Hip

Author Names

Hoeksma, HL, Dekker, J, Ronday, HK, Breedveld, FC and Van den Ende, CHM

Reviewer Name

Sara Zilvetti LAT, ATC, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective. To investigate whether manual therapy has particular benefit in subgroups of patients defined on the basis of hip function, range of joint motion, pain and radiological deterioration. Methods. The study was performed in the out-patient clinic of physical therapy of a large hospital. Data on 109 patients with OA of the hip (clinical ACR criteria) participating in a randomized clinical trial on the effects of manual therapy were used. The outcomes for hip function (Harris hip score), range of joint motion (ROM) and pain (VAS) were compared for specific subgroups. Subgroups were assigned by the median split method. The interaction effect between subgroup and treatment was tested using multiple regression analysis. Results. No differences were observed in the effect of manual therapy in specific subgroups of patients defined on the basis of baseline levels of hip function, pain and ROM. On the basis of radiological grading of osteoarthritis (OA), we found that patients with severe radiological grading of OA had significantly worse outcome on ROM as a result of manual therapy than patients with mild or moderate radiological grading of OA. Conclusion. A significant interaction effect was found for only 1 out of 12 hypotheses investigated. Therefore, we conclude that there is no evidence for the particular benefit of manual therapy in subgroups of patients.

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)?

• Cannot Determine

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

• No

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?

• Cannot Determine

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

• No

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?

• Cannot Determine

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

• Cannot Determine

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

• Cannot Determine

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

There were no relevant differences between the studied groups in the prognostic variables age, sex, duration of complaints, radiological deterioration, hip function, pain and ROM.

Key Finding #2

In comparison with exercise therapy, patients with severe radiological deterioration who were treated with manual therapy had a significantly lower outcomes with respect to ROM than patients with mild or moderate radiological deterioration.

Key Finding #3

The evidence did not show that manual therapy has particular benefit in specific subgroups of patients as only one our of 12 interactions was shown to be significant.

Key Finding #4

While manual therapy does not have benefit for specific subgroups, in general manual therapy should be the first treatment of choice for all patients compared with exercise therapy.

Please provide your summary of the paper

While there is previous research supporting the use of manual therapy in the treatment of hip osteoarthritis (OA), this study explored if certain clinical presentations of OA would have benefits of manual therapy. These subgroups were hip function, hip range of motion, pain, and radiological deterioration. Each subgroup had two groups of patients being assessed, a manual therapy group, which included stretching of the surrounding hip musculature and manipulations of the hip, and an exercise group with the exercise program tailored to each patient. Upon review of the data, there was no significant findings supporting the use of manual therapy for these subgroups. However, the patients that received manual therapy had better results than those that completed an exercise program which indicates that manual therapy is a good modality to include while treating patients with hip OA.

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

This study has some limitations regarding the patients who were selected. They did not account for patient demographics, age, or comorbidities which can all impact the study outcomes. Furthermore, each exercise program was stated to be “tailored to each patient” which decreases the standardization of the study. Specific explanations of how the exercise programs were modified were not given which makes the study hard to replicate Even with these limitations, the study supported previous literature which shows manual therapy can be an effective technique to include in the treatment of patients with hip OA.

Author Names

Arabzadeh, S., Kamali, F., Bervis, S., & Razeghi, M.

Reviewer Name

Aruna Priya, SPT

Reviewer Affiliation(s)

Duke University School of Medicine – Doctor of Physical Therapy Division

Paper Abstract

People with stroke generally experience abnormal muscle activity and develop balance disorder. Based on the important role of the proximal joints of the lower extremity in balance maintenance, hip joint mobilization with movement technique can be applied to enhance normal joint arthrokinematics. Therefore, the present study aimed to investigate the effectiveness of hip joint mobilization with movement technique on stroke patients’ muscle activity and balance.  Twenty patients aged between 35 and 65 years old with chronic stroke were randomly assigned either to an experimental group (n = 10) or to a control group (n = 10). Both groups participated in a 30-minute conventional physiotherapy session 3 times per week for 4 weeks. The experimental group received an additional 30-minute’s session of hip joint mobilization with movement technique on the affected limb. The muscle activity, berg balance scale, time up and go, and postural stability were measured at baseline, 1-day and 2-week follow-up by a blinded assessor.  The experimental group showed a significant improvement in berg balance scale, time up and go, and postural stability (p ≤ 0.05). The rectus femoris, tibialis anterior, biceps femoris, and medial gastrocnemius muscles’ activations of the affected limb during static balance test markedly changed along with the biceps femoris, erector spine, rectus femoris, and tibialis anterior muscles during dynamic balance test after hip joint mobilization with movement technique. The mean onset time of rectus abdominus, erector Spine, rectus femoris, and tibialis anterior muscles activity significantly decreased in the affected limb after hip joint mobilization with movement technique compared to the control group (p ≤ 0.05).  The results of the present study suggest that a combination of hip joint mobilization with movement technique and conventional physiotherapy could improve muscle activity and balance among chronic stroke patients.

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)?

• No

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?

• No

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)?

• No

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

Hip joint mobilizations combined with conventional physical therapy modalities (AROM/PROM, WB exercises, balance, and gait training) improved muscle activity, postural stability, and balance as shown by the improved clinical outcome scores.

Key Finding #2

There was no difference in muscle activity at baseline between the control and experimental group, therefore improvements seen in muscle activity in the experimental group can be attributed to Mulligan’s principles.

Key Finding #3

To maintain standing balance, it is important to have coordinated activity of the lower extremity and trunk muscles.

Please provide your summary of the paper

This blinded-randomized controlled study investigated the effectiveness of hip joint mobilizations on muscle activity, postural stability, and balance in patients with hemiplegia secondary to chronic stroke. 20 participants were divided into two groups: the control and experimental group. Assessments for all participants included postural stability, Berg balance scale, TUG, and muscle activity pattern performed at baseline and post-treatment. Treatment for both groups consisted of 30-minute sessions, 3 times a week for 4 weeks consisting of physical therapy modalities such as AROM/PROM, WB exercises, balance, and gait training. The experimental group received an additional 30 minutes of Mulligan hip joint mobilizations with movement which included internal-external rotation, flexion, and abduction-adduction during each session. Grade III mobilizations were performed for 10 seconds in 3 sets of 6 repetitions with a 1-minute break between sets and a 5-second break between reptations. SPSS was used for statistical analysis of the raw data collected during the experiment. 4 participants dropped out of the experiment, 1 from the experimental group and 3 from the control group. The experimental group had significant improvements in their outcome measures indicating hip mobilizations with movement positively impacted patients with hemiplegia.

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

From the findings, hip joint mobilizations with movement increased muscle activity and improved balance in patients with hemiplegia. Therefore, hip joint mobilizations such as internal-external rotation, flexion, and abduction-adduction are valuable additions to treating chronic post-stroke patients with hemiplegia. A few limitations of this study include a relatively small sample size and the population that was not diverse. Yet, researchers were able to relate the findings to other studies to further provide evidence for the conclusions from this study. However, further research is needed to investigate the effectiveness of these mobilizations on patients with different types of strokes.

Author Names

Runge N, Aina A, May S.

Reviewer Name

Jaimie Legault, SPT

Reviewer Affiliation(s)

Duke University School of Medicine- Doctor of Physical Therapy Division

Paper Abstract

OBJECTIVE: To evaluate if there was an additional benefit of combining manual therapy (MT) and exercise therapy over exercise therapy alone on pain and function in patients with hip or knee osteoarthritis. DESIGN: Intervention systematic review  LITERATURE SEARCH: We (1) searched 4 databases from inception to June 20, 2021; (2) hand searched a reference list of included trials and relevant systematic reviews; and (3) contacted 2 researchers in the field.  STUDY SELECTION CRITERIA: We included randomized controlled trials that compared MT and exercise therapy to similar exercise therapy programs alone in patients with hip or knee osteoarthritis.  DATA SYNTHESIS: The data were combined using random-effects meta-analyses where appropriate. The certainty of evidence for each outcome was judged using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework.  RESULTS: We included 19 trials. There was very low to moderate certainty of evidence that MT added benefit in the short term for pain, and combined pain, function, and stiffness (WOMAC global scale), but not for performance-based function and self-reported function. In the medium term, there was low- to very-low-certainty evidence that MT added benefit for performance-based function and WOMAC global score, but not for pain. There was high-certainty evidence that MT provided no added benefit in the long term for pain and function.  CONCLUSION: There was very low to moderate certainty of evidence supporting MT as an adjunct to exercise therapy for pain and WOMAC global scale, but not function in patients with knee or hip osteoarthritis in the short term. There was high certainty of evidence of no benefit for additional MT over exercise therapy alone in the long term.

NIH Risk of Bias Tool

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

The benefit of manual therapy with exercise for short- and medium-term OA pain was found to have very-low to low evidence, respectively. Additionally, there is high certainty that there’s no benefit of manual therapy with exercise when compared to exercise alone for long term pain.

Key Finding #2

When analyzing self-reported function, low to very-low certainty evidence was found to support no benefit in the short to medium term, respectively. These results were determined by comparing exercise alone to exercise with manual therapy in both hip and knee OA populations.   There were no articles included that studied self-reported function in the long term.

Key Finding #3

Performance based function was studied utilizing the timed up and go (TUG) outcome measure.  At a short term follow up, moderate certainty evidence was found that manual therapy with exercise showed no benefit when compared to exercise alone.   At medium-term follow up, very-low certainty evidence discovered additional benefit. It’s important to note that this was concluded based on only one trial within the systematic review and meta-analysis.  At long-term follow up, high certainty evidence from 3 trials revealed no additional benefit of manual therapy to exercise.

Key Finding #4

Mixed findings were discovered when analyzing results of the WOMAC global scale among various studies. Including additional benefit with moderate certainty evidence at short-term and very-low certainty evidence at medium-term. But at long term, there was high-certainty evidence of no long-term benefit. The article notes that they were unable to determine if this finding was clinically significant.

Please provide your summary of the paper

This systematic review with meta-analysis studies the use of manual therapy in conjunction with exercise therapy in patients with diagnosed hip or knee osteoarthritis. The manual techniques are defined as joint mobilizations, manipulations, soft tissue techniques, and stretches. The focus of this study was to analyze the benefits of manual techniques and exercise therapy versus exercise alone. Additionally, the benefits of each primary outcome were analyzed at short, medium, and long-term periods of time. The previously mentioned time frames were defined as follows: short-term being up to 4 weeks, medium-term being 4 weeks to 6 months, and long-term being greater than 6 months. The overall conclusion of this article was that there is minimal evidence to support additional benefit of manual therapy for individuals with hip or knee OA. This conclusion was determined based on analysis of pain, self-reported function, performance-based function, and WOMAC global scale.   Limitations included variable dosage and type of manual intervention among the studies included. While statistical analysis was able to conclude very little to no significant benefit of manual therapy within this population, it’s difficult to determine if type, frequency, and dosage of manual therapy intervention would play a role in altering the results of the study. Additionally, there were only two studies included that solely studied manual techniques and hip OA. So it is difficult to differentiate hip versus knee benefits within this article alone.

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

From this, we can conclude that there is very little to no statistical findings supporting the use of manual therapy in conjunction with exercise for patients with hip or knee OA. The results of this study would allow clinicians to focus on other modalities with stronger supporting evidence when treating this population. Ultimately, this would increase the clinicians time efficiency and increase the patient’s likelihood to progress.

Author Names

Markovik, G

Reviewer Name

Claire Hanlon, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

The aim of the present investigation was to evaluate the acute effects of foam rolling (FR) and a new form of instrument-assisted soft tissue mobilization (IASTM), Fascial Abrasion Technique ™ (FAT) on hip and knee range of motion in soccer players. Twenty male soccer players randomly allocated into FR and FAT group (n = 10 each). Passive knee flexion and straight leg raise tests were measured before, immediately after and 24 h after intervention (FR or FAT). The FR group applied a 2-min quadriceps and hamstrings rolling, while FAT group received a 2-min application of FAT to the quadriceps and hamstrings muscles. Both groups significantly improved knee and hip ROM (p < 0.05), with higher gains observed in FAT group (10-19% vs. 5-9%). At 24 h post-treatment, only FAT group preserved most of the gains in ROM (7-13%; p < 0.05). These results support the use of the newly developed IASMT, Fascial Abrasion Technique ™ and FR for increasing lower extremity ROM of athletes.

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)?

• No

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?

• 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

Both the foam rolling (FR) and IASTM (FAT) groups demonstrated increases in knee and hip range of motion immediately following intervention.

Key Finding #2

The FAT IASTM group demonstrated effects twice as large as those in the FR group for acute ROM gains.

Key Finding #3

The FAT IASTM group had continued significant ROM gains 24 hours after treatment while the foam roll (FR) group returned to their pre-test baseline.

Please provide your summary of the paper

This study focused on the benefits of foam rolling and FAT (Fascial Abrasion Technique) instrument assisted soft tissue mobilization on knee and hip range of motion. Range of motion was assessed using 2 examiners and a digital inclinometer. The study was broken into two groups of similarly aged male soccer players; one that performed 2 minutes of foam rolling following a dynamic warm up, and one that underwent 2 minutes of IASTM following a dynamic warm up. The individuals were all given guidelines to restrict alcohol, nicotine, caffeine, pain relievers, and vigorous physical activity for 48 hours prior to the experiment. All individuals were confirmed to be clear of any history of thigh muscle injuries for 2 years prior to the study. The two groups, each consisting of 10 individuals, completed the same dynamic warm up followed by an initial measurement of hip and knee ROM. After the intervention, a second measurement was assessed which gave the results of acute change in ROM. The results demonstrated that both FR and FAT IASTM increased knee and hip ROM acutely, with FAT IASTM having greater effects. The 24-hour measurement indicated that FAT IASTM has a longer lasting effect with continued improvements in ROM versus the FR group returning to pretest baseline

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

One limitation of this study is the small sample size and the narrow scope of individuals involved. This study provides information for young, active males but it is unclear whether these results could translate to the general public. In addition, the FAT IASTM is unique to other instrument assisted soft tissue mobilizations and could have different outcomes. The results of this study can only be generalized for the use of FAT and more research would be necessary to analyze the benefits of other forms of IASTM compared to foam rolling. Additionally, the study did not look at how varying the time spent on each intervention could affect the outcome. Previous studies looking at IASTM and foam rolling used longer intervention times, which could impact the results of this study. This study was significant for the specific interventions tested, however, it would be beneficial to complete larger studies on varying IASTM techniques as well as a more general population of patients.

Author Names

Brun, A. and Sandrey, M.

Reviewer Name

Hunter Dula, SPT

Reviewer Affiliation(s)

Duke University School of Medicine Doctor of Physical Therapy Division

Paper Abstract

Context: Joint mobilizations have been studied extensively in the literature for the glenohumeral joint and talocrural joint (ankle). Consequently, joint mobilizations have been established as an effective means of improving range of motion (ROM) within these joints. However, there is a lack of extant research to suggest these effects may apply within another critical joint in the body, the hip. Objective: To examine the immediate effects of hip joint mobilizations on hip ROM and functional outcomes. Secondarily, this study sought to examine the efficacy of a novel hip mobilization protocol. Design: A prospective exploratory study. Setting: Two research labs. Patients or Other Participants: The study included 19 active male (n = 8) and female (n = 11) college students (20.56 [1.5] y, 171.70 [8.6] cm, 72.23 [12.9] kg). Interventions: Bilateral hip mobilizations were administered with the use of a mobilization belt. Each participant received hip joint mobilization treatments once during 3 weekly sessions followed immediately by preintervention and postintervention testing/measurements. Testing for each participant occurred once per week, at the same time of day, for 3 consecutive weeks. Hip ROM was the first week, followed by modified Star Excursion Balance Test the second week and agility T test during the third week. Main Outcomes Measures: Pretest and posttest measurements included hip ROM for hip flexion, extension, abduction, adduction, internal and external rotation, as well as scores on the modified Star Excursion Balance Test (anterior, posterolateral, and posteromedial directions) and agility T test. Results: A significant effect for time was found for hip adduction, internal and external rotation ROM, as well as the posterolateral and posteromedial directions of the modified Star Excursion Balance Test. A separate main effect for both limbs was found for adduction and internal rotation ROM. Conclusion: Isolated immediate changes in ROM and functional outcomes were evident. Further evaluation is needed.

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%?

• Yes

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?

• Cannot Determine, Not Reported, Not Applicable

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?

• Yes

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?

• Yes

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

• Cannot Determine, Not Reported, Not Applicable

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)?

• Yes

Key Finding #1

There was a significant change in hip adduction, internal and external rotation ROM when comparing pre and post test measurements.

Key Finding #2

There was a significant difference in both the posterolateral and posteromedial directions of the modified Star Excursion Balance Test when comparing pre and post test measurements.

Key Finding #3

There was no significant change in agility scores on the T test when comparing pre and post test measurements.

Key Finding #4

Isolated immediate changes in ROM and functional outcomes were evident, but further evaluation needs to be done.

Please provide your summary of the paper

Active college aged students with near to normal hip range of motion participated in a prospective exploratory study looking to determine the effects of hip joint mobilizations on hip ROM, balance, and agility. Each participant participated in 3 30-60 minute sessions, 7 days apart. During the first session hip ROM was measured using a digital goniometer pre and post Maitland hip joint mobilizations using a Mulligan mobilization belt for all hip motions. During the second session, balance was measured using the mSEBT pre and post mobilization using the same technique as the first week. During the third and final session, agility was measured using the T test pre and post mobilization using the same technique as the first week. Hip internal rotation, external rotation, and adduction range of motion, as well as the posterolateral and posteromedial directions on the mSEBT significantly improved post hip mobilization. significantly improved post hip mobilization. There was no significant difference shown in agility testing post intervention. This study showed it could be beneficial to use hip mobilizations in recreationally active college aged individuals to improve certain hip ROMs and balance scores, but further research needs to be done in populations with restricted hip ROM and hip pathologies.

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, specifically mobilization techniques, can immediately improve hip ROM and balance in individuals with near to normal hip range of motion. While this cannot be verified in individuals with hip pathologies, hip mobilizations can be a useful tool to improve certain hip ROMs and balance in young and active patients.

Author Names

Fukuda TY, Aquino LM, Pereira P, Ayres I, Feio AF, de Jesus FLA, Neto MG.

Reviewer Name

Terry Brown, SPT

Reviewer Affiliation(s)

Duke DPT, Class of 2025

Paper Abstract

Background  The literature is unclear on the need for hip strengthening in persons with low back pain (LBP).  Objectives  To investigate the effectiveness of hip strengthening exercises when added to manual therapy and lumbar segmental stabilization in patients with chronic nonspecific LBP.  Methods  Seventy patients with chronic nonspecific LBP were randomly assigned to either the manual therapy and lumbar segmental stabilization group or the manual therapy and lumbar segmental stabilization plus specific hip strengthening group. A 10 cm visual analogue scale and the Rolland-Morris Questionnaire were the primary clinical outcome measures at baseline, at the end of treatment (posttreatment), and 6- and 12-months posttreatment. Hip strength and kinematics were measured as secondary outcomes .  Results  While within-group improvements in pain, disability, and hip extensors strength occurred in both groups, there were no significant between-group differences at posttreatment or follow-ups. Mean difference in changes in pain level between groups at posttreatment and at 6- and 12-month follow-up were 0.5 points (95% confidence interval [CI]: -0.5, 1.5), 0.3 points (95% CI: -0.9, 1.5), and 0.0 points (95% CI: -1.1, 1.1), respectively. The mean differences in changes in disability were 0.8 points (95% CI: -1.3, 2.7), 0.0 points (95% CI: -2.4, 2.4), and 0.4 points (95% CI: -2.0, 2.8), respectively. Finally, we did not observe any between-group differences for any of the other outcomes at any timepoint.  Conclusion  The addition of specific hip strengthening does not appear to result in improved clinical outcomes for patients with nonspecific LBP.  Keywords: Lumbar spine, Physical therapy, Rehabilitation

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?

• 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?

• 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?

• Yes

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

• Cannot Determine, Not Reported, or Not Applicable

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

The addition of hip strengthening exercises into PT sessions did not have a positive effect on the reduction of LBP compared to normal treatment focuses.

Key Finding #2

Hip extensor strength was improved in the participants of the study and could be further tested to see if long term strengthening helps LBP.

Key Finding #3

Continuing the current route of LBP treatment of manual therapy, mobilizations, and general exercise is currently the most effective treatment for patients that present to PT.

Please provide your summary of the paper

The authors of this paper were hoping to assess if the addition of hip-specific exercises combined with manual therapy and general exercises would improve function and decrease pain and disability in patients with LBP. The study divided the 70 participants into a control group as well as an experiment group. The participants attended 2 sessions of PT a week for 5 weeks equaling 10 sessions of skilled PT. The participants were told to not take pain medication during this time and to not do the exercises outside of the session. The results of this study demonstrated virtually no difference between the two groups suggesting that hip-specific exercises did not have a significant impact on pain reduction compared to regular PT routines.

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 does not highlight the specifics of manual therapy used outside of hip mobilizations. However, it does provide detailed evidence on the impact of exercise specifics for patients who are experiencing LBP. This paper can help PTs guide their LBP patients into weekly exercise and strength training routines to decrease pain and disability and improve function.

Author Names

Hoeksma, H.L., Dekker, J., Ronday, H.K., Heering, A., Van Der Lubber, N., Vel, C., Breedveld, F., Van Den Ende, C.H.M.,

Reviewer Name

Juan Carlos Chavez Casiano

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective: To determine the effectiveness of a manual therapy program compared with an exercise therapy program in patients with osteoarthritis (OA) of the hip.

Methods: A single-blind, randomized clinical trial of 109 hip OA patients was carried out in the outpatient clinic for physical therapy of a large hospital. The manual therapy program focused on specific manipulations and mobilization of the hip joint. The exercise therapy program focused on active exercises to improve muscle function and joint motion. The treatment period was 5 weeks (9 sessions). The primary outcome was general perceived improvement after treatment. Secondary outcomes included pain, hip function, walking speed, range of motion, and quality of life.

Results: Of 109 patients included in the study, 56 were allocated to manual therapy and 53 to exercise therapy. No major differences were found on baseline characteristics between groups. Success rates (primary outcome) after 5 weeks were 81% in the manual therapy group and 50% in the exercise group (odds ratio 1.92, 95% confidence interval 1.30, 2.60). Furthermore, patients in the manual therapy group had significantly better outcomes on pain, stiffness, hip function, and range of motion. Effects of manual therapy on the improvement of pain, hip function, and range of motion endured after 29 weeks.

Conclusion: The effect of the manual therapy program on hip function is superior to the exercise therapy program in patients with OA of the hip.

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?

• No

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

• No

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?

• No

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

• No

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)?

• No

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

The manual therapy program was found to me more effective when compared to the exercise program.

Key Finding #2

The effects of the manual therapy program were found to last up to 6 months after the end of therapy.

Key Finding #3

Beneficial effects of manual therapy on walking speed were found but further studies need to be made.

Please provide your summary of the paper

This study looked at the effect of manual therapy compared to the effects of an exercise therapy program in patients with osteoarthritis (OA) of the hip. The results showed that there was greater improvements of hip function and pain for those that were in the manual therapy group. The participants were randomly placed in one of the two groups. All participants were treated twice a week for 5 weeks. The Manual therapy session involved traction of the hip, followed by traction manipulation in each limited position. In the exercise treatment groups, programs were developed to improve muscle function, muscle length, joint mobility, pain relief, and walking. While this paper supports the idea of the use Manual Therapy in patients with OA of the hip, this was the first study to their knowledge that compared the two. Therefore, further studies are recommended.

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 demonstrated that there were some benefits of manual  therapy in patients with hip OA but other research should be done since it was the first of its kind. I think this can be used clinically by using manual therapy in conjunction with an exercises program to maximize the outcomes of our patients.

Author Names

Li, Yi-Qiang; Li, Ming; Guo, Yue-Ming; Shen, Xian-Tao; Mei, Hai-Bo; Chen, Shun-You; Shao, Jing-Fan; Tang, Sheng-Ping; Canavese, Federico; Xu, Hong-Wen

Reviewer Name

Taylor Doherty, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

This study aimed to investigate the effects of preliminary traction on the rate of failure of reduction and the incidence of femoral head avascular necrosis (AVN) in patients with late-detected developmental dysplasia of the hip treated by closed reduction. A total of 385 patients (440 hips) treated by closed reduction satisfied the inclusion criteria. Patients were divided in two groups according to treatment modality: a traction group (276 patients) and a no-traction group (109 patients). Tönnis grade, rate of failure reduction, AVN rate, acetabular index, center-edge angle of Wiberg, and Severin’s radiographic grade were assessed on plain radiographs, and the results were compared between the two groups of patients. In addition, a meta-analysis was performed based on the existing comparative studies to further evaluate the effect of traction on the incidence of AVN. Tönnis grade in the traction group was significantly higher than in the no-traction group (P = 0.021). The overall rate of failure reduction was 8.2%; no significant difference was found between the traction (9.2%) and no-traction groups (5.6%) (P = 0.203). The rates of failure reduction were similar in all Tönnis grades, regardless of treatment modality (P > 0.05). The rate of AVN in the traction group (14%) was similar to that of the no-traction group (14.5%; P = 0.881). Moreover, the rates of AVN were similar in all Tönnis grades, regardless of treatment modality (P > 0.05). The meta-analysis did not identify any significant difference in the AVN rate whether preliminary traction was used or not (odds ratio = 0.76, P = 0.32). At the last follow-up visit, the two groups of patients had comparable acetabular indices, center-edge angles, and Severin’s radiographic grades (P > 0.05). In conclusion, preliminary traction does not decrease the failure of reduction and the incidence of AVN in developmental dysplasia of the hip treated by closed reduction between 6 and 24 months of age.

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

Is the review based on a focused question that is adequately formulated and described?

• Yes

Were eligibility criteria for included and excluded studies predefined and specified?

• Yes

Did the literature search strategy use a comprehensive, systematic approach?

• Yes

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

• Cannot Determine, Not Reported, Not Applicable

Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

• Cannot Determine, Not Reported, Not Applicable

Were the included studies listed along with important characteristics and results of each study?

Was publication bias assessed?

• Yes

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

• Cannot Determine, Not Reported, Not Applicable

Key Finding #1

Preliminary traction did not decrease the failure of reduction in patients 6-24 months with developmental hip dysplasia treated by closed reduction.

Key Finding #2

Preliminary traction did not decrease the incidence of avascular necrosis in patients 6-24 months with developmental hip dysplasia treated by closed reduction.

Key Finding #3

Preliminary traction did not improve the center-edge angle in patients 6-24 months with developmental hip dysplasia treated by closed reduction.

Key Finding #4

Preliminary traction did not improve radiographic outcomes at final follow-up in patients 6-24 months with developmental hip dysplasia treated by closed reduction.

Please provide your summary of the paper

Longitudinal traction of the hip has been used to treat developmental dysplasia of the hip since the 1800’s when traction was first used to reduce a hip. Now, traction is still used prevalently prior to closed reduction under anesthesia with intent to improve reduction outcomes and decrease the likelihood of developing avascular necrosis (AVN). This study looked retrospectively at 440 dislocated hips in pediatric patients ages 6-24 months and performed a meta-analysis of 7 related studies to determine the effectiveness of preliminary traction of the hip in improving these outcomes. Overall, the difference of rate of reduction failure and development of avascular necrosis is insignificant between groups that received preliminary traction and those that did not after a minimum of 2 years following closed reduction. Additionally, the rate of failure reduction and AVN was similar across different Tonnis grades regardless of treatment intervention.

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

Traction is still used in approximately 50% of DDH cases in children 6-24 months prior to closed reduction of a dislocated hip, while it likely is not making any significant difference in many of these cases. I believe this study and other related studies could and should impact clinical practice to move away from performing preliminary traction in a PT or orthopaedic setting prior to closed hip reduction. Instead clinicians should perhaps focus on strengthening surrounding structures and improving function prior to and after closed reduction rather than focusing on manual traction in an attempt to improve outcomes.

Author Names

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

Reviewer Name

Natalia Engel, SPT

Reviewer Affiliations

Duke University School of Medicine, Physical Therapy Division

Paper Abstract

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

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

Is the review based on a focused question that is adequately formulated and described?

• Yes

Were eligibility criteria for included and excluded studies predefined and specified?

• Yes

Did the literature search strategy use a comprehensive, systematic approach?

• Yes

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

• Yes

Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

• Yes

Were the included studies listed along with important characteristics and results of each study?

Was publication bias assessed?

• Yes

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

• Yes

Key Finding #1

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

Key Finding #2

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

Key Finding #3

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

Please provide your summary of the paper

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

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

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

Author Names

Tak, I., Langhout, R., Bertrand, B., Barendrecht, M., Stubbe, J., Kerkhoffs, G., Weir, A.

Reviewer Name

Jasmin Flores, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objectives: To study the clinical course including return to sport success rates of football players with adductor-related groin pain (ARGP) after manual therapy of the adductor muscles. Design: Prospective case series.

Methods: Thirty-four football players with ARGP with median pre-injury Tegner scores of 9 (IQR 25–75: 9–9) were treated with manual therapy of the adductor muscles. Main outcome measures were numeric pain rating scale (NPRS), Hip and Groin Outcome Score (HAGOS) and global perceived effect (GPE) for treatment and patient satisfaction at 2, 6 and 12 weeks. Return to sport was documented.

Results: Pain during (NPRS 7 (6–8) and after (NPRS 8 (6–8) sports decreased to NPRS 1 (0.2–3) and 1 (0.8–3), respectively (p < 0.001). Within 2 weeks 82% of the players returned to pre-injury playing levels with improved (p < 0.001) HAGOS subscale scores. Eighty-five percent reported clinically relevant improvement, 82% reported to be satisfied. At 12 weeks, 88% had returned to pre-injury playing levels. HAGOS showed symptoms were still present.

Conclusion: Early return to sport seems possible and safe after manual therapy of the adductor muscles in football players with ARGP in the short term. While the majority of injured football players return to sport within two weeks, caution is advised regarding effectiveness as hip and groin symptoms were still present and no control groups were available.

NIH Risk of Bias Tool

Quality Assessment Tool for Case Series Studies

1. Was the study question or objective clearly stated?

• Yes

2. Was the study population clearly and fully described, including a case definition?

• Yes

3. Were the cases consecutive?

• Yes

4. Were the subjects comparable?

• Yes

5. Was the intervention clearly described?

• Yes

6. Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants?

• Yes

7. Was the length of follow-up adequate?

• Yes

8. Were the statistical methods well-described?

• Yes

9. Were the results well-described?

• Yes

Key Finding #1

There was clinical improvement and a reduction of pain with the use of adductor muscle manual manipulation for football players with long-standing adductor-related groin pain.

Key Finding #2

Even though the football players did return to sport, it was noted that most players still experienced hip and groin related problems.

Key Finding #3

After just 6 weeks of adductor muscle manual manipulation, 27 (79%) of the patients reported being able to return to football at their pre-injury level.

Please provide your summary of the paper

Based on the results of this study, manual manipulation of the adductor muscles improved return to sport for football players with groin injuries. However, there still isn’t enough information on whether or not this treatment method is reliable for long-term benefits. Additionally, even though the participant’s were able to return to sport and perform at a pre-injury level, they still experienced some hip and groin related problems.

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

Depending on how long a football player, or athlete in general, have had an adductor-related groin pain, this manual manipulation technique may be beneficial for them in returning to sport sooner. Many of the football players seemed to respond very well to the manual manipulation, even getting them back to sport at their pre-injury level at just 6 weeks. This study also measured pain level and it was recorded that between 6 to 12 weeks there was a significant improvement in pain. A limitation in this study would be that they did not highlight any possible long-term benefits and some football players still continued to have some pain.

Author Names

Carlos Beselga a, b , Francisco Neto c , Francisco Alburquerque-Sendín d, e, * , Toby Hall f , Natalia Oliveira-Campelo

Reviewer Name

Kayla Grace, Duke SPT, B.S Exercise Physiology

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Mobilization with movement (MWM) has been shown to reduce pain, increase range of motion (ROM) and physical function in a range of different musculoskeletal disorders. Despite this evidence, there is a lack of studies evaluating the effects of MWM for hip osteoarthritis (OA). Objectives: To determine the immediate effects of MWM on pain, ROM and functional performance in patients with hip OA. Design: Randomized controlled trial with immediate follow-up. Method: Forty consenting patients (mean age 78 ± 6 years; 54% female) satisfied the eligibility criteria. All participants completed the study. Two forms of MWM techniques (n _ 20) or a simulated MWM (sham) (n _ 20) were applied. Primary outcomes: pain recorded by numerical rating scale (NRS). Secondary outcomes: hip flexion and internal rotation ROM, and physical performance (timed up and go, sit to stand, and 40 m self placed walk test) were assessed before and after the intervention. Results: For the MWM group, pain decreased by 2 points on the NRS, hip flexion increased by 12.2, internal rotation by 4.4, and functional tests were also improved with clinically relevant effects following the MWM. There were no significant changes in the sham group for any outcome variable. Conclusions: Pain, hip flexion ROM and physical performance immediately improved after the application of MWM in elderly patients suffering hip OA. The observed immediate changes were of clinical relevance. Future studies are required to determine the long-term effects of this intervention.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

13/15

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?

• 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?

• 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?

• Cannot Determine, Not Reported, or Not Applicable

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?

• Cannot Determine, Not Reported, or Not Applicable

Were the included studies listed along with important characteristics and results of each study?

• Yes

Key Finding #1

For hip flexion, all patients receiving MWM and 11 patients receiving sham mobilisation, experienced an increase in ROM more than the MDC of 1.11 . For hip internal rotation, 16 patients receiving MWM and 4 patients receiving sham mobilisation, experienced an increase in ROM more than the MDC of 0.55.

Key Finding #2

For functional tests, 15 patients receiving MWM and 3 patients receiving sham mobilisation, experienced a reduction in TUG more than the MDC. For SPW, 18 patients receiving MWM and 7 patients receiving sham mobilisation, experienced a reduction in SPW more than the MDC. For CS, 17 patients receiving MWM and 4 patients receiving sham mobilisation, experienced an increase in repetitions more than the MDC.

Key Finding #3

Hip pain decreased immediately after a single session of MWM when compared to a sham technique in this sample of elderly subjects with hip OA. Furthermore, maximal hip flexion and internal rotation ROM and functional performance improved after MWM of the hip. For hip ROM change scores, a greater proportion of people in the MWM compared to sham group improved more than the MDC values obtained from the preliminary reliability study. Despite this finding, not all subjects improved.

Key Finding #4

16 patients receiving MWM, in contrast to 2 patients receiving sham mobilisation, experienced a decrease in hip pain more than the MDC of 0.83.

Please provide your summary of the paper

This double blind Randomized placebo controlled trial consisted of 40 consenting participants above the age of 65 with a diagnosis of hip OA.  Participants were randomly placed into two even groups (experimental vs control) to receive either two forms of MWM (Mobilization With Movement) or the placebo. MWM combines an accessory glide force with an active or passive movement with the purpose of eliminating pain during movement to enable a greater range and improved function. The primary purpose of the study was to “determine the immediate effects of a single session of MWM on hip pain in people with hip OA”. The secondary objective was “to evaluate the immediate effects of MWM on hip ROM and physical performance in these subjects”.  Prior to and post intervention, participant outcomes were recorded in the form of primary (pain recorded by numerical rating scale (NRS)) and secondary (hip flexion and internal rotation ROM, physical performance (timed up and go, sit to stand, and 40 m self paced walk test)) outcomes. This is the first randomized controlled trial to assess the effectiveness of MWM, when applied alone, on pain, ROM and function in subjects with hip OA. Results of the study included an immediate improvement in pain, hip flexion and internal rotation ROM and physical performance measures after one session of MWM. However, future studies are required to determine the long-term effects of this intervention as this study did not investigate effects past one session of intervention.

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

Following this clinical trial, it is evident that further investigation is necessary to standardize this approach to care.  It would also be beneficial to re-administer a similar trial to include additional treatment sessions, as well as incorporating additional clinical personnel to perform the interventions.  Being able to reproduce positive findings among various clinicians and establishing sound interrater reliability would strengthen the clinical value of the obtained data.  Adding manual therapy to the repertoire of treatment for pts with hip OA adds depth and breadth to a clinicians clinical toolbox, and provides additional opportunities to provide patient-centered and ICF catered care to this pt population.

Author Names

Abott, J

Reviewer Name

Laurel Hale, Duke SPT ‘24

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 x 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 = 54), multi-modal exercise physiotherapy (n = 51), combined exercise and manual physiotherapy (n = 50), or no trial physiotherapy (n = 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 0-240. Intention to treat analysis showed adjusted reductions in WOMAC scores at 1 year compared with the usual care group of 28.5 (95% confidence interval (CI) 9.2-47.8) 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 = 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 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?

• 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?

• No

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

• No

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

All intervention groups improved but usual care PLUS exercise only and usual care PLUS manual therapy only achieved clinically significant reductions from WOMAC (baseline outcome measure)

Key Finding #2

Manual therapy caused clinically significant and sustained changes in symptoms with patients with OA of hip and knee.

Key Finding #3

Exercise therapy lead to sustained improvements in physical performance tests for participants with hip and knee OA that did not have joint replacement surgery during trial.

Please provide your summary of the paper

While this study found positive effects associated with exercise and manual therapy for patients with hip or knee OA, manual therapy remained having the most clinically significant outcome on symptoms even when compared to manual therapy PLUS exercise.

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

I was surprised to see that manual therapy combined with exercise therapy did not have the greatest effect on OA symptoms and would be interested to see further studies investigating these relationships with different exercise interventions.

Author Names

Sampath, K. K., Mani, R., Miyamori, T., & Tumility, S.

Reviewer Name

Jada Holmes, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Rationale: The benefits of providing manual therapy and exercise targeting the hips in individuals with mechanical low‐back pain (LBP) are not well established. Objectives: The objective in this study is to determine whether a formal prescriptive treatment protocol for the hips improves outcomes in patients with a primary complaint of mechanical LBP. Methods: Eighty‐four (84) subjects (50 males, 46.1 ± 16.2 years) were randomized to 1 of 2 groups: pragmatic treatment of the lumbar spine only (LBP) (n = 39) or pragmatic treatment of the lumbar spine and prescriptive treatment of bilateral hips (LBP + HIP) (n = 45). Pragmatic treatment of the lumbar spine was based upon published clinical guidelines. Prescriptive treatment of the hips involved the use of 3 hip exercises targeting the gluteal musculature and 3 mobilization techniques targeting the hips. Subjects were assessed at baseline, 2 weeks, and at discharge with the following measures: Modified Oswestry Disability Index, Numeric Pain Rating Scale, a global rating of change (GRoC) score, the patient acceptable symptom state (PASS), and patient satisfaction. Results: At 2 weeks, significant differences between groups differences were found in GRoC and patient satisfaction (P &lt; .05) favoring the LBP + HIP group. At discharge, there were significant differences on the Modified Oswestry Disability Index, numeric pain rating scale, GRoC, and patient satisfaction favoring the LBP + HIP group (P &lt; .05). Effect sizes were small to medium. Conclusion: Our findings suggest that a prescriptive treatment of the hips may be of clinical value to individuals presenting with the primary complaint of mechanical LBP.

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?

• No

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

• No

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?

• Cannot Determine, Not Reported, or Not Applicable

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?

• Yes

Key Finding #1

The addition of a prescriptive program of exercises targeting the gluteal musculature and manual therapy targeting the hip joints to a pragmatic low‐back pain intervention led to small to medium improvements in self‐reported disability, pain, GRoC, and patient satisfaction in individuals presenting with a primary complaint of mechanical LBP.

Key Finding #2

Further research should examine long-term effectiveness of the current intervention because the study only examined short‐term outcomes, and the effectiveness of this intervention in the long‐term is unknown.

Please provide your summary of the paper

This study shows implementing hip interventions (strengthening and manual therapy) along with the typical LBP treatment provided to patients helped patients see greater improvements in self-reported disability, pain levels, GRoC, and patient satisfaction in 2-weeks and at discharge. This was the first study to look at how adding hip interventions would impact mechanical LBP, so further research would need to be done to see if the findings of this study are similar. The results also showed that the effects of the intervention strengthened over the course of the administration of therapy.

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

Further research should look into the implementation of hip interventions for patients with LBP to see if short-term effects can be substantiated as they were in this study and if long-term effects can be established. For now, I would say that if adding hip interventions to a patient’s treatment that is dealing with LBP is helpful to them, then it would be beneficial to do so. Regardless of what little literature there is about this specific intervention when dealing with LBP, trying things like this on patients has little risk and could generate plenty of reward on a case-to-case basis.

Author Names

Estébanez-de-Miguel, E., Fortún-Agud, M., Jimenez-del-Barrio, S., Caudevilla-Polo, S., Bueno-Gracia, E., Tricás-Moreno, J.M.

Reviewer Name

Jake Isaac, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Manual therapy has been shown to increase range of motion (ROM) in hip osteoarthritis (OA). However, the optimal intensity of force during joint mobilization is not known.  Objective: To compare the effectiveness of high, medium and low mobilization forces for increasing range of motion (ROM) in patients with hip OA and to analyze the effect size of the mobilization.  Design: Randomized controlled trial.  Methods: Sixty patients with unilateral hip OA were randomized to three groups: low, medium or high force mobilization group. Participants received three treatment sessions of long-axis distraction mobilization (LADM) in open packed position and distraction forces were measured at each treatment. Primary outcomes: passive hip ROM assessed before and after each session. Secondary outcomes: pain recorded with Western Ontario and McMaster Universities (WOMAC) pain subscale before and after the three treatment sessions.  Results: Hip ROM increased significantly (p &lt; 0.05) in the high-force mobilization group (flexion: 10.6°, extension: 8.0°, abduction:6.4°, adduction: 3.3°, external rotation: 5.6°, internal rotation: 7.6°). These improvements in hip ROM were statistically significant (p &lt; 0.05) compared to the low-force group. There were no significant changes in the low-force and medium-force groups for hip ROM. No significant differences in hip pain were found between treatment groups. Conclusion: A high force LADM in open packed position significantly increased hip ROM in all planes of motion compared to a medium or low force mobilization in patients with hip OA. A specific intensity of force mobilization appears to be necessary for increasing ROM in hip OA.

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?

• No

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)?

• Cannot Determine, Not Reported, or Not Applicable

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)?

• No

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

Effectiveness of long axis distraction mobilizations for increasing ROM in patients with hip OA appears to be dependent on a particular intensity.

Key Finding #2

A high force LADM compared to a medium or low force mobilization resulted in significant increases in multi-planar hip ROM in patients with hip OA.

Key Finding #3

The study considered a high force mobilization to be a force that exceeded the initial marked resistance (first stop) resulting in a stretch of the surrounding soft tissues.

Key Finding #4

No significant difference was found in pre and post treatment pain levels between the three groups.

Please provide your summary of the paper

This study evaluated the comparative effectiveness of low, medium, and high force long axis distraction mobilization (LADM) on increasing hip range of motion in patients with hip osteoarthritis (OA). The randomized controlled trial included 60 patients (mean age 63 + 9.7 years, 58.3% male) with unilateral hip OA. The participants were randomly assigned to a low, medium, or high force group with each consisting of 20 patients. Each group received three treatment sessions of LADM with distraction forces varying dependent on force classification (low, medium, or high). A force provided before the slack was taken up was utilized for the low force group. A force applied until marked resistance was felt was given to the medium force group. A force that exceeded marked resistance was applied to the high force group. The primary outcome studied was passive hip ROM pre and post treatment. Secondary outcomes included pre and post treatment pain levels recorded with Western Ontario and McMaster Universities (WOMAC) pain subscale. The study found statistically significant (p &lt; 0.05) multiplanar passive ROM increases in the high force mobilization group compared to the low or medium force groups. There was no significant difference found in pain levels pre and post treatment 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.

This study demonstrates that specific intensity is needed to improve effectiveness of long axis distraction mobilizations in patients with hip OA. Although this study utilized dynamometry to measure forces, it included descriptions of each force level dependent on individual patient presentation (i.e. force exceeding marked resistance) which allows for easier application in a clinical setting. The clinical relevance of this study indicates that high force mobilization may be necessary to provide enough distraction force to result in significant ROM increases when using LADMs in those with hip OA. The results also indicate that the resulting ROM gains were not due to hypoalgesic effects, as there was no significant difference in pre and post treatment pain levels between groups. This study can be used as a guide for clinicians aiming to improve passive hip ROM in their patients presenting with hip OA, or those looking to improve the effectiveness of their long axis distraction mobilizations.

Author Names

Kazemi, Mohsen; Legaurd, Sydney Hubbel; Lilja, Sebastian; Mahaise, Steven

Reviewer Name

Jordan Jaklic, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objectives

This study aims to determine whether manipulative therapy of the hip joint can increase range of motion (ROM) and/or decrease pain in individuals experiencing symptomatic hip pain.  Methods

Non-disabled young adults were recruited on campus of a chiropractic college for this randomized crossover study. Subjects’ hip active and passive ROM and pain perception were measured. Subjects then received a drop-piece hip manipulation (DPHM) or an alternative treatment, followed by measurement of active and passive ROM and pain.

Results

Eight males and 12 females (n=20) between the ages of 21–32 years completed the study. Statistically significant improvements in numeric pain scale (NRS) and passive abduction were observed for the manipulation group when compared to the alternative treatment. No significant change was observed for all other hip ranges.

Conclusions

DPHM of the symptomatic hip joint in a small sample of young adults resulted in statistically significant improvements in pain and passive abduction when compared to sham manipulation. Due to low sample size, further research is recommended.

NIH Risk of Bias Tool

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?

• No

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

• Yes

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

• Cannot Determine, Not Reported, Not Applicable

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?

• No

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)?

• No

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?

• Cannot Determine, Not Reported, Not Applicable

Key Finding #1

There were significant improvements in passive hip abduction when using manipulation compared to the alternative technique. All other hip motions, including active hip abduction, did not have significant findings with the manipulation technique.

Key Finding #2

There were improvements in the numeric pain rating scale scores from both the manipulation technique and the alternative treatment, however; improvements were greater with manipulation.

Please provide your summary of the paper

In this paper, the researchers wanted to assess the effect manipulation would have on hip range of motion (ROM) and hip pain using the numeric pain scale. This was a randomized crossover trial in which participants received a random intervention (manipulation or alternative) the first time and the next time would receive the other intervention. The manipulation technique used was a postero-caudal long axis thrust through the affected hip that would engage a drop piece underneath the patient lying in supine. The alternative technique was described as the doctor remaining contact with the affected leg and using the other to initiate an anterior to posterior thrust into the drop piece below the patient, thus the thrust going to the table instead of through the joint. Both procedures were repeated three times.  The number of participants was small (n=20) and were young adults in chiropractic school. The criteria for the study was that the participants had to have hip pain or limited hip ROM and attend the school at Canadian Memorial Chiropractic College. Hip ROM, both passive and active, and pain scores were taken pre and post intervention.  Although there were significant effects found on the numeric pain scale scores, there was no clear answer to why. The authors hypothesized it may be related to the gate control theory, but it was not investigated further. Additionally, only passive hip abduction was found to have significant effects. Authors describe that manipulation can create space in a joint, yet the results of this study do not depict this statement. If the manipulation technique was supposed to gap the joint, then it is thought more active and passive hip ranges would be affected.  In the discussion of this paper, it was stated that the sensors that were responsible for measuring ROM were not placed the same way each time. This ultimately may have skewed the data. Some data points had to be omitted for this reason.

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

I believe that there is value to this study; however, the set up of the crossover study had errors and details that do not make it applicable to use in practice. The participant pool only assessed young adults in chiropractic school. Not only does this not represent the huge portion of the population with hip pain, student health professionals have a deep understanding on the mechanics of the body. Additionally, chiropractic students in this study may have been familiar with the manipulation technique. 85% of the students were able to guess correctly on the first visit whether they were receiving the manipulation or alternative treatment. This is likely to skew data. It is best that if this study is replicated, that it is done so with more participants with a wider range of demographics.  In this study, all hip pain was considered unless there was a previous surgery, severe arthritis, avascular necrosis, full hip ROM, numbness/tingling below the knee, or the subject had a recent hip manipulation. The study did not identify conditions that would benefit from this hip manipulation. In order for this study to be implemented into clinical practice, there needs to be more information on which conditions this manipulation technique best serves.   Lastly, this study only occurred over a short period of time. In order for the techniques in this study to be implemented, I believe it is important to understand the long-term effects of the treatment (whether it improves ROM and numeric pain scale scores over a period of months). Although this study shows the manipulation technique’s effectiveness in the short-term, many patients come to physical therapists looking for a more permanent fix. There is no data in this study to show it is a long-term effector of hip ROM and pain.

Author Names

Bade, M., Cobo-Esteves, M., Neeley, D., Pandya, J., Gunderson, T., Cook, C.

Reviewer Name

Mallory Martlock, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Rationale- The benefits of providing manual therapy and exercise targeting the hips in individuals with mechanical low-back pain (LBP) are not well established.  Objectives- The objective in this study is to determine whether a formal prescriptive treatment protocol for the hips improves outcomes in patients with a primary complaint of mechanical LBP.  Methods- Eighty-four (84) subjects (50 males, 46.1 ± 16.2 years) were randomized to 1 of 2 groups: pragmatic treatment of the lumbar spine only (LBP) (n = 39) or pragmatic treatment of the lumbar spine and prescriptive treatment of bilateral hips (LBP + HIP) (n = 45). Pragmatic treatment of the lumbar spine was based upon published clinical guidelines. Prescriptive treatment of the hips involved the use of 3 hip exercises targeting the gluteal musculature and 3 mobilization techniques targeting the hips. Subjects were assessed at baseline, 2 weeks, and at discharge with the following measures: Modified Oswestry Disability Index, Numeric Pain Rating Scale, a global rating of change (GRoC) score, the patient acceptable symptom state (PASS), and patient satisfaction.  Results- At 2 weeks, significant differences between groups differences were found in GRoC and patient satisfaction (P &lt; .05) favoring the LBP + HIP group. At discharge, there were significant differences on the Modified Oswestry Disability Index, numeric pain rating scale, GRoC, and patient satisfaction favoring the LBP + HIP group (P &lt; .05). Effect sizes were small to medium.  Conclusion- Our findings suggest that a prescriptive treatment of the hips may be of clinical value to individuals presenting with the primary complaint of mechanical LBP

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?

• No

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

• No

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?

• 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?

• Yes

Key Finding #1

Hip interventions and mobilizations in addition to normal treatment of mechanical LBP appeared to be more effective that treatment of LBP alone.

Key Finding #2

This study was unique to other studies that have investigated the effect of hip interventions in addition to LBP treatment by including hip manipulation and mobilization techniques.

Key Finding #3

Statistically significant differences were found in favor for the LBP + Hip group at discharge for the ODI, NPRS, GRoC and patient satisfaction.

Please provide your summary of the paper

This study investigated the effect of hip interventions and mobilizations on patients with mechanical LBP. Patients were randomly assigned to two groups, one which intervened with only LBP treatment, and the other group which intervened with mechanical LBP treatment plus hip interventions and mobilizations. Significant differences were found by discharge in favor of the LBP + Hip treatment protocol. A small to medium effect size was found in the group that had the additive hip protocol in their treatment. Since the therapists were responsible for collecting the data, it was impossible to carry out a double blinded study, which could contribute to some bias in the results. Overall, the addition of hip interventions and mobilizations was shown to provide some additional relief in LBP patients compared to low-back interventions alone.

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

This paper showed support of hip interventions and mobilizations for patients with low back pain through improved scores in self reported disability and pain, as well as improved patient satisfaction. While the effect sizes were small, and the experimental set up was prone to some bias, these results can impact clinical practice by providing therapists with some additional treatment options for their patients struggling with low back pain. The prevalence and chronicity of this condition can be frustrating for both the patient and the therapist, so it is valuable to consider any treatment option that could provide the patient relief, including treatment to the joints above and below the area of concern.

Author Names

MS YilDirim, S Ouyrek, OÇ Tosun, S Uzer, and N Gelecek

Reviewer Name

Nikol Papa, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

The aim of this study was to compare the effects of static stretching, proprioceptive neuromuscular facilitation (PNF) stretching and Mulligan technique on hip flexion range of motion (ROM) in subjects with bilateral hamstring tightness. A total of 40 students (mean age: 21.5±1.3 years, mean body height: 172.8±8.2 cm, mean body mass index: 21.9±3.0 kg · m^-2) with bilateral hamstring tightness were enrolled in this randomized trial, of whom 26 completed the study. Subjects were divided into 4 groups performing (I) typical static stretching, (II) PNF stretching, (III) Mulligan traction straight leg raise (TSLR) technique, (IV) no intervention. Hip flexion ROM was measured using a digital goniometer with the passive straight leg raise test before and after 4 weeks by two physiotherapists blinded to the groups. 52 extremities of 26 subjects were analyzed. Hip flexion ROM increased in all three intervention groups (p<0.05) but not in the no-intervention group after 4 weeks. A statistically significant change in initial–final assessment differences of hip flexion ROM was found between groups (p<0.001) in favour of PNF stretching and Mulligan TSLR technique in comparison to typical static stretching (p=0.016 and p=0.02, respectively). No significant difference was found between Mulligan TSLR technique and PNF stretching (p=0.920). The initial–final assessment difference of hip flexion ROM was similar in typical static stretching and no intervention (p=0.491). A 4-week stretching intervention is beneficial for increasing hip flexion ROM in bilateral hamstring tightness. However, PNF stretching and Mulligan TSLR technique are superior to typical static stretching. These two interventions can be alternatively used for stretching in hamstring tightness.

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?

• 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?

• 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?

• 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

Mulligan TSLR technique was significantly more effective than typical static stretching, but no significant difference was found between Mulligan TSLR technique and PNF stretching

Key Finding #2

No statistically significant difference was found between typical static stretching and the no-intervention group, although typical static stretching led to significant improvement in hip flexion ROM within the group

Please provide your summary of the paper

The authors experimented with three different mobility interventions compared to a control group to determine which intervention had the greatest impact on hip flexion ROM after four weeks. All three interventions demonstrated statistically significant increases in the participants’ hip flexion ROM with the most robust improvements found after using the Mulligan TSLR technique and PNF stretching.

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 suggests that all three approaches can be effective, but clinicians may help patients gain more hip flexion ROM by using either the Mulligan TSLR technique or PNF stretching. One way to implement the findings of this literature is to educate patients experiencing limited hip flexion on how to correctly perform PNF stretching in the clinic and make that a part of their HEP rather than static stretching to maximize gains in mobility.

Author Names

Sampath K, Mani R, Miyamori T, Tumilty S.

Reviewer Name

Jaime Pardee, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective: To determine whether manual therapy or exercise therapy or both is beneficial for people with hip osteoarthritis in terms of reduced pain, improved physical function and improved quality of life.  Methods: Databases such as Medline, AMED, EMBASE, CINAHL, SPORTSDiscus, PubMed, Cochrane Library, Web of Science, Physiotherapy Evidence Database, and SCOPUS were searched from their inception till September 2015. Two authors independently extracted and assessed the risk of bias in included studies. Standardised mean differences for outcome measures (pain, physical function and quality of life) were used to calculate effect sizes. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used for assessing the quality of the body of evidence for each outcome of interest.  Results: Seven trials (886 participants) that met the inclusion criteria were included in the meta-analysis. There was high quality evidence that exercise therapy was beneficial at post-treatment (pain-SMD-0.27,95%CI-0.5to-0.04;physical function-SMD-0.29,95%CI-0.47to-0.11) and follow-up (pain-SMD-0.24,95%CI- 0.41to-0.06; physical function-SMD-0.33,95%CI-0.5to-0.15). There was low quality evidence that manual therapy was beneficial at post-treatment (pain-SMD-0.71,95%CI-1.08to-0.33; physical function-SMD-0.71,95%CI-1.08to-0.33) and follow-up (pain-SMD-0.43,95%CI-0.8to-0.06; physical function-SMD-0.47,95%CI-0.84to-0.1). Low quality evidence indicated that combined treatment was beneficial at post-treatment (pain-SMD-0.43,95%CI-0.78to-0.08; physical function-SMD-0.38,95%CI-0.73to-0.04) but not at follow-up (pain-SMD0.25,95%CI-0.35to0.84; physical function-SMD0.09,95%CI-0.5to0.68). There was no effect of any interventions on quality of life.  Conclusion: An Exercise therapy intervention provides short-term as well as long-term benefits in terms of reduction in pain, and improvement in physical function among people with hip osteoarthritis. The observed magnitude of the treatment effect would be considered small to moderate.

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

Is the review based on a focused question that is adequately formulated and described?

• Yes

Were eligibility criteria for included and excluded studies predefined and specified?

• Yes

Did the literature search strategy use a comprehensive, systematic approach?

• Yes

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

• Yes

Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

• Yes

Were the included studies listed along with important characteristics and results of each study?

Was publication bias assessed?

• Yes

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

• Yes

Key Finding #1

There was high-quality evidence that exercise was more effective than the control group at follow-up for the pain outcome.

Key Finding #2

There was low-quality evidence for pain outcome that manual therapy was better than the control post-treatment.

Key Finding #3

Low-quality evidence showed that manual therapy was more effective than the control for follow-up treatments.

Key Finding #4

There was low-quality evidence that combined treatment was more effective than the control for pain and physical function.

Please provide your summary of the paper

This study was conducted to answer whether manual therapy alone, exercise therapy alone, or combined treatment can reduce pain, improve physical function and quality of life in individuals with hip osteoarthritis. A meta-analysis was conducted that included 886 participants that met the inclusion criteria. There was high-quality evidence that exercise therapy was beneficial for patients post-treatment and at follow-up. There was low-quality evidence that combined treatment was effective at post-treatment but not at the follow-up treatment. None of the interventions had an impact on quality of life. The study concluded that therapeutic exercise intervention provides short-term and long-term benefits for pain reduction and improved physical function in individuals with hip osteoarthritis.

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 highlights the importance of combining therapeutic exercise with manual therapy to improve physical function and reduce pain in patients with hip osteoarthritis. Ultimately, therapeutic exercise has higher-quality evidence to support it, but these findings can support that manual therapy techniques are safe and beneficial for patients with hip osteoarthritis. More research is needed in this area of physical therapy to support these findings further.