Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: A randomised controlled trial* – Duke Center of Excellence in Manual and Manipulative Therapy

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

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

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

Were study participants and providers blinded to treatment group assignment?

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

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

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

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

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

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

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

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)?

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?

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.