Author Names
French, H; Cusack, T; Brennan, A; Caffrey, A; Conroy, R; Cuddy, V; FitzGerald, O; Gilsenan, C; Kane, D; O’Connell, P; White, B; McCarthy, G
Reviewer Name
Morgan Baxter, SPT
Reviewer Affiliations
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Objectives: To determine the effectiveness of exercise therapy (ET) compared with ET with adjunctive manual therapy (MT) for people with hip osteoarthritis (OA); and to identify if immediate commencement of treatment (ET or ET+MT) was more beneficial than a 9-week waiting period for either intervention. Design: Assessor-blind randomized controlled trial with a 9-week and 18-week follow-up. Setting: Four academic teaching hospitals in Dublin, Ireland. Participants: Patients (N=131) with hip OA recruited from general practitioners, rheumatologists, orthopedic surgeons, and other hospital consultants were randomized to 1 of 3 groups: ET (n=45), ET+MT (n=43), and waitlist controls (n=43). Interventions: Participants in both the ET and ET+MT groups received up to 8 treatments over 8 weeks. Control group participants were rerandomized into either ET or ET+MT groups after 9 week follow-up. Their data were pooled with original treatment group data: ET (n=66) and ET+MT (n=65). Main Outcome Measures: The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical function (PF) subscale. Secondary outcomes included physical performance, pain severity, hip range of motion (ROM), anxiety/depression, quality of life, medication usage, patient-perceived change, and patient satisfaction. Results: There was no significant difference in WOMAC PF between the ET (n=66) and ET+MT (n=65) groups at 9 weeks (mean difference, .09; 95% confidence interval [CI] −2.93 to 3.11) or 18 weeks (mean difference, .42; 95% CI, −4.41 to 5.25), or between other outcomes, except patient satisfaction with outcomes, which was higher in the ET+MT group (P=.02). Improvements in WOMAC, hip ROM, and patient-perceived change occurred in both treatment groups compared with the control group. Conclusions: Self-reported function, hip ROM, and patient-perceived improvement occurred after an 8-week program of ET for patients with OA of the hip. MT as an adjunct to exercise provided no further benefit, except for higher patient satisfaction with outcome.
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?
- No
- 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?
- Cannot Determine, Not Reported, or Not Applicable
- 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?
- No
- 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
ET+MT for treatment of hip OA results in increased patient satisfaction compared to ET alone.
Key Finding #2
The addition of MT to an ET program does not change physical function outcomes for hip OA.
Key Finding #3
ET or ET+MT are more effective than no treatment for hip OA.
Please provide your summary of the paper
Participants with hip OA were randomized into the ET, ET+MT, or control groups for 9 weeks. The ET group had 6-8 30-minute sessions that mainly targeted glute strengthening and were given a home exercise program. The ET+MT group had an additional 15 minutes during each session where they received mobilization manual therapy techniques. After 9 weeks the control group was randomized into ET or ET+MT groups. While self-reported physical function, active hip ROM, pain, and functional outcomes such as 5x sit to stand or 50 ft walk tests showed no significant difference between the ET or ET+MT groups at 9 and 18 weeks, the ET+MT group had significantly higher patient satisfaction. Compared to the control group, both ET and ET+MT groups had significantly improved WOMAC scores for physical function, perceived improvement, and active hip ROM at 9 weeks. This study did not show that manual therapy would improve functional outcomes for hip OA, but showed it could be beneficial to increase patient satisfaction with their care. It also showed that treatment, whether that be ET or ET+MT, was more beneficial than no treatment 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.
Physical therapy intervention, whether that be exercise therapy or exercise therapy in conjunction with mobilization techniques, improves physical outcomes in individuals with hip OA. While manual therapy does not cause greater physical improvements than exercise alone for those with hip OA, it can be a useful tool to improve patient satisfaction.
