Hip

Author Names

Wright, A., Hegedus, E., Taylor, J., Dischiavi, S., Stubbs, A

Reviewer Name

Margaret Pohl, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objectives: To determine the efficacy of physical therapy on pain and physical function in patients with femoroacetabular impingement.

Design: Randomized, participant- and assessor blinded controlled trial pilot study.

Methods: This trial was registered at ClinicalTrials.gov (NCT01814124) and reported according to Con- solidated Standards of Reporting Trials (CONSORT) requirements. Patients were randomly assigned to receive either a combination of manual therapy and supervised exercise (MTEX), plus advice and home exercise or advice and home exercise alone (Ad + HEP) over six weeks. Primary outcomes were average pain (Visual Analog Scale) and physical function (Hip Outcome Score) at week seven.

Results: Fifteen patients, mean age 33.7 (SD 9.5, 73% female) satisfied the eligibility criteria and completed week seven measurements. The between group differences for changes in pain or physical function were not significant. Both groups showed statistically significant improvements in pain: the MTEX group improved a mean of 17.6 mm and the Ad + HEP group, 18.0 mm.

Conclusions: The results of this pilot study provide preliminary evidence that symptomatic femoroac- etabular impingement may be amenable to conservative treatment strategies however further full-scale randomized controlled trials are required to demonstrate this. In this small pilot study, supervised man- ual therapy and exercise did not result in greater improvement in pain or function compared to advice and home exercise in patients with symptomatic femoroacetabular impingement.

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

2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?

• Yes

3. Was the treatment allocation concealed (so that assignments could not be predicted)?

• Yes

4. Were study participants and providers blinded to treatment group assignment?

• Yes

5. Were the people assessing the outcomes blinded to the participants’ group assignments?

• Yes

6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

• Yes

7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

• Yes

8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

• Yes

9. Was there high adherence to the intervention protocols for each treatment group?

• Yes

10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

• Yes

11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

• Yes

12. 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

13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

• Yes

14. 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

No significant between-group differences were observed in primary or secondary outcomes at week 7.

Key Finding #2

Advice and Home-Exercise (ad + HEP) group showed statistically significant improvements in the HOS (hip outcome scale) ADL and Sport sub-scales.

Key Finding #3

Both groups, manual therapy with exercises and advice with HEP, showed statistically significant improvements in pain as well as hip flexion range of motion.

Please provide your summary of the paper

This study looked to compare physical therapy treatment approaches for patients with femoacetabular impingement (FAI).  The study originally had 18 participants satisfying the eligibility and completing the baseline examination with 15 of the original 18 patients completing the 7-week follow-up.  Of the 15, 8 were randomly placed in the Advice and Home-Exercise (ad + HEP) group and 7 were placed in the Manual Therapy and Exercise group.  Both groups used the same primary outcome measures of average pain, measured by the Visual Analog Scale, and physical function measured by the Hip Outcome Scale, 7 weeks after the beginning of the study.  Overall, both groups showed statistically significant improvements in pain as well as significant hip flexion range of motion.  There was no statistical difference between the two groups in pain or physical function improvements.  Overall, the study shows that, over a 6-week treatment time period, both physical therapy interventions of manual therapy and home exercise programs provided the patients with clinical improvements in both functional abilities and pain levels.

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

I think that this study is very important to the future of treatment approaches for FAI.  As this is the first study to look at the combination of manual therapy with supervised exercise in patients with FAI, and had a very small sample size, more information would be gained from a larger study with more participants and therefore more data.  As the intervention of manual therapy and exercise in comparison to the advice and HEP both showed improvement to the patient’s function and pain levels, this study supports the need for more research of the intervention.  Clinically, as there is no statistical difference between the two treatment groups, patient preference and response should be taken into consideration when determining individual treatment courses.

Author Names

Weir, A.; Jansen, J.A.C.G.; van de Prot, I.G.L.; Van de Sande, H.B.A., Tol, J.L.; Backx, F.J.G.

Reviewer Name

Abigail Reichow, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Hypothesis: A multi-modal treatment program (MMT) is more effective than exercise therapy (ET) for the treatment of long-standing adductor-related groin pain. Study design: Single blinded, prospective, randomized controlled trial.  Methods: Patients: Athletes with pain at the proximal insertion of the adductor muscles on palpation and resisted adduction for at least two months. Interventions: ET: a home-based ET and a structured return to running program with instruction on three occasions from a sports physical therapist. MMT: Heat, Van den Akker manual therapy followed by stretching and a return to running program. Primary outcome: time to return to full sports participation.  Secondary outcome measures: objective outcome score and the visual analogue pain score during sports activities. Outcome was assessed at 0, 6, 16 and 24 weeks.   Results: Athletes who received MMT returned to sports quicker (12.8 weeks, SD 6.0) than athletes in the ET group (17.3 weeks, SD 4.4. p 1⁄4 0.043). Only 50e55% of athletes in both groups made a full return to sports. There was no difference between the groups in objective outcome (p 1⁄4 0.72) or VAS during sports (p 1⁄4 0.12).  Conclusions: The multi-modal program resulted in a significantly quicker return to sports than ET plus return to running but neither treatment was very effective.

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)?

• Cannot Determine, Not Reported, or Not Applicable

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?

• Cannot Determine, Not Reported, or Not Applicable

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

• Cannot Determine, Not Reported, or Not Applicable

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

Athletes receiving manual therapy interventions for adductor-related groin pain demonstrated quicker return to sport on average (12.8 weeks) when compared to athletes receiving exercise therapy (17.3 weeks).

Key Finding #2

There was no statistically significant difference in objective treatment outcome rating between the athletes who received manual therapy and the athletes who received exercise therapy interventions.

Key Finding #3

Both groups (manual therapy and exercise therapy) had significant improvements in pain score at 16 weeks from baseline. There was no significant difference in pain score between groups.

Key Finding #4

There was no significant difference in hip range of motion when compared to baseline following both treatments (manual therapy or exercise therapy) or between groups.

Please provide your summary of the paper

This study was a randomized controlled clinical trial that included two intervention groups: exercise therapy (ET) and mixed-modal treatment (MMT). ET has the highest level of evidence for the treatment of groin pain from previous studies. Athletes in the ET group received training on a home exercise program (HEP) which they performed three times a week for two weeks. At two weeks they returned to physical therapy to receive a progression of their HEP, and at six weeks they received a return to running program. Athletes in the MMT group received heat therapy, followed by Van Den Akker manual therapy, and stretching for two weeks. If no pain was experienced after the two weeks, these athletes then progressed to the return to running program. Both groups were assessed by a blinded physician at baseline and at 6 and 16 weeks following treatment. Time to return to sport, objective outcome rating, pain score using visual analog scale (VAS), and hip range of motion were assessed and used to determine outcomes of both intervention groups. The study found that athletes in the MMT group demonstrated quicker return to sport on average (12.8 weeks) when compared to athletes receiving ET (17.3 weeks). There was no statistically significant difference in objective treatment outcome ratings between the athletes who received MMT and the athletes who received ET. Additionally, both groups had significant improvements in pain score at 16 weeks from baseline yet there was no significant difference in pain score between groups. Finally, there was no significant difference in hip range of motion when compared to baseline following both treatments or between groups.

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

Adductor-related groin pain is a common complaint in athletes involving cutting, sprinting, and twisting motions such as soccer, football, and rugby to name a few. While many athletes recover quickly, chronic incidences of groin pain can cause significant delays in return to sport. This study aimed to determine the efficacy of both ET and MMT for the treatment of adductor-related groin pain in athletes. The results of this study show that both ET and MMT are effective treatments for groin pain in this population. Both groups showed significant reductions in pain score as well as overall return to sport and therefore, can be employed as treatments in this population. MMT did show quicker return to sport on average when compared to ET and therefore, could be used as the preferred treatment if time to return to sport is a major factor in the athlete’s treatment plan. However, athletes in the MMT group began the return to running program quicker than the ET group, which may account for the finding of earlier return to sport. Standardization of the transition to the return to running program between ET and MMT may provide more insight that will assist in better comparing return to sport in both groups. Further research should be done to include a control group as well as a group that receives both ET and MMT to determine the best course of treatment for these athletes.

Author Names

Abbott, J. H., Robertson, M. C., Chapple, C., Pinto, D., Wright, A. A., Leon de la Barra, S., Baxter, G. D., Theis, J. C., Campbell, A. J

Reviewer Name

Abbrianna Robert

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 1⁄4 54), multi-modal exercise physiotherapy (n 1⁄4 51), combined exercise and manual physiotherapy (n 1⁄4 50), or no trial physiotherapy (n 1⁄4 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 0e240. Intention to treat analysis showed adjusted re- ductions in WOMAC scores at 1 year compared with the usual care group of 28.5 (95% confidence interval (CI) 9.2e47.8) 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 1⁄4 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. Trial registration number: Australian New Zealand Clinical Trials Registry ACTRN12608000130369.

NIH Risk of Bias Score: 14/14

Key Findings of the Study:

1. Usual care plus manual therapy showed clinically significant improvements in the self-reported primary outcome, the Western Ontario and McMaster osteoarthritis index (WOMAC).
2. Usual care plus exercise therapy showed clinically significant improvements in all three physical performance measures (timed-up and go, 30-second sit to stand, and 40-meter self-paced walk test).
3. Usual care plus a combination of manual and exercise therapy was found to be generally less effective or no more effective than each intervention alone.

Reviewer Summary:

This study found that usual care in addition to manual therapy for individuals with hip and knee OA provided self-reported improvements on the WOMAC at 1-year post intervention, and usual care in addition to exercise therapy provided improvements in physical performance measures. Manual therapy and exercise therapy in addition to usual care was less effective or no more effective than usual care alone. This particular finding may be the result of insufficient time spent on each intervention when they were both performed in session. The authors suggest that therapists spend adequate time on each intervention if used together. Interestingly, the results include participants that received joint replacements prior to the 1-year assessment. Therefore, it is suggested that the subgroup analysis excluding these participants is likely to be a more accurate representation of the intervention effects.

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

This study showed that manual therapy can improve self-reported outcomes, for individuals with hip and knee osteoarthritis (OA), in domains including pain, quality of life, and general health. These results can be used to encourage the use of manual therapy and conservative care for individuals with OA, to improve function and postpone surgical intervention.

Author Names

Galleher, M., Crowe, B., & Selhorst, M.

Reviewer Name

Rose O’Donoghue, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

OBJECTIVE: The purposes of this study were to: (1) assess the benefit of adding manual therapy (MT) to physical therapy care in pediatric patients with anterior hip pain; (2) assess the relative risk of adverse reactions when MT is used; and (3) report the types of MT used. METHODS: This study was a retrospective chart review of patients treated in a hospital-based sports medicine clinic. The charts of 201 patients (mean age = 14.23 ± 2.15 years) met the inclusion criteria and were reviewed. Patients were grouped into those who received MT during their episode of care, and those who did not. Pain efficiency (change in pain/number of visits), number and type of adverse reactions, as well as frequency and type of manual therapy interventions used, were the outcomes of interest. RESULTS: The mean pain efficiency was significantly less if manual therapy was performed (MT = 0.60 [95% CI 0.47–0.72], no MT = 0.80 [95% CI 0.71–0.90] p = 0.01). There was no significant difference between groups in risk of adverse reactions (MT = 5, no MT = 5). The number of visits was significantly different between groups (MT = 9.43 ± 3.9 sessions, and no MT = 7.6 ± 5.2 sessions). DISCUSSION: MT did not increase the risk of an adverse reaction in pediatric patients with anterior hip pain. While it appears to be a safe intervention, it did not improve pain efficiency or patient adherence. Future research should be performed to assess the effectiveness of MT, when performed by skilled therapists, in pediatric patients with hip pain in a controlled manner.

NIH Risk of Bias Tool

Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies

1. Was the research question or objective in this paper clearly stated?

• Yes

2. Was the study population clearly specified and defined?

• Yes

3. Was the participation rate of eligible persons at least 50%?

• Cannot Determine, Not Reported, Not Applicable

4. Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants?

• Yes

5. Was a sample size justification, power description, or variance and effect estimates provided?

• No

6. For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured?

• Yes

7. Was the timeframe sufficient so that one could reasonably expect to see an association between exposure and outcome if it existed?

• Yes

8. For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e.g., categories of exposure, or exposure measured as continuous variable)?

• No

9. Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?

• No

10. Was the exposure(s) assessed more than once over time?

• Yes

11. Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?

• Cannot Determine, Not Reported, Not Applicable

12. Were the outcome assessors blinded to the exposure status of participants?

• Yes

13. Was loss to follow-up after baseline 20% or less?

• Yes

14. Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)?

• No

Key Finding #1

Manual therapy did not increase the risk of an adverse reaction in pediatric patients with anterior hip pain (no significant difference between groups).

Key Finding #2

The average pain efficiency (change in pain/number of visits) was significantly lower when manual therapy was incorporated into the treatment session.

Key Finding #3

Manual therapy was shown to be a safe intervention for pediatric patients with a diagnosis of anterior hip pain, however, it resulted in a lower pain efficiency.

Please provide your summary of the paper

This study examined the potential benefits and risks of adding manual therapy to physical therapy care in pediatric patients with anterior hip pain. While manual therapy was shown to be a safe intervention, it was actually significantly less efficient in reducing pain among patients in this population. Since this was a retrospective study and there was limited reporting of outcome measures, there were limitations as to what could be analyzed (effect of manual therapy on function, level of disability, quality of manual therapy received, etc). Without the ability to evaluate the quality of manual therapy performed, there was no way to control for differences between therapists and their techniques used. Further studies are needed in which the manual therapy received can be standardized among patients.

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

This study concluded that there is no increased risk of adverse reactions when incorporating manual therapy into the treatment of pediatric patients with anterior hip pain. This means that it is a safe treatment method for this population. While there was less pain improvement in those who received manual therapy, every patient responds differently so implementing some form of manual may be beneficial depending on the patient’s reported pain response.

Author Names: Harris-Hayes, M., Zorn, P., Steger-May, K., Burgess, M. M., DeMargel, R. D., Kuebler, S., Clohisy, J., & Haroutounian, S.

Reviewer Name: Abbie Bushinski, SPT

Reviewer Affiliation(s): Duke University School of Medicine, Doctor of Physical Therapy Program

Paper Abstract:

Objective: The objective of this study was to assess the feasibility of completing a randomized clinical trial (RCT) and examine the preliminary effects of 2 interventions for hip-related groin pain (HRGP).

Methods: In this pilot RCT, patients with HRGP, who were 18 to 40 years old, were randomized (1:1 ratio) to a joint mobilization (JtMob) group or a movement pattern training (MoveTrain) group. Both treatments included 10 supervised sessions and a home exercise program. The goal of JtMob was to reduce pain and improve mobility through peripherally and centrally mediated pain mechanisms. The key element was physical therapist-provided JtMob. The goal of MoveTrain was to reduce hip joint stresses by optimizing the biomechanics of patient-specific tasks. The key element was task-specific instruction to correct abnormal movement patterns displayed during tasks. Primary outcomes were related to future trial feasibility. The primary effectiveness outcome was the Hip Disability and Osteoarthritis Outcome Score. Examiners were blinded to group; patients and treatment providers were not. Data collected at baseline and immediately after treatment were analyzed with analysis of covariance using a generalized linear model in which change was the dependent variable and baseline was the covariate. The study was modified due to the coronavirus disease 2019 (COVID-19) pandemic.

Results: The COVID-19 pandemic affected participation; 127 patients were screened, 33 were randomized (18 to the JtMob group and 15 to the MoveTrain group), and 29 (88%) provided post treatment data. Treatment session adherence was 85%, and home exercise program component adherence ranged from 71 to 86%. Both groups demonstrated significant mean within-group improvements of ≥5 points on Hip Disability and Osteoarthritis Outcome Score scales. There were no between-group differences in effectiveness outcomes.

Conclusions: A large RCT to assess the effects of JtMob and MoveTrain for patients with HRGP may be feasible. Preliminary findings suggested that JtMob or MoveTrain may result in improvements in patient-reported pain and activity limitations. Impact: The COVID-19 pandemic interfered with participation, but a randomized controlled trial may be feasible. Modification may be needed if the trial is completed during future pandemics.

Keywords: Femoroacetabular Impingement, Hip Dysplasia, Joint Mobilization, Kinematics, Movement System, Musculoskeletal, Physical Therapy, Physiotherapy, Rehabilitation

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)?

Cannot determine

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

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)?

No

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)?

Cannot determine

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

One of the goals of this RCT was to determine if a larger RCT would be feasible for the future. The RCT did determine that further trials with larger subject pools may be feasible and that there is a need for further assessments to draw sound conclusions on the efficacy of JtMob and MoveTrain interventions on hip-related groin pain. The feasibility of future research was determined through an assessment of patient recruitment, adherence/attendance, and HEP performance.

Key Finding #2

The RCT determined that both intervention groups (the MoveTrain and the JtMob) were deemed safe interventions to utilize in patients with hip-related groin pain. Additionally, the RCT concluded that both interventions demonstrated improvements in pain and activity limitations as measured by improvements on their HOOS and that there weren’t any significant differences between the two groups.

Key Finding #3

Although both intervention groups demonstrated improvements as measured by the HOOS. The participants in the MoveTrain group had additional improvements in their movement quality during single-leg tasks such as a single-leg squat. However, neither intervention group had a significant effect on increasing the patient’s pain pressure threshold.

Please provide your summary of the paper

Participants of this RCT were between the ages of 18-40yrs old and had reports of hip or groin pain that was at least a 3/10 and lasted for at least 3 months. Following recruitment, the hip ROM of each patient was screened in several different positions and their onset of pain with motion was recorded. Additionally, activity limitations were assessed before treatment by using the HOOS, single-leg squats were assessed to determine movement quality, and pain pressure thresholds were assessed using Wagner instruments. Following the baseline screening, patients were randomly assigned to either the JtMOB or MoveTrain intervention groups. The JtMOB group focused on the utilization of manual mobilization techniques that targeted specific hip ROM limitations that were associated with activity limitations experienced by the patients. Whereas, the MoveTrain group focused on task-specific training and the improvement of movement patterns during these specific tasks. Both intervention groups underwent 12 weeks of treatment and were given a specific HEP to follow and then a reassessment of pain, activity limitations, movement quality, and pain pressure thresholds was completed. Overall, the study found positive results associated with decreased pain and activity limitations in both groups. However, the RCT also highlighted limitations of this study such as having a small sample size due to recruitment difficulties caused by COVID-19. Therefore, the study determined that further research is needed to assess the long-term effects of these treatments on hip-related groin pain and identified the need for the completion of future trials with larger sample sizes to effectively determine if there is a positive effect of JtMOB and MoveTrain interventions on hip-related groin pain.

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

Overall, the RCT highlights a positive correlation between JtMOB and MoveTrain interventions on reductions in pain and activity limitations. However, the study also determined that there were limitations in the study such as having a small sample size. Due to these study limitations, more research needs to be conducted utilizing larger sample sizes to determine the long-term effects of JtMOB and MoveTrain interventions on hip-related groin pain. Overall, this study did conclude that both interventions may be impactful in improving pain and activity limitations and that both interventions are safe for clinical implementation.

Author Names: Weckström, Kristoffer and Söderströmb, Johan

Reviewer Name: Holly Brown

Reviewer Affiliation(s): Duke University School of Medicine, Division of Physical Therapy (DPT)

Paper Abstract: Background: Although different conservative treatment options have been proposed, there is a paucity of research on the management of iliotibial band syndrome (ITBS) in runners. Objective: To compare two treatment protocols for ITBS; radial shockwave therapy (RSWT) and manual therapy (ManT). Both therapies were administered concurrently with an exercise rehabilitation programme. Methods: The study was designed as a randomised controlled clinical trial. Twenty-four runners with ITBS received 3 treatments at weekly intervals of either RSWT (n= 11) or ManT (n= 13). In addition, all subjects followed an exercise programme for at least 4 weeks. Main outcome measures were established as mean differences (MD) in pain during treadmill running. Results: There was no significant difference in pain reduction between the two interventions at 4 weeks (p= 0.796), and 8 weeks (p= 0.155) follow-up. Thus, both groups reported similar magnitude of reduced pain during the intervention (p= 0.864). The shockwave therapy (SWT) group reported a 51% decrease in pain at week 4 (p= 0.022), and a 75% decrease at week 8 (p= 0.004). The ManT group showed a 61% reduction in pain at week 4 (p= 0.059), and a 56% reduction at week 8 (p= 0.067). Conclusions: RSWT and ManT were equally effective in reducing pain in subjects with ITBS.

Quality Assessment Tool for Before-After (Pre-Post) Studies With No Control Group

Was the study question or objective clearly stated?

Yes

Were eligibility/selection criteria for the study population prespecified and clearly described?

Yes

Were the participants in the study representative of those who would be eligible for the test/service/intervention in the general or clinical population of interest?

Yes

Were all eligible participants that met the prespecified entry criteria enrolled?

Yes

Was the sample size sufficiently large to provide confidence in the findings?

No

Was the test/service/intervention clearly described and delivered consistently across the study population?

Yes

Were the outcome measures prespecified, clearly defined, valid, reliable, and assessed consistently across all study participants?

No

Were the people assessing the outcomes blinded to the participants’ exposures/interventions?

Yes

Was the loss to follow-up after baseline 20% or less? Were those lost to follow-up accounted for in the analysis?

Yes

Did the statistical methods examine changes in outcome measures from before to after the intervention? Were statistical tests done that provided p values for the pre-to-post changes?

Yes

Were outcome measures of interest taken multiple times before the intervention and multiple times after the intervention (i.e., did they use an interrupted time-series design)?

Yes

If the intervention was conducted at a group level (e.g., a whole hospital, a community, etc.) did the statistical analysis take into account the use of individual-level data to determine effects at the group level?

NA/Unable to be determined

Key Finding #1: Both radial shockwave therapy (RSWT) and manual therapy (ManT) led to significant overall pain reduction over time, with no significant group x time interaction. No significant differences in effect on pain reduction between the SWT and ManT groups were found at any of the measured time points.

Key Finding #2: Participants receiving SWT reported significant pain reductions of 51% from baseline to week 4 and 75% from baseline to week 8. Pain-free treadmill tests were reported by 55% at week 4 and week 8.

Key Finding #3: Participants in the ManT group tended to report reduced pain from baseline to week 4 and from baseline to week 8. Pain-free treadmill tests were reported by 70% at week 4 and 44% at week 8.

Key Finding #4: All participants who were pain-free at week 8, regardless of the intervention they received, remained pain-free at the 6 month follow-up.

Please provide your summary of the paper

This randomized clinical trial compared the efficacy of two treatment protocols–radial shockwave therapy (RSWT) and manual therapy (ManT)–in decreasing the pain of runners with iliotibial band syndrome (ITBS). A sample of 24 eligible runners were randomized into two treatment groups, with interventions being administered over 3 treatment sessions at weekly intervals concurrently with an exercise rehabilitation program. Pain was measured using Noble’s test and a treadmill run test at baseline, with follow-ups conducted at 4 weeks, 8 weeks, and a phone call symptom check at 6 months. The research team concluded that neither treatment could be recommended over the other, but noted that both treatment groups had a similar decrease in pain levels. However, the lack of a control group, small sample size, and higher loss to follow up, limit the clinical application of these findings.

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

This research demonstrates a comparable effectiveness between RSWT and ManT in the conservative management of ITBS in runners when combined with an exercise program. However, the methodological shortcomings, including the lack of a control, a smaller sample size, and significant loss to follow up, limit the generalizability of these findings. Additionally, since both treatment groups concurrently participated in an exercise rehabilitation program throughout the study, it is impossible to determine to what degree this exercise contributed to the findings. Though, this does serve to help emphasize a structured and progressive exercise program as a cornerstone in the management of ITBS. It also highlights that RSWT and ManT do not seem to negatively impact recovery, with positive effects persisting in the long-term. This opens doors for future research discussions based on larger, randomized controlled trials to better evaluate the efficacy of treatment options for ITBS in isolation in runners.

Author Names: Qiong Wang, Teng-teng Wang, Xiao-feng Qi, Min Yao, Xue-jun Cui, Yong-jun Wang, and Qian-qian Liang.

Reviewer Name: Torri Tippett

Reviewer Affiliation(s): Duke University School of Medicine, Doctor of Physical Therapy
Division

Paper Abstract:
Background: Hip osteoarthritis (HOA) is one of the major causes of disability in seniors and
is costly to society. Manual therapy is one therapeutic approach to treating HOA.

Objectives: To assess the eOect of manual therapy compared to the placebo or wait-list/no
treatment or a minimal intervention control for HOA at post-treatment and short-,
intermediate- and long-term follow-ups.

Study Design: A systematic review and meta-analysis of randomized controlled trials
(RCTs).

Setting: Hospital outpatient clinic in China.

Methods: We searched PubMed, EMBASE, the Cochrane Library, CINAHL, ISI web of
knowledge, and Chinese databases from the inception to October 2014 without language
restrictions. References of systematic reviews and other related reviews, files in our
department, and conference proceedings as grey literature were also screened by hand.
RCTs compared manual therapy to the placebo, wait-list/no treatment or a minimal
intervention control with an appropriate and precise description of randomization. Two
reviewers independently conducted the search results identification, data extraction, and
methodological quality assessment. We calculated the risk difference (RD) for
dichotomous data and the mean difference (MD) or standardized mean difference (SMD)
for continuous data in a fixed or random effect model.

Outcome Measures: The primary outcomes were self-reported pain in the past week and physical function. The secondary outcomes were the quality of life, global perceived effect, patients’ satisfaction, cost, and adverse events.

Results: Six studies involving 515 HOA patients were included. Five of the 6 studies ranked
as high quality in the methodological assessment. Immediately post-treatment, there was
low-quality evidence that manual therapy could not statistically significantly relieve pain
(SMD: -0.07 [95%CI -0.38 to 0.24]); for physical function, a moderate quality of evidence
showed that manual therapy could not improve the physical function significantly (SMD:
0.14 [95%CI -0.08 to 0.37]). We still found low-quality evidence that manual therapy did not
benefit the patients in the global perceived eOect (RD: 0.12 [95%CI -0.12 to 0.36]), and in
terms of quality of life. In addition, the risks of patients in the manual therapy group was
0.13 times higher than that in the controls (RD: 0.13 [95%CI -0.05 to 0.31]) in the low quality evidence studies. We could not find any evidence that manual therapy benefits the
patients at short-, intermediate- or long-term follow-up. There were no studies reporting
patients’ satisfaction or cost.
Limitations: The limitations of this systematic review include the paucity of literature and inevitable heterogeneity between included studies.

Conclusion: This review did not suggest there was enough evidence for manual therapy for
the management of HOA. However, we are not confident in making such a conclusion due
to the limitations listed above.

Quality Assessment of Systematic Reviews and Meta-Analyses
1. Is the review based on a focused question that is adequately formulated and
described? Yes
2. Were eligibility criteria for included and excluded studies predefined and
specified? Yes
3. Did the literature search strategy use a comprehensive, systematic approach?
Yes
4. Were titles, abstracts, and full-text articles dually and independently reviewed
for inclusion and exclusion to minimize bias? Yes
5. Was the quality of each included study rated independently by two or more
reviewers using a standard method to appraise its internal validity? Yes
6. Were the included studies listed along with important characteristics and
results of each study? Yes
7. Was publication bias assessed? Yes
8. Was heterogeneity assessed? (This question applies only to meta-analyses.)
Yes

Key Finding #1
Manual Therapy for Hip Osteoarthritis: A Systematic Review and Meta-analysis found that
manual therapy did not significantly reduce pain in patients with hip osteoarthritis when
compared to placebo, wait-list/no treatment, or minimal intervention control groups. This
lack of significant eOect was observed at post-treatment, short-term, intermediate-term,
and long-term follow-ups.
Key Finding #2
Manual therapy did not result in a significant improvement in physical function for patients
with hip osteoarthritis across diOerent time frames (post-treatment and follow-up periods).
Key Finding #3
The study concluded that high-quality randomized controlled trials (RCTs) with larger
sample sizes and more consistent methodologies are needed to provide more definitive
conclusions regarding the effectiveness of manual therapy for treating hip osteoarthritis.
Key Finding #4
The authors noted that the quality of evidence was low due to several factors, including the
limited number of included studies, heterogeneity among them, and the small sample
sizes in many of the trials.

Please provide your summary of the paper
The study “Manual Therapy for Hip Osteoarthritis: A Systematic Review and Meta-analysis”
aimed to evaluate the eOectiveness of manual therapy in managing hip osteoarthritis
(HOA). The authors conducted a systematic review and meta-analysis of six randomized
controlled trials (RCTs) involving 326 participants. The analysis found that manual therapy
did not significantly reduce pain or improve physical function in HOA patients at posttreatment or during short-term, intermediate-term, and long-term follow-ups. The quality of evidence was assessed as low due to the limited number of studies, heterogeneity among them, and small sample sizes. The study concluded that there is insufficient evidence to support manual therapy as an eOective treatment for HOA and emphasized the need for high-quality RCTs with larger sample sizes and more rigorous methodologies to better assess its potential benefits.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Given the age of this article and the abundance of research published since its release, it is
unlikely that this study significantly influences current clinical practices regarding the use
of manual therapy for treating patients. Although the study does call for further high-quality
research in this area. Clinicians may support and advocate for future studies that explore
manual therapy’s role in HOA using larger sample sizes, improved methodologies, and
better reporting to determine under what conditions, if any, manual therapy might be
beneficial.

Author Names

Burns, S., Cleland, J., Rivett, D., O’Hara, M., Egan, W., Pandya, J., Snodgrass, S.

Reviewer Name

Katey Wang, SPT

Reviewer Affiliation(s)

Duke University

Paper Abstract

Objective: To determine whether adding hip treatment to usual care for low back pain (LBP) improved disability and pain in individuals with LBP and a concurrent hip impairment. Design: Randomized controlled trial. Methods: Seventy-six participants (age, 18 years or older; Oswestry Disability Index, 20% or greater; numeric pain-rating scale, 2 or more points) with LBP and a concurrent hip impairment were randomly assigned to a group that received treatment to the lumbar spine only (LBO group) (n = 39) or to one that received both lumbar spine and hip treatments (LBH group) (n = 37). The individual treating clinicians decided which specific low back treatments to administer to the LBO group. Treatments aimed at the hip (LBH group) included manual therapy, exercise, and education, selected by the therapist from a predetermined set of treatments. Primary outcomes were disability and pain, measured by the Oswestry Disability Index and the numeric pain-rating scale, respectively, at baseline, 2 weeks, discharge, 6 months, and 12 months. The secondary outcomes were fear-avoidance beliefs (work and physical activity subscales of the Fear-Avoidance Beliefs Questionnaire), global rating of change, the Patient Acceptable Symptom State, and physical activity level. We used mixed-model 2-by-3 analyses of variance to examine group-by-time interaction effects (intention-to-treat analysis). Results: Data were available for 68 patients at discharge (LBH group, n = 33; LBO group, n = 35) and 48 at 12 months (n = 24 for both groups). There were no between-group differences in disability at discharge (-5.0; 95% confidence interval [CI]: -10.9, 0.89; P = .09), 12 months (-1.0; 95% CI: -4.44, 2.35; P = .54), and all other time points. There were no between-group differences in pain at discharge (-0.2; 95% CI: -1.03, 0.53; P = .53), 12 months (0.1; 95% CI: -0.53, 0.72; P = .76), and all other time points. There were no between-group differences in secondary outcomes, except for higher Fear-Avoidance Beliefs Questionnaire (work subscale) scores in the LBH group at 2 weeks (-3.35; 95% CI: -6.58, -0.11; P = .04) and discharge (-3.45; 95% CI: – 6.30, -0.61; P = .02). Conclusion: Adding treatments aimed at the hip to usual low back physical therapy did not provide additional short- or long-term benefits in reducing disability and pain in individuals with LBP and a concurrent hip impairment. Clinicians may not need to include hip treatments to achieve reductions in low back disability and pain in individuals with LBP and a concurrent hip impairment. J Orthop Sports Phys Ther 2021;51(12):581-601. Epub 16 Nov 2021. 2021. doi:10.2519/jospt.2021.10593.

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?

No

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

N/A

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?

N/A

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

N/A

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

N/A

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 primary finding of this paper is that the addition of specific hip interventions to typical low back care did not significantly reduce standard low back pain nor improve disability when the patient presented with both low back and hip impairment. The addition of hip treatment such as: long axis distraction, AP hip mobilization, PA hip mobilization in flexion, abduction, and external rotation, and supine caudal non-thrust along with hip strengthening and mobility exercises were deemed unnecessary as it was just as effective as solely treating the low back.

Key Finding #2

Another key finding would involve the studies additional focus on the varying factors influencing low back pain such as socioeconomic status, medication, education level, fear avoidance, catastrophizing, and physical activity. Lower fear avoidance scores were reported for the group that only received back-focused care, however, these differences had no significant effect on the outcomes. Patients with lower initial fear avoidance scores experienced greater improvements with disability and pain, however this was inconsistent in patients with chronic symptoms and control of symptom duration did not reveal any differences between groups.

Please provide your summary of the paper

This study by Burns, S. et al., inquired about the effects of providing hip specific physical therapy intervention in addition to standard treatment of the low back for patients with coexisting low back and hip impairment on disability and back pain levels. The participants were randomly divided into 2 groups – one receiving independent low back treatment, and the other additionally receiving hip specific intervention as well. Manual therapy of the hip included distraction, manual glides and mobilization, and oscillatory non thrust force in addition to exercises. These methods were primarily measured by the Oswestry Disability Index and numeric pain rating scale at varying points of time. The results of the study demonstrate no significant benefit of the additional hip specific treatment, indicating a treatment plan focusing on the low back alone is sufficient to achieve goals of decreased pain and improved disability levels.

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

This study impacts clinical practice by providing evidence for clinicians to efficiently deliver care for patients with low back pain with concomitant hip impairment. Treatment plans for this population can be simplified to focus on techniques for the back instead of applying unnecessary hip treatments, in the case that the patients goals are to reduce their back pain and improve disability levels. Additionally, this will be a more efficient use of resources such as time and billing. Overall, treatment for this population can be streamlined and optimize patient outcomes without superfluous testing of the hip, allowing the clinician to efficiently deliver care.

Author Names

Studnicki, R., Skup, K., Sochaj, M., Niespodziński, B., Aschenbrenner, P., Laskowski, R., & Łuczkiewicz, P

Reviewer Name

Breanna Nachazel

Reviewer Affiliation(s)

Duke DPT

Paper Abstract

(1) Background: Activation of the gluteus medius (GM) muscle while minimizing the involvement of the tensor fascia latae (TFL) is crucial in treating many lower limb and lumbar spine injuries. Previous studies have demonstrated the effectiveness of joint manipulations in regulating muscle activity. The main objective of this study was to evaluate the effects of hip joint manipulation (HJM) on the muscle strength and activity (GM and TFL) of hip abductors in asymptomatic young participants. (2) Methods: The study followed a double-blind randomized controlled design. Thirty healthy, physically active women and men, free from spinal and lower limb injuries, voluntarily participated. The participants were allocated to two groups: those allocated to the HJM intervention and those in the control group receiving a sham intervention. They were assessed before and after the intervention using surface electromyography to measure muscle activation (EMGRMS) of the GM and TFL during maximal voluntary isometric hip abduction. (3) Results: HJM resulted in a significant increase in EMGRMS amplitude solely within the GM muscle (p < 0.01); (4) Conclusions: This study suggests that HJM may increase EMGRMS amplitude in the GM muscle; however, the effects are neither statistically nor clinically significant when compared to the control group for most of the muscles analyzed.

Key Finding #1

Changes in the SEMG (muscle activity) was found only in the gluteus medius during hip abduction after intervention. 

Key Finding #2

Neuromuscular recruitment patterns  on the TFL remained unaltered by the intervention. 

Key Finding #3

Results were variable based on each participant and there were no significant findings in muscle strength and limited findings in muscle activity. 

Please provide your summary of the paper

The purpose of this study was to look at the effectiveness of hip joint manipulation to help gluteus medius activation and decrease overactive TFL use. 30 participants were assessed for eligibility, none were excluded and then they were randomized equally into the 2 groups. The intervention group received a 1-s lateral hip manipulation, performed by the same therapist for each participant. The sham group mirrored the technique, but there was no tissue tension throughout the movement, and was blocked from reaching lateral movement. The given interventions were repeated twice by the same therapist to ensure reliability. Measurement of muscle strength and activity were recorded before and after the given interventions. Muscle strength was tested at the hip abductors through Biodex System 4. Muscle activity was tested at the tensor fasciae latae (TFL) and gluteus medius (GM) during maximum voluntary isometric contraction of hip abduction using the surface electromyography (SEMG). Post- hoc tests indicated that there is an observed increase in the intervention group for gluteus medius activation. 

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

This study is beneficial in showing a possible relationship between hip manipulation and muscle activity with the gluteus medius during hip abduction. Results were varied based on individual participants and showed inconsistencies with TFL activation and both GM and TFL strength. The study was helpful in determining possible benefits of hip joint manipulation in terms of hip abduction strength and activation. Further studies should be done to minimize variations in participants or to identify how those variations affect hip manipulation outcomes. 

Author Names: Kim L. Bennell, PhD; Thorlene Egerton, PhD; Joel Martin, BAppSc; J. Haxby Abbott, PhD; Ben Metcalf, BSci; Fiona McManus, BPhysio; Kevin Sims, PhD; Yong-Hao Pua, PhD; TimV.Wrigley, MSc; Andrew Forbes, PhD; Catherine Smith, MSc (Applied Statistics); Anthony Harris, MSc; Rachelle Buchbinder, PhD

Reviewer Name: Samantha Kim SPT

Reviewer Affiliation(s): Duke University

Paper Abstract: Hip osteoarthritis is a prevalent and costly chronic musculoskeletal condition. Clinical guidelines recommend conservative nonpharmacological physiotherapeutic treatments for symptomatic hip osteoarthritis, irrespective of disease severity, pain levels, and functional status. However, the costs of physical therapy are significant and evidence about the efficacy of physical therapy is inconclusive. Physical therapy typically takes a multimodal approach, which involves exercise, manual therapy, education and advice, and prescription of gait aids, if indicated. Although there is limited support for some components, namely, exercise and manual therapy, there is a paucity of trials evaluating multimodal approaches. Given the substantial contribution of the placebo effect to improvements following treatment of osteoarthritis, which includes contact with a caring therapist, these trials also require a sham control. The primary aim of this study was to test the hypothesis that a 12-week multimodal physical therapy program, with components typical of clinical practice, leads to greater improvements in pain and physical function than sham physical therapy among people with symptomatic hip osteoarthritis.

Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies

Was the research question or objective in this paper clearly stated? YES

Was the study population clearly specified and defined? YES

Was the participation rate of eligible persons at least 50%? YES

Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants? YES

Was a sample size justification, power description, or variance and effect estimates provided? YES

For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured? NO

Was the timeframe sufficient so that one could reasonably expect to see an association between exposure and outcome if it existed? YES

For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e.g., categories of exposure, or exposure measured as continuous variable)? YES

Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants? YES

Was the exposure(s) assessed more than once over time? YES

Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants? YES

Were the outcome assessors blinded to the exposure status of participants? YES

Was loss to follow-up after baseline 20% or less? YES

Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)? YES

Key Finding #1: The goal for the researchers was to see a correlation of a .60 standard deviation change between the different factors of pain, physical function, and baseline for 13 weeks.

Key Finding #2: When reviewing the results of the clinical trial, the between-groups of pain and functional saw significantly more significant improvement with the balance step test. As for the sham treatment group, they experienced overall improved pain relief at week 13.

Key Finding #3: When combining both exercise and manual therapy for specifically hip OA, there wasn’t a significant overall greater benefit for participants. At times, it caused more adverse interactions for hip OA.

Key Finding #4: Researchers identified that when approaching treatment for hip OA, recognizing the benefits of both active therapy and sham treatment obtained positive results, but that sham treatment might have been more effective due to the more patient-focused communication and encouragement.

Please provide your summary of the paper: This paper researched the overall effect of the patient’s experience and impairment improvement. This was measured by a randomized clinical trial where all participants were blind to their group and any expectations. All the participants were evaluated based on age, impairment, pain, function level, and imaging of the pelvic/hip region to have a common baseline. The results showed that patients with the sham treatment (caring PT with inactive ultrasound) had a significantly more significant impact on pain and function compared to solely just manual therapy and/or exercise therapy. Participants in other groups of manual therapy and exercise therapy experienced substantial improvement not in pain and function but not as much as the researchers hypothesized.

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

After reviewing the paper, I recognize the value of interventions and using other modalities, such as manual therapy, and the impact of a caring therapist. This clinical trial provided significant data on patient care and the value of placebo effects and patient-focused treatment, especially for patients with chronic pain. The paper also addressed the impact of multimodal therapy and if this type of treatment has greater benefits than others, but results showed there was no clinical benefit. The paper questions the benefits of manual therapy and physical therapy overall, but I would challenge that question because this paper admitted to flaws within their study design and assessments. When taking this paper into consideration of practice, as physical therapists, we need to recognize the complexity of each patient and the complexity of their response to different treatments. It also reminds therapists to go into sessions with patient-centered care that can significantly impact the overall results for patients.

Monteiro, E; Victorina, A; Cunha, M; Muzzi, R; De Oliveira, J

Maria Gonzalez-Alvarez

Duke University School of Medicine Doctor of Physical Therapy

Paper Abstract

This study investigated how different manual therapies applied to the posterior thigh muscles affect the ten-repetitions maximum performance test (10 RM) and hip flexion range-of-motion among young soccer players. Seventeen non-professional male soccer players performed the 10RM and range of motion pre-testing, and, in separate laboratory visits, they underwent three different experimental activities presented to each participant in a randomized order: (a) rest control activity with no intervention, (b) manual massage, and (c) muscle energy. Comparing pre-testing performances to repeated tests after each intervention condition, participants increased their maximum load lift on the 10-repeitions maximum test following manual massage and muscle energy interventions but not following the control condition. They also increased their hip range-of-motion on flexibility testing following manual massage and muscle energy but not following the control condition. Thus, both manual massage and muscle energy therapies applied to the posterior thigh were beneficial to performance. This finding has clear implications when preparing athletes for competition.

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?

no

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?

Cannot Determine, Not Reported, or Not Applicable

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

Increased maximum load lifts in the 10-rep Max Test following manual massage and muscle energy interventions.

Key Finding #2

Both manual massage and muscle energy therapies led to increased hip ROM.

Key Finding #3

No significant changes with control conditions.

Key Finding #4

Incorporating manual therapies targeting the posterior thigh muscles can be beneficial for enhancing performance and flexibility in young soccer players.

Please provide your summary of the paper

The goal of this study was to assess the effects of manual therapies on strength performance and flexibility in young male soccer players. Specifically, in the 10-Rep Max Test. The study found that both manual massage and muscle energy techniques can significantly improve performance in the 10RM test and increase hip ROM. This suggests that manual therapies and muscle energy techniques can enhance strength and improve flexibility. Incorporating manual therapies can also be beneficial in injury prevention and athletic performance. In conclusion, when performing manual therapy, focusing on the posterior thigh muscles, it can enhance strength and flexibility in young players.

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

This study provides insight into the potential benefits manual therapy can have for improving strength and flexibility in young soccer players. The study found that both manual massage and muscle energy techniques, specifically focused on posterior thigh muscles, can significantly improve performance in the 10RM test and increase hip ROM. This suggest that manual therapies and muscle energy techniques can enhance strength and improve flexibility. Incorporating manual therapies can also be beneficial in injury prevention and athletic performance. This is shown by the absence of significant changes from the control condition, rest. This helps reinforce their objective of the value that manual therapy can have on a young athlete over rest. These findings may lead to seeing an increase in manual therapy use within Athletic Trainers, Sports Physical Therapists and Physiotherapists not only to enhance performance but also as a preventative measure. The use of manual therapy in conjunction with strength training and rehabilitation can be expected to be seen implemented across all levels of sports. These findings also show how active recovery can be more beneficial for an athlete than a passive rest alone. This means more athletes will prescribe manual therapy, stretching and mobility work to do on their off days to promote recovery and increase function between practices and games. The study’s within-subject design suggests that treatment can be athlete specific allowing for a more personalized approach in treatment.

Author Names

Assogba, T; Zounon, D; Natta, D; Sogbossi, E; Lawson, T; Kpadonou, T; Mahaudens, P; Detrembleur, C

Reviewer Name

Riley Hobson, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Orthopedic manual therapy is currently considered as an alternative approach for treating hip osteoarthritis. However, studies assessing its efficacy in low-income countries in Sub-Saharan Africa are scarce. Objectives: Investigating the effectiveness of Maitland passive joint mobilization (Maitland PJM) compared to self-rehabilitation in patients with hip osteoarthritis in Benin, a low-income country, in Sub-Saharan Africa. Methods: This was a pragmatic, single-blind, two-arm randomized trial involving 66 participants randomly assigned into two groups (Maitland PJM group, n = 33, and self-rehabilitation group, n = 33). Both interventions took 5 weeks. The primary outcome (pain) was evaluated using numerical rating scale. Secondary outcomes (passive hip range of motion, muscles strength, walking, and quality of life) were assessed using goniometry, medical research council, 10 m walk test, and short-form 36. Participants were assessed at baseline, after interventions and 3-month follow-up. Results: Forty-nine patients (Maitland PJM group, n = 22, self-rehabilitation, n = 27) completed the sessions. Within-group analyses showed a significant improvement in body function, walking speed, and quality of life (p < 0.05) after interventions and at 3-month follow-up within both groups. No significant differences in any outcomes were observed between the Maitland PJM and self-rehabilitation groups, after interventions and at the 3-month follow-up (p > 0.05). Conclusion: Maitland passive joint mobilization and self-rehabilitation similarly improved function, walking speed, and quality of life in Beninese patients with hip osteoarthritis.

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?

No

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

Patients with hip osteoarthritis who received either Maitland PJM or participated in a self-rehabilitation protocol as treatment both demonstrated improvements in body function, walking speed, and quality of life after interventions and at a 3-month follow up.

Key Finding #2

Patients with hip osteoarthritis who received either Maitland PJM or participated in a self-rehabilitation protocol as treatment both demonstrated improvements in body function, walking speed, and quality of life after interventions and at a 3-month follow up.

Please provide your summary of the paper

Patients with hip osteoarthritis who received either Maitland PJM or participated in a self-rehabilitation protocol as treatment both demonstrated improvements in body function, walking speed, and quality of life after interventions and at a 3-month follow up.

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

The study showed that both passive joint mobilization and self-rehabilitation improved outcomes in patients with hip osteoarthritis, and no significant differences were found between groups. These findings suggest that these orthopedic manual therapy techniques are both effective and can be implemented to conservatively treat hip osteoarthritis in the clinical setting. Since no significant differences were found between the groups, it suggests that either can be used, but treatment should be individualized to meet patient-specific limitations and needs. Self-rehabilitation can be an effective treatment option for patients with financial or transportation limitations with proper adherence. Further research should be done on the effects these treatment approaches, and their efficacy for treating other musculoskeletal conditions.

Author Names
Todègnon Franck Assogba, Diane‐Aurore Zounon, Ditouah Didier Niama Natta, Emmanuel Segnon Sogbossi, Teefany Lawson, Toussaint Kpadonou, Philippe Mahaudens, Christine Detrembleur

Reviewer Name Fei Luyu

Reviewer Affiliation(s) Duke University

Paper Abstract

Background: Orthopedic manual therapy is currently considered as an alternative approach for treating hip osteoarthritis.However, studies assessing its efficacy in low‐income countries in Sub‐Saharan Africa are scarce.
Objectives: Investigating the effectiveness of Maitland passive joint mobilization
(Maitland PJM) compared to self rehabilitation in patients with hip osteoarthritis in Benin, a low‐income country, in Sub‐Saharan Africa.

Methods: This was a pragmatic, single‐blind, two‐arm randomized trial involving 66 participants randomly assigned into two groups (Maitland PJM group, n = 33, and self‐rehabilitation group, n = 33). Both interventions took 5 weeks. The primary outcome (pain) was evaluated using numerical rating scale. Secondary outcomes (passive hip range of motion, muscles strength, walking, and quality of life) were assessed using goniometry, medical research council, 10 m walk test, and short‐form 36. Participants were assessed at baseline, after interventions and 3‐month follow‐up.

Results: Forty‐nine patients (Maitland PJM group, n = 22, self‐rehabilitation, n = 27) completed the sessions. Within‐group analyses showed a significant improvement in body function, walking speed, and quality of life (p < 0.05) after interventions and at 3‐month follow‐up within both groups. No significant differences in any outcomes were observed between the Maitland PJM and self‐rehabilitation groups, after interventions and at the 3‐month follow‐up (p > 0.05). Conclusion: Maitland passive joint mobilization and self‐rehabilitation similarly improved function, walking speed, and quality of life in Beninese patients with hip osteoarthritis.

Quality Assessment of Controlled Intervention Studies

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
YES

2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?
YES

3. Was the treatment allocation concealed (so that assignments could not be predicted)?
CAN NOT DETERMINE

4. Were study participants and providers blinded to treatment group assignment?
NO

5. Were the people assessing the outcomes blinded to the participants’ group assignments?
YES

6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
YES

7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
CAN NOT DETERMINE

8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
YES
9. Was there high adherence to the intervention protocols for each treatment group?
YES

10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

YES
11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
YES

12. 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

13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
YES

14. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

NO

Key Finding #1
Both Interventions Improved Pain, Function, and Quality of Life. Both Maitland Passive Joint Mobilization (PJM) and self-rehabilitation (SR) led to
significant improvements in pain reduction, hip function, muscle strength, walking speed, and quality of life immediately after the intervention and at the
3-month follow-up.

Key Finding #2
No Significant Differences Between Maitland PJM and Self-Rehabilitation. Despite the hands-on approach of Maitland PJM and the hands-off approach
of SR, there were no statistically significant differences between the two groups in terms of improvements in pain, mobility, and quality of life.

Key Finding #3
Given that self-rehabilitation was equally effective as Maitland PJM, it presents a cost-effective and alternative for treating hip osteoarthritis, especially in
low-income settings where access to physical therapy services may be limited.

Please provide your summary of the paper

This study shows that both Maitland Passive Joint Mobilization (PJM) and self-rehabilitation (SR) help reduce pain, improve movement, and enhance
quality of life for people with hip osteoarthritis (HOA). The research, conducted in Benin, found no major difference between the two treatments, meaning that self-rehabilitation, which involves home exercises, can be just as effective as hands-on therapy from a physical therapist. This is important for people who do not have access to professional treatment, as self-rehabilitation is a simple and affordable option. While Maitland PJM remains useful, especially for those who need direct manual therapy, self-rehabilitation allows patients to take control of their own recovery. These findings suggest that home- based exercise programs could be a great way to help more people manage hip osteoarthritis, especially in areas with limited healthcare resources.

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

This study shows that self-rehabilitation can be just as effective as hands-on therapy (Maitland Passive Joint Mobilization) for treating hip osteoarthritis,
which could make treatment more accessible and affordable for many patients. In practice, clinics can encourage home-based exercise programs, providing simple guides and follow-up support through telehealth. Patients can take an active role in their recovery, reducing the need for frequent clinic visits while still improving their pain, mobility, and quality of life. Healthcare providers can combine in-person sessions with self-rehabilitation. This approach can help rural or underserved communities receive effective care without relying on in-person physical therapy, making treatment more widely available.