to show the long-term effects of manual therapy coupled with an exercise protocol for reduction in pain rating and functional disability.

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

For this randomized controlled trial, there is evidence that coupling manual therapy with typical exercise is the most beneficial to short-term pain reduction for patients with knee osteoarthritis. However, I would not rely solely on this study as there are many limitations such as a very specific exercise protocol and manual therapy techniques. Knowing the strengths of this article, incorporating manual therapy with routine physical therapy sessions could be very beneficial in reducing pain during flare-ups of increased knee pain with our osteoarthritic patients. Clinically, manual therapy may not be used in every session with patients with knee osteoarthritis, although, during short-term pain bouts manual therapy is a tool that can be used for pain modulation.