Knee

Efficacy of Specified Manual Therapies in Combination with a Supervised Exercise Protocol for Managing Pain Intensity and Functional Disability in Patients with Knee Osteoarthritis

Author Names

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

Reviewer Name

Megan Shoemaker, SPT

Reviewer Affiliation(s)

Duke University Doctor of Physical Therapy Department

Paper Abstract

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

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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?

Cannot Determine, Not Reported, or Not Applicable

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?

Cannot Determine, Not Reported, or Not Applicable

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?

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?

Key Finding #1

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

Key Finding #2

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

Key Finding #3

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

Key Finding #4

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

Please provide your summary of the paper

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

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

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

Effect of hip joint mobilisations and strength training on pain, physical function and dynamic balance in patients with Knee Osteoarthritis: A randomized controlled trial

Author Names

Mehwish B, Ali SS, Mirza Baig AA.

Reviewer Name

Madison Navarro, SPT

Reviewer Affiliation(s)

Duke University Doctor of Physical Therapy Division

Paper Abstract

Objective: To determine the effects of hip joint mobilisations and strengthening exercises on pain, physical function and dynamic balance in patients with knee osteoarthritis. Method: The single-blind three-arm parallel randomised controlled trial was conducted at Sindh Institute of Physical Medicine and Rehabilitation, the outpatient department of Dow University of Health Sciences’ Ojha Campus, Rabia Moon Memorial Welfare Trust and the Civil Hospital, Karachi, from January to July 2021. The sample comprised patients aged at least 50 years having knee osteoarthritis grade 1-3. The patients were randomised into 3 equal groups, with group A receiving hip mobilisations along with strengthening exercises of hip and conventional knee exercises, group B receiving strengthening exercises of hip along with conventional knee interventional exercises, and group C receiving conventional knee exercises only. Pain, physical function and dynamic balance were assessed using visual analogue scale, knee injury osteoarthritis outcome score and four-step square test, respectively, at baseline and after 18th session. Data was analysed using SPSS 21. Results: Of the 74 subjects assessed, 66(89.2%) were included; 22(33.3%) in each of the three groups. The sample had 19(28.8%) male subjects and 47(71.2%) female. The mean age in groups A, B and C were 55.64±3.56 years, 53.64±4.65 years and 54.91±4.30 years, respectively. There was significant difference among groups post-treatment (p<0.001). Significant improvement was also found in inter-group analyses of all outcomes (p<0.001). Conclusion: Addition of hip joint mobilisations provided better results compared to the other two groups.

Clinical Trial Number: https://clinicaltrials.gov/ct2/show/NCT04769531.

Keywords: Clinical trial Manual therapy, Knee osteoarthritis, Lower extremity manual therapy, Musculoskeletal, Posture, Resistance training. (JPMA 73: 749; 2023)

DOI: https://doi.org/10.47391/JPMA.6223

Submission completion date: 14-02-2022 – Acceptance date: 20-10-2022

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?

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)?

Cannot Determine, Not Reported, or Not Applicable

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?

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?

Key Finding #1

Incorporating hip mobilizations and hip strengthening exercises into rehab programs for patients with knee OA was more effective at improving pain than conventional knee exercises alone.

Key Finding #2

Incorporating hip mobilizations and hip strengthening exercises into rehab programs for patients with knee OA was more effective at increasing dynamic balance than conventional knee exercises alone.

Key Finding #3

Incorporating hip mobilizations and hip strengthening exercises into rehab programs for patients with knee OA was more effective at improving physical function than conventional knee exercises alone.

Please provide your summary of the paper

Sixty-six participants with knee osteoarthritis were randomly assigned to one of three treatment groups: Group A received hip mobilizations (anterior posterior glide, posterior anterior glide, caudal glide, posterior anterior glide with abduction, flexion and lateral rotation; 3 sets at 120 oscillations per minute) along with hip and knee strengthening exercises. Group B received hip and knee strengthening exercises, and Group C received knee strengthening exercises only. 18 sessions occurred over the course of 4 weeks. The Knee Injury and Osteoarthritis Outcome Score (KOOS) for physical functions, VAS for pain intensity, and four-step square test (FSST) were administered at baseline and after the last session. Group A showed significant inter-group difference (P<.001) in respect to improvements in KOOS, FSST, and VAS scores. The results suggest that adding hip mobilizations and strengthening exercises to knee osteoarthritis rehabilitation results in better outcomes for patients in regards to pain levels, dynamic balance, and physical function.

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

The results of this study align with previous research that has found that incorporating hip mobilizations and strengthening exercises into physical therapy for knee osteoarthritis significantly improves a variety of outcomes for patients. The findings of this study are feasible to incorporate into clinical practice, as all physical therapists should be skilled at administering hip mobilizations. Further, this study reiterates to clinicians the importance of analyzing joints outside of the primarily affected joint in their clinical decision making.

Effects of Myofascial Release Using Finding-Oriented Manual Therapy Combined with Foam Roller on Physical Performance in University Athletes. A Randomized Controlled Study

Author Names

Afanador-Restrepo, D, Rodríguez-López, C, Rivas-Campo, Y Baena-Marín, M, Castellote-Caballero, Y, Quesada-Ortiz, R, Osuna-Pérez, M, Carcelén-Fraile, M, and Aibar-Almazán, A.

Reviewer Name

Jamie Lynn Murff, SPT

Reviewer Affiliation(s)

Duke DPT

Paper Abstract

Sport is a science of constant reinvention that is always searching for strategies to improve performance. Objective: This study seeks to compare the effects of myofascial release with Findings- Oriented Orthopedic Manual Therapy (OMT) combined with Foam Roller (FR), versus FR by itself, on the physical performance of university athletes. A randomized controlled study was conducted with a total of twenty-nine university athletes, measuring Range of Motion (ROM), jump height and flight time, strength and dynamic flexibility using Goniometer pro, CMJ protocol in OptoGait, 1 Repetition Maximum (1RM) and Mean Propulsive Velocity (MPV) and the Sit and Reach (V) test, correspondingly. This study was registered at clinicaltrials.gov prior to the initial measurement of the participants under the code NCT05347303. Through a univariate analysis, together with an analysis of independent groups with ANOVA and an analysis of covariance, it was evidenced that OMT combined with FR generated more and better effects in all the evaluated ROM, jump height and flight time, RM and VMP tests. Finally, it was found that OMT combined with FR is better when it is desired to improve ROM, muscle power, strength and flexibility, while FR alone only improves dynamic flexibility.

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

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)?

Cannot Determine, Not Reported, or Not Applicable

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

Key Finding #1

Myofascial release using foam rolling alone facilitated improvements in ROM, muscle power, strength, & dynamic flexibility.

Key Finding #2

Myofascial release using foam rolling combined with findings-oriented manual therapy facilitated greater improvements in ROM, muscle power, strength, and flexibility.

Please provide your summary of the paper

This article compared the effects of myofascial release with findings-oriented orthopedic manual therapy combined with foam roller versus foam roller by itself on range of motion, jump height and flight time (muscle power), strength, and dynamic flexibility. Pre-intervention and post-intervention testing were completed for range of motion, muscle power, strength, and dynamic flexibility using Goniometer pro, CMJ protocol in OptoGait, 1 Repetition Maximum, Mean Propulsive Velocity, and the Sit and Reach (V) test, respectively. The participants were university athletes split randomly into two groups. The control group received myofascial release protocol with foam rolling and the intervention group received myofascial release protocol based on findings-oriented orthopedic manual therapy and foam rolling. The foam rolling series included rolling out the triceps suralis (gastroc-soleus complex), hamstrings, tensor fasciae latae, and quadriceps muscles for 50 seconds with a 30 second break between each one. This series was performed twice on each leg. The control group received this intervention twice a week on discontinuous days for 8 weeks, 16 total sessions. The findings-oriented manual therapy intervention protocol consisted of evaluating restriction in the quadriceps, hamstrings, triceps suralis, and tensor fasciae latae in both legs. These areas were then treated with 2 manual techniques. The first manual technique was pressure on painful points until the pain disappears or 1 and a half minutes is reached. The next manual technique was longitudinal sliding down the muscle fibers performed with the therapist’s elbow. This intervention did not exceed 15 minutes total per participant. The intervention group received this intervention once a week along with the foam rolling series discussed above on discontinuous days for 8 weeks, 24 total sessions. Both interventions facilitated improvements from pre- to post-intervention test values, however, the group that received findings-oriented orthopedic manual therapy and foam rolling had a greater improvement in post intervention test values.

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

The results from this study showed that foam rolling facilitated improvements in range of motion, muscle power, strength, and dynamic flexibility. Foam rolling was performed individually by the participant which means, clinically, that this intervention could be included in a home exercise program for an appropriate patient. Additionally, the results showed that having a physical therapist apply manual therapy on top of the participant performing foam rolling facilitated greater improvements in range of motion, muscle power, strength, and dynamic flexibility than foam rolling alone. The physical capacities mentioned previously are all important aspects to athletes and non-athletes having the best building blocks possible to enhance physical performance and physical function, respectively. Clinically, this is relevant because it justifies the impact a physical therapist can have in providing care. It is important to remember that the target population of the study was university athletes with no lower extremity injury that could affect the results. This should be taken into consideration if trying to use the findings of this study for other populations.

The Benefits of Adding Manual Therapy to Exercise Therapy for Improving Pain and Function in Patients With Knee or Hip Osteoarthritis: A Systematic Review With Meta-analysis

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

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

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

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

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

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

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

Was publication bias assessed?

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

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.

Effectiveness and safety of manual therapy for knee osteoarthritis: An overview of systematic reviews and meta-analyses

Author Names

Feng T, Wang X, Jin Z, Qin X, Sun C, Qi B, Zhang Y, Zhu L and Wei X

Reviewer Name

Rachel Jablonski, SPT

Reviewer Affiliation(s)

Duke University

Paper Abstract

Background: Manual therapy has been used as an alternative approach to treat knee osteoarthritis (KOA) for many years. Numerous systematic reviews (SRs) or meta-analyses (MAs) were published to evaluate its effectiveness and safety. Nevertheless, the conclusions of SRs/MAs are inconsistent, and the uneven quality needs to be critically appraised. Objectives: To conduct a comprehensive overview of the effectiveness and safety of manual therapy for KOA and the quality of relevant SRs/MAs, thus providing critical evidence and valuable direction for future researchers to promote the generation of advanced evidence. Methods: The pre-defined search strategies were applied to eight electronic databases from inception to September 2022. Suitable SRs/MAs were included in accordance with the inclusion and exclusion criteria. The methodological quality, risk of bias, reporting quality, and evidence quality were assessed by two independent reviewers who used respectively the A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR-2), the Risk of Bias in Systematic Reviews (ROBIS), the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 Version (PRISMA 2020), and Grades of Recommendations, Assessment, Development and Evaluation (GRADE) based on the method of narrative synthesis. We excluded the overlapping randomized controlled trials (RCTs) and performed a re-meta-analysis of the total effective rate. Results: A total of eleven relevant SRs/MAs were included: nine SRs/MAs were rated critically low quality, and two were rated low quality by AMSTAR-2. According to ROBIS, all SRs/MAs were rated low risk in Phase 1 (assessing relevance) and Domain 1 (study eligibility criteria) of Phase 2. Three SRs/MAs (27.27%) were rated low risk in Domain 2 (identification and selection of studies). Ten SRs/MAs (90.91%) were rated low risk in Domain 3 (data collection and study appraisal). Five SRs/MAs (45.45%) were rated low risk in Domain 4 (synthesis and findings). And five SRs/MAs (45.45%) were rated low risk in Phase 3 (risk of bias in the review). By PRISMA 2020, there were some reporting deficiencies in the aspects of abstract (2/11, 18.18%), search strategy (0/11, 0%), preprocessing of merging data (0/11, 0%), heterogeneity exploration (6/11, 54.55%), sensitivity analysis (4/11, 36.36%), publication bias (5/11, 45.45%), evidence quality (3/11, 27.27%), the list of excluded references (3/11, 27.27%), protocol and registration (1/11, 9.09%), funding (1/11, 9.09%), conflict of interest (3/11, 27.27%), and approach to relevant information (0/11, 0%). In GRADE, the evidence quality was defined as moderate quality (8 items, 21.05%), low quality (16 items, 42.11%), and critically low quality (14 items, 36.84%). Among the downgraded factors, risk of bias, inconsistency, imprecision, and publication bias were the main factors. A re-meta-analysis revealed that manual therapy can increase the total effective rate in KOA patients (risk ratio = 1.15, 95% confidence interval [1.12, 1.18], p < 0.00001; I2 = 0, p = 0.84). There are four reviews that narratively report adverse effects, and no severe adverse reactions occurred in the manual therapy group. Conclusions: Manual therapy may be clinically effective and safe for patients with KOA. However, this conclusion must be interpreted with caution because of the generally unsatisfactory study quality and inconsistent conclusions of the included SRs/MAs. Further rigorous and normative SRs/MAs are expected to be carried out to provide robust evidence for definitive conclusions.

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?

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

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

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

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

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

Was publication bias assessed?

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

Key Finding #1

The use of manual therapy to treat knee osteoarthritis was significantly superior to the control group in terms of the total effective rate.

Key Finding #2

In terms of the safety of manual therapy, they found no significant adverse reactions in the group receiving manual therapy.

Key Finding #3

There were inconsistent findings regarding the effectiveness of manual therapy on improving pain and function in patients with knee OA. This topic will require further exploration.

Please provide your summary of the paper

This article reviewed nine different systematic reviews and meta-analyses that explored the effectiveness of manual therapy for treating knee osteoarthritis. They used two independent reviewers to assess quality, risk of bias, reporting quality, and evidence quality of the studies. The results showed manual therapy can be used as an effective tool to combat pain and functional deficits originating from knee osteoarthritis. They also found reported adverse reactions were rare, supporting the motion that this technique is safe. However, many of the studies were rated as low quality and there is a need for further quality studies about manual therapy and knee OA.

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

It is clear from this study that there is a need for higher quality studies of manual therapy and knee osteoarthritis. There is a surplus of published studies supporting manual therapy as a treatment for knee OA but it is not clear that many of them are low quality. The low quality could create confounding variables that impact the results of the studies. I believe the results of these studies are accurate and can be used in support of manual therapy but more studies with higher quality and less risk of bias need to be published. This will help with using manual therapy as evidence based practice.

Short-Term Effects of Mobilization-With-Movement (MWM) and Auto-MWM Application in Recreational Runners with Iliotibial Band Syndrome

Author Names

Zemadanis, K; Betsos, T

Reviewer Name

Alexis Hawbaker, SPT

Reviewer Affiliation(s)

Duke Doctor of Physical Therapy Division

Paper Abstract

Background: It is well known that Iliotibial band syndrome (ITBS) is the most frequent overuse injury in recreational runners. Given the fact that there are no clear guidelines on the optimal conservative treatment approach regarding ITBS rehabilitation, manual therapy effect by a functional joint mobilization is still unknown. The purpose of the study was to investigate whether implementation of mobilization-with-movement (MWM) and auto-mobilization had a significant short-term improvement in pain and functionality of recreational runners with ITBS. Methods: Participants: thirty ITBS patients, were randomly assigned into two groups. Design and Settings: One group pre-test /post-test with the control group. Interventions: Runners on the treatment group followed an MWM protocol of six sessions with an additive program of auto-MWM, while the control group received a SHAM form of MWM. Outcome measurements: Pain and functionality were measured at baseline and post-treatment, via Numeric Pain Rating scale and Lower Extremity Functional Scale respectively. Mixed-ANOVA test detected possible differences among treatment phases and between groups, but also interactions among factors. Result: The present findings revealed significant interactions between factors and significant main effects of each TIME and GROUP factors on pain and functionality. MWM-treatment group showed significant improvement in post-intervention NPRT and LEFS scores, compared to baseline scores (p<.001). SHAM-MWM group exhibited no significant differences on post-NPRT and LEFS scores, compared to baseline (p>.001). Differences between groups were significant in post-treatment scores (p<.001). Conclusion: Our findings suggest that MWM and auto-MWM are a significant treatment approach, improving pain and functionality in recreational runners suffering from ITBS.

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?

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

Key Finding #1

Pain (Numeric Pain Rating Scale during running) and functionality (LEFS) measures were more significantly improved over the course of treatment within the MWM group compared to within the sham group.

Key Finding #2

Post-treatment measures were more significantly improved in the MWM group compared to the sham group.

Key Finding #3

Use of MWM in recreational runners with ITBS may allow for an earlier return to running than conventional ITBS interventions.

Reviewer Summary:

The authors chose 5 MWM exercises that addressed the IT band both proximally and distally based on common biomechanical patterns noted in ITBS literature. The specific dosage parameters of the MWM intervention make the study easy to replicate and apply in clinical practice. Notably, numeric pain rating scale values were obtained as subjects were running, which was sensible given that ITBS pain typically arises during running. This study had a small sample size and uniquely incorporates joint mobilization into ITBS rehabilitation, so further research is required to elucidate the utility of MWM in treating ITBS and whether its effects are generalizable to elite and differently aged runner populations.

Clinical Interpretation:

The described ITBS MWM intervention is easily replicable and, based on the length of treatment in the study (2 weeks), may allow for an earlier return to recreational running than conventional ITBS interventions. Presumably, specific exercises may be chosen out of the 5 described based on patient-specific impairments and gait mechanics. As previously mentioned, further research is needed to determine whether other populations would benefit from this intervention.

Periosteal Electrical Dry Needling as an Adjunct to Exercise and Manual Therapy for Knee Osteoarthritis

Author Names

James Dunning, DPT, MSc, FAAOMPT, Raymond Butts, DPT, MSc, PhD, Ian Young, DSc, PT, Dip Osteopractic,Firas Mourad, PT, OMT, Dip Osteopractic, Victoria Galante, DPT, FAAOMPT, Paul Bliton, DPT, FAAOMPT, Michelle Tanner, DPT, FAAOMPT, and César Fernández-de-las-Peñas, DMSc, PT, PhD

Reviewer Name

Katharina Harding, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

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?

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?

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?

Key Finding #1

Patients receiving electrical dry needling experienced greater improvements in related disability than those receiving manual therapy and exercise alone.

Key Finding #2

Individuals receiving electrical dry needling experienced significantly greater decrease in knee pain than those receiving manual therapy and exercise alone.

Key Finding #3

Patients receiving electrical dry needling were 1.7 times more likely to have completely stopped taking medication for their pain at 3 months than individuals receiving manual therapy and exercise alone.

Please provide your summary of the paper

This article compares two different treatment groups in those with knee osteoarthritis (OA) via a randomized clinical trial. One group received manual therapy and an exercise program, while the other received electrical dry needling, manual therapy, and an exercise program. The main objective of this study was to compare the effects of using electrical dry needling as an adjunct treatment to manual therapy and an exercise program on pain, stiffness, function, and disability in individuals with knee OA over 3 months. This study uses Western Ontario and McMaster Universities (WOMAC total score) Osteoarthritis Index to measure related disability. Other outcomes included knee pain intensity via the Numeric Pain Rating Scale (NPRS), and all of the WOMAC subscales. These outcome measures in addition to the tools utilized for data analysis are validated for RCTs to determine that the electrical dry needling, manual therapy, and exercise program group had statistically significant improvements in pain and related disability when compared to the manual therapy and exercise program group.

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

This article provides significant data that highlights the short-term benefits when including the use of electrical dry needling with manual therapy and an exercise program when treating individuals with painful knee OA. This study indicates that electrical dry needling should be utilized as an adjunctive therapy for those with knee OA to aid in pain reduction and decreasing related disability. However, these specific results were attained with performing dry needling with a 9-point protocol which physical therapists will need to consider if performing dry needling when treating these individuals. Furthermore, it has not been determined that these results can be generalized with different doses, protocols, and techniques of dry needling. This study also defines manual therapy as passive joint mobilizations and muscle stretching, which can be performed with great variability, thus, also making these results difficult to generalize. Additionally, these results are only applicable within a 3-month time frame, indicating that there should be continued research on the long-term effects of this treatment method. Overall, this study presents a new category of research and practice that physical therapists should continue to consider and investigate when treating individuals with painful knee OA.

The immediate effect of lumbopelvic manipulation on knee pain, knee position sense, and balance in patients with patellofemoral pain: A randomized controlled trial

Author Names

Motealleh, A., Barzegar, A., and Abbasi, L.

Reviewer Name

Elizabeth Farmer, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy

Paper Abstract

Background Patellofemoral pain (PFP) is a common musculoskeletal disorder. Quadriceps and core muscle neuromuscular control impairments are frequently associated with PFP. Lumbopelvic manipulation (LPM) has been shown to improve quadriceps and core muscle activation and decrease their inhibition, but changes in balance and knee joint position sense (JPS) after this intervention remain unknown. Objective To determine whether LPM decreases knee pain and JPS error and increases balance performance in patients with PFP. Design Randomized controlled trial. Setting Biomechanics laboratory at a rehabilitation science research center. Methods Forty-four patients with PFP participated in this study that randomly divided into two equal groups. One group received LPM and the other received sham LPM (positioning with no thrust) in a single session. At baseline and immediately after the intervention, the outcomes of pain using a visual analog scale, balance using the modified star excursion balance test (mSEBT), and JPS at 20° and 60° of knee flexion using a Biodex dynamometer. Results There was a statistically significant improvement in pain, balance control (anterior direction) and JPS in the LPM group immediately after the intervention. In addition, we observed significant differences between groups in pain, balance control (anterior direction) and JPS at 60° of knee flexion immediately after the intervention. Conclusion A single session of LPM immediately improved balance control, knee JPS, and pain in patients diagnosed with PFP. Clinical rehabilitation impact Findings suggest that LPM may be used as a therapeutic tool for immediate improvement of symptoms of PFP. However, more research is needed to determine long term results.

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?

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?

Cannot Determine, Not Reported, or Not Applicable

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?

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

Cannot Determine, Not Reported, or Not Applicable

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

Key Finding #1

There was a statistically significant decrease in pain (measured by VAS, mean change of 1.34 points) after supine rotational lumbopelvic manipulation was performed in patients with patellofemoral pain syndrome. In the control group who received a “sham manipulation” described as the manipulation set up with no thrust, there was no difference in pain levels before vs after the intervention.

Key Finding #2

Knee joint position sense (JPS) error at 20 and 60 degrees decreased significantly when measured via an isokinetic dynamometer immediately after lumbopelvic manipulation. The sham manipulation group did not experience a change in JPS error.

Key Finding #3

Immediately after lumbopelvic manipulation, the experimental group demonstrated as significant increase in anterior excursion distance in the modified star excursion balance test (mSEBT) as compared to both the pre-test results and the results of the sham manipulation group. This increase in anterior excursion represents an improved balance performance post manipulation.

Please provide your summary of the paper

This study examined the effect of a supine rotational lumbopelvic manipulation on pain, joint position sense error, and balance performance on patients with patellofemoral pain syndrome. Outcomes were measured via a Visual Analogue Scale rating, isokinetic dynamometer testing of joint position sense at 20 and 60*, and performance and directional excursion during the modified star excursion balance test (mSEBT) immediately following the experimental treatment. 44 participants were randomly allocated to the experimental group receiving the manipulation, or a control group receiving a sham manipulation consisting of the set up for the manipulation but no actual thrust. The study reported a significant decrease in pain, decrease in joint position sense error, and increase in mSEBT scores following manipulation, with no changes in scores for the sham manipulation group. The authors state that these findings are similar to those of studies done on upper extremity joints and cervical manipulations. However, the mechanism through which lumbopelvic manipulations can decrease pain, JPS error, and improve balance has yet to be fully elucidated and further studies should be done to examine the long term effects on manipulation on these variables in participants with patellofemoral pain syndrome.

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 lumbopelvic manipulation can play a role in the care of patients with PFPS by not just providing immediate symptom improvement, but improving biomechanic performance as well. The paper builds on a body of literature suggesting that osteopathic manipulations of regions near the region of the primary diagnosis can provide benefit to the patient. The findings highlight the importance of examining the entire kinetic chain while treating a patient. One limitation in the application of these findings to clinical practice is that there is not yet any research suggesting that these gains in balance and proprioception are long-lasting. Finally, as with other osteopathic manipulations, this should not be used as the primary mechanism through which a therapist treats a patients, but rather a way to facilitate participation in other therapeutic exercises necessary for the patient’s recovery.

Long term efficacy of mobilisation with movement on pain and functional status in patients with knee osteoarthritis: a randomised clinical trial

Author Names

Nigam, A, Satpute, K, Hall, T

Reviewer Name

Andrew Erker, SPT, CSCS

Reviewer Affiliation(s)

Duke University Doctorate of Physical Therapy

Paper Abstract

Objectives: To evaluate the long term effect of mobilisation with movement on disability, pain and function in subjects with symptomatic knee osteoarthritis. Design: A randomised controlled trial. Setting: A general hospital. Subjects: Forty adults with knee osteoarthritis (grade 1-3 Kellgren-Lawrence scale). Interventions: The experimental group received mobilisation with movement and usual care (exercise and moist heat) while the control group received usual care alone in six sessions over two weeks. Main measures: The primary outcome was the Western Ontario McMaster University Osteoarthritis index, higher scores indicating greater disability. Pain intensity over 24 hours and during sit to stand were measured on a 10 centimetre visual analogue scale. Functional outcomes were the timed up and go test, the 12 step stair test, and knee range of motion. Patient satisfaction was measured on an 11 point numerical rating scale. Variables were evaluated blind pre- and post intervention, and at three and six months follow-up. Results: Thirty five participants completed the study. At each follow-up including six-months, significant differences were found between groups favouring those receiving mobilisation with movement for all variables except knee mobility. The primary outcome disability showed a mean difference of 7.4 points (95% confidence interval, 4.5 to 10.3) at six-months and a mean difference of 13.6 points (95% confidence interval, 9.3 to 17.9) at three-months follow-up. Conclusion: In patients with symptomatic knee osteoarthritis, the addition of mobilisation with movement provided clinically significant improvements in disability, pain, functional activities and patient satisfaction six months later. Keywords: Knee osteoarthritis; manual therapy; mobilisation with movement.

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

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?

Cannot Determine, Not Reported, or Not Applicable

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?

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?

Key Finding #1

Subjects that received mobilization with movement, along with an exercise program and heat treatment sustained better outcomes (lower pain, higher self-reported function, and patient satisfaction) at 3 and 6 months compared to subjects who participated in an exercise program and heat treatment.

Key Finding #2

There were no differences in range of motion improvements between the experimental and control subjects at any point in the evaluation timeline.

Key Finding #3

The authors hypothesize that the reduction in pain in the subjects receiving mobilization with movement can be due to an alteration of nociceptive inputs.

Key Finding #4

All subjects were guided to continue exercise treatment at home, however this was never monitored. Therefore, adherence to a home exercise program is a variable that is not accounted for in the results.

Please provide your summary of the paper

This randomized clinical trial provided a new view on the effects of mobilization with movement by examining various outcomes both immediately and long-term (6 months). This study included 40 subjects with a similar age (50-70 y/o), pain intensity (4-8/10), functional status, lack of complex medical history, and Kellgren and Lawrence osteoarthritis scale score (1-3). The subjects were selected randomly to either receive exercise and moist heat with/without mobilization with movement. The mobilization with movement was provided at the tibia with stabilization of the femur in all directions during active range of motion knee flexion and extension. This program lasted two weeks, and the subjects all had six 45-minute treatment sessions. Pain, function, range of motion and patient satisfaction were all assessed by a blinded, qualified physical therapist at the conclusion of the two week program, as well as in re-evaluations at 3 months and 6 months. After the conclusion of the two weeks, all subjects were guided to continue their exercise program at home, and the experimental subjects were educated on how to self-mobilize. However, there was no documentation regarding adherence to the home program. There were improvements in pain, function, range of motion and patient satisfaction by both groups. There was a clinically significant improvement in pain, function and patient satisfaction in experimental subjects compared to their controlled counterparts. There was not a clinically significant difference in the range of motion between the experimental and control 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 used a small sample size with adequate power. The results of the study are promising for the implementation of mobilization with movement techniques in clinical practice. However, the participants of this study were highly specific, therefore more research should be conducted to determine more universal guidelines for appropriateness. Furthermore, it is important to note that implementation of Mulligan manual therapy should be utilized in congruence with an adequate rehabilitative exercise program to achieve optimal outcomes.

Exercise, education, manual-therapy and taping compared to education for patellofemoral osteoarthritis: a blinded, randomised clinical trial

Author Names

Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy MG, Ozturk H, Hinman RS.

Reviewer Name

Claire DeBoer, SPT

Reviewer Affiliation(s)

Duke University Doctor of Physical Therapy Program, Class of 2025

Paper Abstract

Objective: Patellofemoral joint osteoarthritis (PFJ OA) contributes considerably to knee OA symptoms. This study aimed to determine the efficacy of a PFJ-targeted exercise, education manual-therapy and taping program compared to OA education alone, in participants with PFJ OA. Methods: A randomised, participant-blinded and assessor-blinded clinical trial was conducted in primary-care physiotherapy. 92 people aged 40 years with symptomatic and radiographic PFJ OA participated. Physiotherapists delivered the PFJ-targeted exercise, education, manual-therapy and taping program, or the OA-education (control condition) in eight sessions over 12 weeks. Primary outcomes at 3-month (primary) and 9-month follow-up: (1) patient-perceived global rating of change (2) pain visual analogue scale (VAS) (100 mm); and (3) activities of daily living (ADL) subscale of the Knee injury and Osteoarthritis Outcome Score (KOOS). Results: 81 people (88%) completed the 3-month follow-up and data analysed on an intention-to-treat basis. Between-group baseline similarity for participant characteristics was observed. The exercise, education, manual-therapy and taping program resulted in more people reporting much improvement (20/44) than the OA-education group (5/48) (number needed to treat 3 (95% confidence interval (CI) 2 to 5)) and greater pain reduction (mean difference: 15.2 mm, 95% CI 27.0 to 3.4). No significant effects on ADL were observed (5.8; 95% CI 0.6 to 12.1). At 9 months there were no significant effects for self-report of improvement, pain (10.5 mm, 95% CI 22.7 to 1.8) or ADL (3.0, 95% CI 3.7 to 9.7). Conclusion: Exercise, education, manual-therapy and taping can be recommended to improve short-term patient rating of change and pain severity. However over 9-months, both options were equivalent.

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

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?

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?

Key Finding #1

Exercise, education, manual-therapy and taping can provide superior outcomes for patient-perceived change in condition and pain compared to physiotherapist-delivered OA-education for patients with patellofemoral joint osteoarthritis (PFJ OA).

Key Finding #2

There was no difference in physical function between two groups of individuals with PFJ OA receiving exercise, education, manual-therapy and taping vs physiotherapist-delivered OA-education.

Key Finding #3

After 9 months, both treatment options were equivalent and there were no differences between the two groups.

Please provide your summary of the paper

This study was used to determine the efficacy of a patellofemoral joint osteoarthritis (PFJ OA)-targeted exercise, education, manual-therapy and taping program compared to OA education alone in participants with PFJ OA. A randomized trial was conducted with both participants and assessors blinded. 92 total participants with symptomatic and radiographic PFJ OA took part in the study with one group receiveing PFJ-targeted exercise, education, manual-therapy and taping program while the control group received OA-education. Both groups received treatment during eight sessions over 12 weeks. The group who received exercise, education, manual-therapy and taping experienced superior outcomes for patient-perceived change in condition and pain. At a nine-month follow up, both treatment options were equivalent.

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

On a short term basis, a targeted-exercise, education, manual therapy and taping program can provide more benefits than OA education alone for patients with patellofemoral joint osteoarthritis (PFJ OA). However, over a longer period of time both treatment options can provide equivalent otucomes. This information can be useful as a physical therapist because either treatment option can provide benefit to patients with PFJ OA depending on length of care.

Talonavicular joint mobilization and foot core strengthening in patellofemoral pain syndrome: a single-blind, three-armed randomized controlled trial

Author Names

Kim, H. J., Cho, J., & Lee, S.

Reviewer Name

Timothy Chang, SPT

Reviewer Affiliation(s)

Duke University, School of Medicine, Physical Therapy Department

Paper Abstract

Background Patellofemoral pain syndrome (PFPS) is defined as pain around the patella while performing activities such as squats, running, and climbing steps. One of the inherent risk factors for PFPS is an excessively pronated foot posture. The aim of this study was to investigate the effect of foot intervention, talonavicular joint mobilization (TJM) and foot core strengthening (FCS), on PFPS. Methods Forty-eight patients with PFPS (mean age, 21.96 ± 2.34 years; BMI, 22.77 ± 2.95 kg/m2) were enrolled in the study. Participants were randomly assigned in a 1:1:1 ratio to three groups, and received 12 sessions of TJM, FCS, and blended intervention at university laboratory for 4 weeks. The primary outcomes were pain while the secondary outcomes were lower extremity function, valgus knee, foot posture, and muscle activity ratio measured at baseline, after 12 sessions, and at the 4-week follow-up. Results The two-way repeated-measures ANOVA revealed significant interactions in all groups (p < 0.05). TJM reduced pain more than the FCS at post-test (mean difference, − 0.938; 95% Confidence interval [CI], − 1.664 to − 0.211; p < 0.05), and blended intervention improved lower extremity function (mean difference, 6.250; 95% CI, 1.265 to 11.235; p < 0.05) and valgus knee (mean difference, − 11.019; 95% CI, − 17.007 to − 5.031; p < 0.05) more than the TJM at 4 weeks follow-up. TJM was more effective in post-test (mean difference, − 1.250; 95% CI, − 2.195 to − 0.305; p < 0.05), and TJM (mean difference, − 1.563; 95% CI, − 2.640 to − 0.485; p < 0.05) and blended intervention (mean difference, − 1.500; 95% CI, − 2.578 to − 0.422; p < 0.05) were more effective in foot posture than the FCS in 4 weeks follow-up. Blended intervention displayed greater improvement in muscle activity than the TJM (mean difference, 0.284; 95% CI, 0.069 to 0.500; p < 0.05) and the FCS (mean difference, 0.265; 95% CI, 0.050 to 0.481; p < 0.05) at 4 weeks follow-up. Conclusions Our study is a novel approach to the potential impact of foot interventions on patellofemoral pain. Foot intervention including TJM and FCS is effective for pain control and function improvement in individuals with PFPS.

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

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?

Cannot Determine, Not Reported, or Not Applicable

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?

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?

Key Finding #1

Results suggested that talonavicular joint mobilization is effective for immediate control of patellofemoral pain and foot posture. The mobilization can help activate the muscles around the joints because of stimulation to the mechanorecptors in the joint and muscles.

Key Finding #2

Blended intervention has a positive effect on dynamic knee valgus, increased vastus medialis muscle activity compared to vastus lateralis and controlled pain.

Please provide your summary of the paper

This was a single blind, three group, parallel arm, randomized controlled trial with three evaluation sessions at basline, post-test, and four week follow up with a 4 week intervention. The three groups included a talonavicular joint mobilization, foot core strengthening, and a blended intervention group. It was found that talonavicular joint mobilization is effective for immediate control of patellofemoral pain and foot posture. Additionally, the blended intervention had a positive effect on the knee’s biomechanics and muscle activity of the quadriceps.

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

This article suggests that clinicians can consider incorporating talonavicular joint mobilization into treatment plans for patients with patellofemoral pain. It also highlights the importance of considering joint and muscle receptor interactions in the management of lower extremity conditions. Additionally, the use of comprehensive treatment strategies that address both biomechanical alignment and muscle function are supported. Clinicians may use this information to design rehabilitation programs that target muscle imbalances and control pain more effectively, potentially leading to better outcomes for patients with knee-related issues. Lastly, these findings can inform physical therapists and other healthcare professionals in their clinical decision-making, potentially leading to more targeted and effective interventions for patients with patellofemoral pain and related musculoskeletal disorders.

Physical Therapy versus Glucocorticoid Injection for Osteoarthritis of the Knee.

Article: Deyle G, Allen C, Allison S, Gill N, Hando B, Petersen E, Dusenberry D, Rhon D. Physical Therapy versus Glucocorticoid Injection for Osteoarthritis of the Knee. N Engl J Med 2020;382:1420-9. DOI: 10.1056/NEJMoa1905877

Full Text

Study Design: randomized controlled trial Abstract: Both physical therapy and intraarticular injections of glucocorticoids have been shown to confer clinical benefit with respect to osteoarthritis of the knee. Whether the short-term and long-term effectiveness for relieving pain and improving physical function differ between these two therapies is uncertain. We conducted a randomized trial to compare physical therapy with glucocorticoid injection in the primary care setting in the U.S. Military Health System. Patients with osteoarthritis in one or both knees were randomly assigned in a 1:1 ratio to receive a glucocorticoid injection or to undergo physical therapy. The primary outcome was the total score on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 1 year (scores range from 0 to 240, with higher scores indicating worse pain, function, and stiffness). The secondary outcomes were the time needed to complete the Alternate Step Test, the time needed to complete the Timed Up and Go test, and the score on the Global Rating of Change scale, all assessed at 1 year. We enrolled 156 patients with a mean age of 56 years; 78 patients were assigned to each group. Baseline characteristics, including severity of pain and level of disability, were similar in the two groups. The mean (±SD) baseline WOMAC scores were 108.8±47.1 in the glucocorticoid injection group and 107.1±42.4 in the physical therapy group. At 1 year, the mean scores were 55.8±53.8 and 37.0±30.7, respectively (mean between-group difference, 18.8 points; 95% confidence interval, 5.0 to 32.6), a finding favoring physical therapy. Changes in secondary outcomes were in the same direction as those of the primary outcome. One patient fainted while receiving a glucocorticoid injection. Patients with osteoarthritis of the knee who underwent physical therapy had less pain and functional disability at 1 year than patients who received an intraarticular glucocorticoid injection.

NIH Risk of Bias: 8/11 (PEDRO)

Key Findings:

1. Knee OA met the criteria of the American College of Rheumatology

2. Data was long term. The final assessment was at one year after the study began.

3. Physical Therapy included, but was not limited to, Manual Therapy

4. Outcomes at one year, measured by WOMAC, and pain were better in the PT group

5. Costs were not much different

Reviewer Summary: This is a well done randomized controlled trial published in The England Journal of Medicine, whose impact factor is 91.24. Limitations occur in pragmatic trials which allow for clinician variation of the reported standardized treatment options. A strength of this study is undoubtably the one year follow up, showing a meaningful effect of PT with MT compared to injection. The paper contains an infographic for patient education.

Effect of physical therapy on the flexibility of the infrapatellar fat pad: A single-blind randomised controlled trial.

Article: Kitagawa T, Ozaki N, Aoki Y. Effect of physical therapy on the flexibility of the infrapatellar fat pad: A single-blind randomised controlled trial. PLoS One. 2022 Mar 17;17(3):e0265333.

Full Text

Study Design: Randomized Controlled Trial

Abstract: The infrapatellar fat pad (IPFP) plays a biomechanical role in the knee joint. After knee injury or surgery, its dynamics decrease because of an inflammatory response. Physical therapy might be one of the valuable treatments for the recovery of knee joint mobility. This study aimed to evaluate the immediate effect of physical therapy on the dynamics of the infrapatellar fat pad in healthy participants using ultrasonography. In this prospective, single-blind, randomised controlled trial, 64 healthy young participants were enrolled and randomly assigned to one of the following three interventions: manual therapy, hot pack treatment, and control. Ultrasound images of the infrapatellar fat pad were obtained before and after the intervention. The thickness change ratio of the infrapatellar fat pad was calculated to compare the changes between and within groups before and after the intervention. No significant intergroup differences were observed. The effect sizes were relatively small. Manual therapy or hot pack intervention might not have an immediate effect on infrapatellar fat pad flexibility in healthy participants. Thus, it is necessary to consider more intensive treatments to change the dynamics of the infrapatellar fat pad.

NIH Risk of Bias Score: 11/14 (Low Risk of Bias) Key Findings of the Study:

1. Manual therapy and hot packs demonstrated almost no immediate effect on IPFP flexibility changes in healthy participants.

2. It is necessary to consider more intensive treatments to change the dynamics of the IPFP.

Reviewer Summary: This study shows that the type of interventions and/or the intensity with which they were done didn’t elicit a large change in the flexibility of the IPFP (minimal changes observed). Because research in this specific area is lacking, other studies would need to replicate the current study to see if these interventions only cause minimal changes in the IPFP. Many conservative treatments are available to address IPFP stiffness, such as physical therapy, taping, muscle training, gait training, and injections. Most of these interventions fall under the scope of practice for physical therapists and could be worth exploring in research to see if they have an effect in on IPFP flexibility.

Evaluating the Effectiveness of Soft Tissue Therapy in the Treatment of Disorders and Postoperative Conditions of the Knee Joint — A Systematic Review

Author Names

Jurecka, A , Papiez, M , Skucinska, P , Gadek, A

Reviewer Name

Semat Adekoya, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

The term “soft tissue therapy” (STT) refers to mechanical methods of treatment involving passive kneading, pressing and stretching of pathologically tense tissues in supporting the process of recovery after surgery or trauma to the musculoskeletal system. The objective of this study was to review current scientific reports evaluating the effectiveness of the use of STT in patients with diseases or after surgical procedures of the knee joint. A systematic search of the popular scientific databases PubMed, Scopus and Embase was performed from inception to 15 October 2021. Eight articles met eligibility criteria and were included in the review. Six papers were related to disorders of the knee joint, while the remaining two studies were related to dysfunctions associated with the conditions after surgical intervention. The findings presented confirmed the effectiveness of STT in orthopaedic patients who showed an increase in lower limb functional parameters. The research has shown that the use of various methods of STT has a significant impact on increasing muscle activity and flexibility as well as increasing the range of motion in the knee joint. The physiotherapeutic methods used had a significant impact on reducing pain and increasing physical function and quality of life. The techniques used reduced the time to descend stairs in patients with knee osteoarthritis. This review summarises the effectiveness of STT as an important form of treatment for orthopaedic patients with various knee joint dysfunctions.

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?

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

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

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

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

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

Was publication bias assessed?

Cannot Determine, Not Reported, Not Applicable

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

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

The applied Soft Tissue Therapy techniques significantly increased the ROM of the knee joint.

Key Finding #2

The applied Soft Tissue Therapy techniques significantly reduced knee joint pain

Key Finding #3

After the application of manual therapy, there was a significant reduction in the results of subscales: pain, stiffness, and function

Please provide your summary of the paper

Many studies were analyzed in this systematic review over a 12 year span and brought forth the following results following studies conducted on 228 orthopedic patients. First, the application of soft tissue therapy increased range of motion at the knee joint. Another study demonstrated the increase in flexibility of the hamstring and iliotibial band following soft tissue mobilization techniques. Soft tissue therapy proved to significantly reduce knee joint pain in the majority of subjects, with a few noting no change and one person disclosing a worsening pain. Lastly, after the application of manual therapy techniques, there was a reduction in pain, stiffness, and an increase in function.

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

Research shows manual therapy and soft tissue therapy are effective in the treatment in post-operative orthopedic conditions and diseases. This systematic analysis focused on the knee as it is the “most exposed to pathological loads”, but is applicable to other portions of the body as well. These methods, although effective, should be paired with other treatment including physical therapy and exercise in order to maximize results

Manual Therapy (Postisometric Relaxation and Joint Mobilization) in Knee Pain and Function Experienced by Patients with Rheumatoid Arthritis: A Randomized Clinical Pilot Study

Author Names

Romanowski,M., Špiritović, M., and Straburzyńska-Lupa, A.

Reviewer Name

Jessika Barnes, SPT, LPTA

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objectives. The purpose of this study was to evaluate the impact of manual therapy on the management of rheumatoid arthritis (RA) patients with knee pain. Materials and Methods. This was a small, randomized clinical pilot study. Subjects were 46 patients with diagnosed RA, randomly assigned to the manual therapy group (postisometric relaxation and joint mobilization) or control group (standard exercise). Subjects in each group had 10 sessions of interventions, once a day with one day break after the sixth day. Outcomes included the pain intensity of knee, Knee Society Score, Oxford Knee Score, and Health Assessment Questionnaire. Results. There were no statistically significant differences between groups, except for the pain intensity of the knee. Conclusions. This study suggests that manual therapy (postisometric relaxation and joint mobilization) may have clinical benefits for treating knee pain and function in rheumatoid patients. Further extended studies are expected to determine the effectiveness of manual therapy in RA patients with knee pain.

NIH Risk Bias Tool 12/14

Key Finding #1

After the intervention, the manual therapy group showed a significantly greater reduction in the VAS than the control group. There were no signiﬁcant differences in the Knee Society Score and Oxford Knee Score between the groups.

Key Finding #2

Manual therapy may alter the imbalance between facilitatory and inhibitory inputs, thereby enhancing descending pain modulation.

Please provide your summary of the paper

This study looks at the effects of manual therapy on patients with rheumatoid arthritis of the knee compared to conventional exercise. This study focused on manual techniques: post-isometric relaxation of muscles, patella mobilization, and knee joint mobilization. Results show that manual therapy elicitated positive change in the VAS, although the groups did differ in VAS before the start of treatment. It is essential to be mindful of matching manual therapy techniques to patients’ individual needs. Research in the use of manual therapy with patients who experience RA of the knee is lacking, so it would be beneficial for further extended studies.

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

My clinical interpretation of this paper is that manual therapy would benefit patients experiencing rheumatoid arthritis in their knees. Manual therapy primarily decreased knee pain and improved patients’ functional ability due to reduced knee pain. When it comes to clinical practice, I would like to use manual therapy to help reduce pain in my patients experiencing RA since this is a primary complaint in this patient population. I would also ensure I match manual therapy techniques to patients’ individual needs.

Osteopathic Manipulative Treatment Versus Exercise Program in Runners With Patellofemoral Pain Syndrome: A Randomized Controlled Trial.

Author Names:

Zago, Julio; J, Amatuzzi, Fellipe; Rondinel, Tatiana; Matheus, João Paulo

Reviewer Name:

Kendall Bietsch, SPT

Reviewer Affiliations:

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract:

Context: The effects of an exercise program (EP) for the treatment of patellofemoral pain syndrome (PFPS) are well known. However, the effects of osteopathic manipulative treatment (OMT) are unclear. Objective: To evaluate the effects of OMT versus EP on knee pain, functionality, plantar pressure in middle foot (PPMF), posterior thigh flexibility (PTF), and range of motion of hip extension in runners with PFPS. Design: This is a randomized controlled trial. Setting: Human performance laboratory. Participants: A total of 82 runners with PFPS participated in this study. Interventions: The participants were randomized into 3 groups: OMT, EP, and control group. The OMT group received joint manipulation and myofascial release in the lumbar spine, hip, sacroiliac joint, knee, and ankle regions. The EP group performed specific exercises for lower limbs. The control group received no intervention. Main Outcome Measures: The main evaluations were pain through the visual analog scale, functionality through the Lysholm Knee Scoring Scale, dynamic knee valgus through the step-down test, PPMF through static baropodometry, PTF through the sit and reach test, and range of motion through fleximetry. The evaluations were performed before the interventions, after the 6 interventions, and at 30-day follow-up. Results: There was a significant pain decrease in the OMT and EP groups when compared with the control group. OMT group showed increased functionality, decreased PPMF, and increased PTF. The range of motion for hip extension increased only in the EP group. Conclusion: Both OMT and EP are effective in treating runners with PFPS.

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

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)?

Cannot Determine, Not Reported, or Not Applicable

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

Key Finding #1:

Both osteopathic manipulative treatment (OMT) and exercise programs (EP) are effective in reducing knee pain in runners with patellofemoral pain syndrome (PFPS).

Key Finding #2:

While OMT had greater effects on plantar pressure in middle foot (PPMF), dynamic knee valgus (DKV), and hip extension ROM compared to the EP, its effect sizes were not clinically significant for patients. Thus, there were no differences in results between the osteopathic manipulative treatment and exercise program (EP) interventions.

Key Finding #3:

Assessing for PPMF, DKV, and hip extension ROM may be useful in identifying individual etiological factors that cause PFPS.

Reviewer Summary:

This randomized controlled trial compared the effectiveness between osteopathic manipulative treatment (OMT) versus exercise for improving knee pain and functionality in runners diagnosed with patellofemoral pain syndrome (PFPS). The OMT consisted of joint thrusts of the lumbosacral spine and/or hip, sacroiliac joint, knee, and ankle with high-velocity low-amplitude (HVLA) techniques, combined with myofascial release. The exercise program (EP) consisted of strengthening exercises targeting hip flexion, hip adduction, hip abduction, hip external rotation, hip extension, knee extension, squats, and side-stepping with resistance bands. The EP also included passive stretching of the hamstrings, iliotibial tract, and plantar flexors. Despite the differences in intervention, this study found that both the OMT group and the EP group had significantly improved knee pain associated with PFPS, with no clinically significant differences between the two groups. Therefore, the authors recommend the use of both OMT or EP to treat runners with PFPS. Future studies are recommended for the combined use of OMT and EP in runners with PFPS.

Clinical Interpretation of the Paper:

This study shows that both OMT and EP significantly improve pain and functionality in runners with PFPS, but that there are no clinically significant differences between OMT and EP. Because there are no differences between OMT and EP, and they are equally clinically effective, this impacts clinical practice by allowing the physical therapist’s or the patient’s preference to dictate which form of intervention to use: OMT or EP. If a patient prefers exercise over manipulation techniques, a therapist can use the results of this study to create an exercise program tailored to strengthening the hip posterolateral and knee extensor musculature to improve the patient’s symptoms. However, if the patient preferred OMT rather than exercise, the therapist could implement the joint thrust manipulations with HVLA techniques and myofascial release. Giving the patient the option to choose their form of intervention provides them with more autonomy, and has the potential to improve the therapeutic relationship between the patient and the clinician.

Effectiveness of Manual Therapy for Pain and Self-reported Function in Individuals With Patellofemoral Pain: Systematic Review and Meta-analysis

Author Names

Eckenrode, B; Kietrys, D; Parrott, J

Reviewer Name

Jordan Burnett, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Study Design Systematic literature review with meta-analysis. Background Management of patellofemoral pain (PFP) may include the utilization of manual therapy (MT) techniques to the patellofemoral joint, surrounding soft tissues, and/or lumbopelvic region. Objectives To determine the effectiveness of MT, used alone or as an adjunct intervention, compared to standard treatment or sham for reducing pain and improving self-reported function in individuals with PFP. Methods An electronic literature search was conducted in the PubMed, Ovid, Cochrane Central Register of Controlled Trials, and CINAHL databases for studies investigating MT for individuals with PFP. Studies published through August 2017 that compared MT (local or remote to the knee), used alone or in combination with other interventions, to control or sham interventions were included. Patient-reported pain and functional outcomes were collected and synthesized. Trials were assessed via the Cochrane risk-of-bias tool, and a meta-analysis of the evidence was performed. Results Nine studies were included in the review, 5 of which were rated as having a low risk of bias. The use of MT, applied to the local knee structure, was associated with favorable short-term changes in self-reported function and pain in individuals with PFP, when compared to a comparison (control or sham) intervention. However, the changes were clinically meaningful only for pain (defined as a 2-cm or 2-point improvement on a visual analog scale or numeric pain-rating scale). The evidence regarding lumbopelvic manipulation was inconclusive for pain improvement in individuals with PFP, based on 3 studies. Conclusion The data from this review cautiously suggest that MT may be helpful in the short term for decreasing pain in patients with PFP. Several studies integrated MT into a comprehensive treatment program. Changes in self-reported function with the inclusion of MT were shown to be significant, but not clinically meaningful. The limitations in the studies performed to date suggest that future research should determine the optimal techniques and dosage of MT and perform longer follow-up to monitor long-term effects.

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?

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

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

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

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?

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

Key Finding #1

Manual therapy directed around the patella may be beneficial to decrease pain in patients with patellofemoral pain (PFP).

Key Finding #2

Local manual therapy for PFP is likely effective when performed alongside other therapies such as proximal hip strengthening, stretching, and activity modification.

Key Finding #3

In order to determine whether manual therapy alone has an effect on pain and function for patients with PFP, more studies with consistent methods of intervention are necessary.

Please provide your summary of the paper

In this systematic review and meta-analysis, the authors performed a thorough search through multiple engines and developed inclusion and exclusion criteria to standardize the articles they analyzed as much as possible. Main criteria included parameters requiring texts to be full length randomized control trials and specific to anterior knee pain and/or patellofemoral pain (PFP), to include manual therapy as a main treatment strategy, and to have at least ten participants with a dropout rate of less than 20%. After the analysis, the authors found that manual therapy to the patellar area showed moderate evidence of short-term pain relief as compared to controls or sham treatment. While patients also self-reported increases in function following manual therapy intervention as part of their PFP rehabilitation, the effects were variable and not clinically significant. The effects of lumbopelvic manual therapy on PFP pain reduction was inconsistent among the studies, though quadriceps muscle strength improvement was noted in the studies involving lumbosacral manual therapy. Overall, the authors recognized that the varying etiological definitions of PFP, and therefore differing intervention approaches, resulted in studies with inconsistent treatment approaches that are challenging to compare in analyses. While it was determined that more defined research is necessary, the authors also concluded that manual therapy is likely beneficial when provided as part of multimodal treatment to best help patients with PFP until more specific and applicable data are obtained.

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

The clinical implications of this paper highlight the need for individualized treatment based on patient responses as well as evidence from the literature. Manual therapy targeted at the patella may be beneficial in treating patients with patellofemoral pain, and the analysis suggests this is especially true when manual therapy is paired with other intervention approaches.

The Efficacy of Manual Therapy in Patients with Knee Osteoarthritis: A Systematic Review

Author Names

Tsokanos, A.; Livieratou, E.; Billis, E.; Tsekoura, M; Tatsios, P.; Tsepis, E.; Fousekis, K.

Reviewer Name

Kyra Callens

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background and objectives: Osteoarthritis (OA) is among the most common degenerative diseases that induce pain, stiffness and reduced functionality. Various physiotherapy techniques and methods have been used for the treatment of OA, including soft tissue techniques, therapeutic exercises, and manual techniques. The primary aim of this systemic review was to evaluate the short-and long-term efficacy of manual therapy (MT) in patients with knee OA in terms of decreasing pain and improving knee range of motion (ROM) and functionality. Materials and Methods: A computerised search on the PubMed, PEDro and CENTRAL databases was performed to identify controlled randomised clinical trials (RCTs) that focused on MT applications in patients with knee OA. The keywords used were ‘knee OA’, ‘knee arthritis’, ‘MT’, ‘mobilisation’, ‘ROM’ and ‘WOMAC’. Results: Six RCTs and randomised crossover studies met the inclusion criteria and were included in the final analysis. The available studies indicated that MT can induce a short-term reduction in pain and an increase in knee ROM and functionality in patients with knee OA. Conclusions: MT techniques can contribute positively to the treatment of patients with knee OA by reducing pain and increasing functionality. Further research is needed to strengthen these findings by comparing the efficacy of MT with those of other therapeutic techniques and methods, both in the short and long terms.

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?

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

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

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

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?

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

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

In the short term after utilization of manual therapy, findings indicate a decrease in pain and increase in functionality.

Key Finding #2

In the long term, manual therapy jointly with therapeutic exercise shows a small to satisfactory decrease in pain and increase in functionality.

Key Finding #3

Patient’s symptoms improved when therapeutic exercise was used in combination with manual therapy as compared to a single therapeutic exercise.

Please provide your summary of the paper

This systematic review analyzed the effectiveness of manual therapy on knee OA. Research eligible for this study included randomized trials and randomized controlled trials regarding individuals with OA in one knee. The results of this study showed an improvement in patient symptoms with the use of manual therapy. However, there were limitations to this study (i.e. only English language surveys used, small number of surveys reaching the inclusion criteria, intervention duration). Therefore, additional research is needed to further determine the effectiveness of manual therapy regarding knee OA.

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

For this systematic review, the clinical interpretation is that manual therapy is effective in improving patient symptoms in those with knee OA. However, I would not fully rely on this study, as there were many limitations to it, and would look to similar studies for further evidence. With that said, the interventions used in the study included mobilizations with movement and passive mobilizations at various degrees of knee flexion and extension. This can easily to be added to a session after ROM, to determine the degree of movement for the patient.

The Incremental Effects of Manual Therapy or Booster Sessions in Addition to Exercise Therapy for Knee Osteoarthritis: A Randomized Clinical Trial

Author Names

Abbott, J; Chapple, C; Fitzgerald, G; Fritz, J; Childs, J; Harcombe, H; Stout, K

Reviewer Name

Andres Carro SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Abstract: Study Design A factorial randomized controlled trial

Objectives: To investigate the addition of manual therapy to exercise therapy for the reduction of pain and increase of physical function in people with knee osteoarthritis (OA), and whether “booster sessions” compared to consecutive sessions may improve outcomes.

Background: The benefits of providing manual therapy in addition to exercise therapy, or of distributing treatment sessions over time using periodic booster sessions, in people with knee OA are not well established.

Methods: All participants had knee OA and were provided 12 sessions of multimodal exercise therapy supervised by a physical therapist. Participants were randomly allocated to 1 of 4 groups: exercise therapy in consecutive sessions, exercise therapy distributed over a year using booster sessions, exercise therapy plus manual therapy without booster sessions, and exercise therapy plus manual therapy with booster sessions. The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC score; 0-240 scale) at 1-year follow-up. Secondary outcome measured were the numeric pain rating scale and physical performance tests Results Of 75 participants recruited, 66 (88%) were retained at 1-year follow-up. Factorial analysis of covariance of the main effects showed significant benefit from booster sessions (P = .009) and manual therapy (P = .023) over exercise therapy alone. Group analysis showed that exercise therapy with booster sessions (WOMAC score, -46.0 points; 95% confidence interval [CI]: -80.0, -12.0) and exercise therapy plus manual therapy (WOMAC score, -37.5 points; 95% CI: -69.7, -5.5) had superior effects compared with exercise therapy alone. The combined strategy of exercise therapy plus manual therapy with booster sessions was not superior to exercise therapy alone.

Conclusion: Distributing 12 sessions of exercise therapy over a year in the form of booster sessions was more effective than providing 12 consecutive exercise therapy sessions. Providing manual therapy in addition to exercise therapy improved treatment effectiveness compared to providing 12 consecutive exercise therapy sessions alone. Trial registered with the Australian New Zealand Clinical Trials Registry (ACTRN12612000460808).

Level of Evidence Therapy, level 1b-. J Orthop Sports Phys Ther 2015;45(12):975–983. Epub 28 Sep 2015. doi:10.2519/jospt.2015.6015

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

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?

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?

Key Finding #1

Providing manual therapy as an adjunct to exercise therapy over a course of 12 consecutive sessions resulted in superior outcomes in pain and self-reported disability at 1-year follow up when compared to 12 consecutive sessions of exercise therapy alone.

Key Finding #2

Providing exercise therapy with 2 booster sessions at 5 months, 1 at 8 months, and 1 at 11 months had superior benefits in self-reported disability and 30-second sit-to-stand at 1-year follow-up compared to those who received 12 consecutive sessions of exercise therapy alone.

Key Finding #3

The results of this study did not find superior outcomes for the group that received both manual therapy and booster sessions when compared to the group that received exercise therapy alone.

Please provide your summary of the paper

This article provides a comparison via a randomized controlled trial of 4 different treatment groups over 12 sessions: exercise alone, exercise with manual therapy, exercise with booster sessions, and exercise with manual therapy utilizing booster sessions. The main objective of the article was to determine the effectiveness of manual therapy as an adjunct to exercise therapy over 1-year if the treatment strategy of using booster sessions at 5 months (2 sessions), 8 months (1 session), and 11 months (1 session) was utilized. The article uses multiple functional, self-reported functional, and self-reported pain outcome measures and utilizes tools for data analysis that are validated for RCTs to determine that the exercise with booster sessions group and the exercise with manual therapy without booster sessions group had statistically significant improvements in functional and self-reported pain and function outcome scores when compared to the reference group of exercise alone. The study did not find any statistically significant benefit for the exercise with manual therapy group that used booster sessions when compared to the exercise alone group. The article states that the small sample size may not have been able to prevent the possibility of this outcome being reached by chance and encourages further investigation of this treatment type using larger sample sizes.

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

While this paper includes a very small sample size that may not necessarily be representative of the general population that has knee OA (especially when considering the exclusion criteria and how many people may have the conditions included in those criteria), it does add to the breadth of research that supports the use of manual therapy as an adjunct to exercise therapy especially when considering patients’ views of their own outcomes. It also supports the use of booster sessions instead of consecutive sessions when using exercise therapy in order to maintain the progress the therapist has made with a patient in their initial time with them. Using these booster sessions, therapists can monitor maintenance of patient health and progress with their condition over a longer period of time so that positive functional and pain-related outcomes may persist for longer periods of time. This article does not disprove the potential for the utilization of booster sessions of exercise and manual therapy, but instead presents a category of research and practice that may be important for therapists and researchers to consider investigating and utilizing in the future. Larger sample size groups may in the future show this treatment type and plan to be more effective upon further investigation, and it may be beneficial for certain patients to have the option of manual therapy along with exercise therapy utilizing the booster session model of care.

Lumbopelvic Joint Manipulation and Quadriceps Activation of People With Patellofemoral Pain Syndrome

Author Names

Grindstaff, TL. Hertel, J. Beazell, JR. Magrum, EM. Kerrigan, DC. Fan, X. Ingersoll, CD.

Reviewer Name

Brielle Ciccio, SPT, CSCS

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Context: Quadriceps weakness and inhibition are impairments associated with patellofemoral pain syndrome (PFPS). Lumbopelvic joint manipulation has been shown to improve quadriceps force output and inhibition, but the duration of the effect is unknown. Objective: To determine whether quadriceps strength and activation are increased and maintained for 1 hour after high-grade or low-grade joint mobilization or manipulation applied at the lumbopelvic region in people with PFPS. Design: Randomized controlled clinical trial. Setting: University laboratory. Patients or other participants: Forty-eight people with PFPS (age = 24.6 ± 8.9 years, height = 174.3 ± 11.2 cm, mass = 78.4 ± 16.8 kg) participated. Intervention(s): Participants were randomized to 1 of 3 groups: lumbopelvic joint manipulation (grade V), side-lying lumbar midrange flexion and extension passive range of motion (grade II) for 1 minute, or prone extension on the elbows for 3 minutes. Main outcome measure(s): Quadriceps force and activation were measured using the burst superimposition technique during a seated isometric knee extension task. A 2-way repeated-measures analysis of variance was performed to compare changes in quadriceps force and activation among groups over time (before intervention and at 0, 20, 40, and 60 minutes after intervention). Results: We found no differences in quadriceps force output (F(5.33,101.18) = 0.65, P = .67) or central activation ratio (F(4.84,92.03) = 0.38, P = .86) values among groups after intervention. When groups were pooled, we found differences across time for quadriceps force (F(2.66,101.18) = 5.03, P = .004) and activation (F(2.42,92.03) = 3.85, P = .02). Quadriceps force was not different at 0 minutes after intervention (t(40) = 1.68, P = .10), but it decreased at 20 (t(40) = 2.16, P = .04), 40 (t(40) = 2.87, P = .01) and 60 (t(40) = 3.04, P = .004) minutes after intervention. All groups demonstrated decreased quadriceps activation at 0 minutes after intervention (t(40) = 4.17, P < .001), but subsequent measures were not different from preintervention levels (t(40) range, 1.53-1.83, P > .09). Conclusions: Interventions directed at the lumbopelvic region did not have immediate effects on quadriceps force output or activation. Muscle fatigue might have contributed to decreased force output and activation over 1 hour of testing.

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

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)?

Cannot Determine, Not Reported, or Not Applicable

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?

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

Cannot Determine, Not Reported, or Not Applicable

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

Key Finding #1

Overall, interventions applied to the lumbopelvic region in this study did not immediately affect quadriceps force output or activation.

Key Finding #2

Quadriceps force output did not change at 0 minutes postintervention but decreased at both 20 minutes and 60 minutes postintervention, potentially due to local muscle fatigue experienced over the 1-hour testing session.

Key Finding #3

This study could not differentiate between the effects of intervention and running because there was no control used to determine the effects of running on quadriceps force output and activation.

Key Finding #4

The participants that withdrew from the study (7/48) experienced discomfort, apprehension, or anxiety with burst superimposition testing. Most of the participants that withdrew from the study (6/7) were female and had activation levels > 0.90.

Please provide your summary of the paper

This randomized control clinical trial aimed to determine whether quadriceps strength and activation are increased and maintained for 1 hour after high-grade or low-grade joint mobilization or manipulation applied at the lumbopelvic region in people with patellofemoral pain syndrome (PFPS). The participants were not actively seeking medical care for PFPS but did reveal deficits in quadriceps activation and self-reported function utilizing the Lower Extremity Functional Scale (LEFS). For this study, PFPS was classified as self-reported insidious onset of unilateral or bilateral pain that could be reproduced with at least 2 of the following: patellar compression, squatting, prolonged sitting, walking up or down stairs, or isometric quadriceps contraction. There were 48 participants (age =24.6 ± 8.9 years) with PFPS that were randomized into 1 of 3 groups: grade V lumbopelvic joint manipulation, grade II side-lying lumbar midrange flexion and extension passive range of motion for 1 minute, or prone extension on the elbows for 3 minutes. Quadriceps force and percentage of quadriceps activation were measured using burst superimposition technique during a seated isometric knee extension task. Changes between quadriceps force and activation among groups over time (before intervention, 0, 20, 40, and 60 minutes after intervention) were analyzed with a 2-way repeated-measures analysis of variance. The examiner obtaining measures was blinded to treatment group allocation. Of the 48 participants, 7 of them withdrew (6 women, 1 man), and their data was not used in the final statistical analysis. The findings revealed that interventions applied at the lumbopelvic region did not have an immediate effect on quadriceps force output or percent activation. Due to 1-hour testing session, it is possible that local muscle fatigue might have resulted in decreased force output and activation.

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

Prior to this study being completed, there was no evidence about the duration of increased quadriceps strength or activation after lumbopelvic joint manipulation in a symptomatic population. Evidence was also lacking when comparing joint manipulation to lower-grade mobilizations on neurophysiologic effects in individuals with PFPS. The findings in this study revealed that interventions applied at the lumbopelvic region did not have an immediate effect on quadriceps force output or percent activation. However, joint manipulation may address specific impairments associated with PFPS such as decreased quadriceps activation and asymmetries in hip rotation. When considering clinical practice, this reveals that joint manipulation could be a component of a comprehensive rehabilitation program for an individual with PFPS as opposed to a primary treatment method. There were 7 participants (of 48) that withdrew from the study due to discomfort with burst superimposition testing. Future research implications could include examining changes in pain or discomfort in individuals with PFPS when lumbopelvic interventions were applied. Further research could also be done in order to determine the effect of running on muscular fatigue prior to performing measures of quadriceps force output and activation as this could have altered the results found in the study.

Immediate effects of Mulligan’s techniques on pain and functional mobility in individuals with knee osteoarthritis: A randomized control trial

Author Names

Bhagat M., Neelapala YVR., Gangavelli R.

Reviewer Name

Casie Coffman SPT, NBC-HWC

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background and Purpose: Mulligan’s mobilization with movement was shown to be effective when implemented in multimodal therapy for knee osteoarthritis. However, no study has evaluated the Mulligan’s technique in isolation and compared the relative effectiveness with sham-controlled interventions. Hence, the present study examined the immediate effects of Mulligan’s techniques with sham mobilization on the numerical pain rating scale (NPRS) and timed up and go (TUG) test in individuals with knee osteoarthritis. Methods: Thirty participants (mean age: 55.3 ± 8.3 years) with symptoms at the knee and radiographic diagnosis of knee osteoarthritis were randomized into sham (n = 15) and intervention (n = 15) groups. The intervention (I) group received Mulligan’s mobilization glides that resulted in relative pain relief for three sets of 10 repetitions. For the sham (S) group, the therapist’s hand was placed over the joint surfaces mimicking the pain-relieving glides, without providing the gliding force. The outcome measures NPRS and TUG were recorded by a blinded assessor pre- and post-intervention. Results: Statistically significant differences were identified between the groups in post-intervention median (interquartile range) NPRS (I group: 4.00 [2.00–5.00]; S group: 6.00 [4.00–7.00]) and TUG scores (I group: 10.9 [9.43–10.45]; S group: 13.18 [10.38–16.00]) with the intervention group demonstrating better outcomes (p < .05). Within-group, the post-intervention scores of NPRS and TUG were significantly lower (p < .05) compared to the pre-intervention scores in the intervention group. In the sham group, a statistically significant pre–post change was noticed only in the NPRS scores but not in the TUG scores. Conclusion: Mulligan’s techniques were effective in improving pain and functional mobility in individuals with knee osteoarthritis. The underlying mechanisms for observed effects must be examined further, as participants reported pain relief following sham mobilization.

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

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?

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

Cannot Determine, Not Reported, or Not Applicable

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

Key Finding #1

Posttreatment, both the intervention and sham groups showed statistically significant improvement in numeric pain rating. However, the intervention group also demonstrated a statistically significant improvement in TUG score.

Key Finding #2

The study found between group differences in numeric pain rating with an effect size of 0.41 when comparing the intervention and sham groups posttreatment.

Key Finding #3

The study found between group differences in TUG score with an effect size of 0.49 when comparing the intervention and sham groups posttreatment.

Please provide your summary of the paper

This randomized control trial utilized numeric pain rating and timed up and go measures to study the immediate efficacy of Mulligan’s mobilization with movement (MWM) in individuals with knee osteoarthritis (OA). The intervention group receiving MWM was compared to a sham group, which underwent the same process of treatment excluding the gliding force of mobilization. Prior to administration of 3×10 glides, direction of mobilization (medial rotational, lateral rotational, medial translational, or lateral translational) was determined by individualized symptom reduction via 3 trials. Following treatment, both groups received standard therapy as well which was not outlined. Based on blinded assessment after treatment, the intervention and sham groups demonstrated statistically significant reduction in numeric pain rating. Statically significant improvement in TUG score was observed solely in the intervention group. The study found between group differences in numeric pain rating and TUG scores with medium effect sizes. This information suggests that MWM may offer immediate benefit on knee pain and functional mobility in individuals with knee OA.

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

As acknowledged by the authors of this article and other scientists studying manual therapy around the world, the results of this study suggest that MWM is safe and can be beneficial (in this case for knee OA), yet the mechanisms behind why are not yet clear. Biomechanical, neurophysiological, and/or non-specific mechanisms may be considered. This study emphasizes the potential for non-specific effects given that the sham group experienced pain reduction posttreatment as well. Based on the duration of this study with respect to employing sham treatment, the clinical utility may be in the short term, and future areas of research may involve seeking long term effects of MVM.

Physical Therapy versus Glucocorticoid Injection for Osteoarthritis of the Knee

Author Names:

Deyle G, Allen C, Allison S, Gill N, Hando B, Petersen E, Dusenberry D, Rhon D.

N Engl J Med 2020;382:1420-9. DOI: 10.1056/NEJMoa1905877

Study Design:

Randomized controlled trial

Paper Abstract:

Both physical therapy and intraarticular injections of glucocorticoids have been shown to confer clinical benefit with respect to osteoarthritis of the knee. Whether the short-term and long-term effectiveness for relieving pain and improving physical function differ between these two therapies is uncertain. We conducted a randomized trial to compare physical therapy with glucocorticoid injection in the primary care setting in the U.S. Military Health System. Patients with osteoarthritis in one or both knees were randomly assigned in a 1:1 ratio to receive a glucocorticoid injection or to undergo physical therapy. The primary outcome was the total score on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 1 year (scores range from 0 to 240, with higher scores indicating worse pain, function, and stiffness). The secondary outcomes were the time needed to complete the Alternate Step Test, the time needed to complete the Timed Up and Go test, and the score on the Global Rating of Change scale, all assessed at 1 year. We enrolled 156 patients with a mean age of 56 years; 78 patients were assigned to each group. Baseline characteristics, including severity of pain and level of disability, were similar in the two groups. The mean (±SD) baseline WOMAC scores were 108.8±47.1 in the glucocorticoid injection group and 107.1±42.4 in the physical therapy group. At 1 year, the mean scores were 55.8±53.8 and 37.0±30.7, respectively (mean between-group difference, 18.8 points; 95% confidence interval, 5.0 to 32.6), a finding favoring physical therapy. Changes in secondary outcomes were in the same direction as those of the primary outcome. One patient fainted while receiving a glucocorticoid injection. Patients with osteoarthritis of the knee who underwent physical therapy had less pain and functional disability at 1 year than patients who received an intraarticular glucocorticoid injection.

NIH Risk of Bias: 8/11 (PEDRO)

Key Finding #1

Knee OA met the criteria of the American College of Rheumatology

Key Finding #2

Data was long term. The final assessment was at one year after the study began.

Key Finding #3

Physical Therapy included, but was not limited to, Manual Therapy

Key Finding #4

Outcomes at one year, measured by WOMAC, and pain were better in the PT group

Key Finding #5

Costs were not much different

Reviewer Summary:

This is a well done randomized controlled trial published in The England Journal of Medicine, whose impact factor is 91.24. Limitations occur in pragmatic trials which allow for clinician variation of the reported standardized treatment options. A strength of this study is undoubtably the one year follow up, showing a meaningful effect of PT with MT compared to injection. The paper contains an infographic for patient education.

The Effects of an Aquatic Manual Therapy Technique, Aquastretch on Recreational Athletes with Lower Extremity Injuries

Author Names

Alejo T, Shilhanek C, McGrath M, and Heick J

Reviewer Name

Jaydee Dillon, SPT, B.S

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

When paired together, manual therapy and exercise have been effective for regaining range of motion (ROM) in multiple conditions across varied populations. Although exercise in an aquatic environment is common, research investigating manual therapy in this environment is limited. There is little evidence on AquaStretchTM an aquatic manual therapy technique, but anecdotal clinical evidence suggests its effectiveness. The purpose of this study was to investigate the effects of AquaStretch™ on ROM and function in recreational athletes with self-reported lower extremity injury and pain. Injured recreational athletes participated in a 30-minute intervention session of AquaStretch.™ Injuries ranged from ankle (sprains and overuse), knee (contusions, sprains, and overuse), and hip conditions (contusions, overuse, and pain). Before a single intervention (preintervention) and within 24 hours after the intervention (postintervention), participants completed the following patient-reported outcome instruments: the Lower Extremity Functional Scale (LEFS) and the Foot and Ankle Ability Measure (FAAM) Sports subscale. AROM measurements of the ankle, knee, and hip and the following muscle length tests were measured: Ober’s test, measurement of the popliteal angle, and the modified Thomas test. Finally, the overhead deep squat test was performed as a test of function. Twenty-six recreational athletes with lower extremity injuries of the ankle, knee, and hip, aged 18-60 years (18 males, 8 females, mean age 27.4 years) completed the study. The overall group by time interaction for the mixed model Generalized Estimating Equations analysis was statistically significant for the LEFS (all p< .002) and for the FAAM sports subscale (p < 0.01). There were no statistically significant time (pre vs post) by group interactions for range of motion and other measures, including the Ober’s test, the overhead deep squat test, popliteal angle, and the modified Thomas test for injured athletes. One session of AquaStretch™ in recreational athletes improved the patient-rated outcome measures of function specifically the LEFS and FAAM Sports subscale. These results suggest that AquaStretch™ may be an effective form of manual therapy to improve lower extremity function in injured athletes.

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?

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

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?

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

Cannot Determine, Not Reported, Not Applicable

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

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

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

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

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

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?

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)?

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

Statistically significant differences were found for the uninjured limb of the athletes for the Ober’s test, the popliteal angle test, modified Thomas hip test, and for the overhead deep squat hip measurements.

Key Finding #2

A single 30 min Aqua-stretch intervention session improved function, as measured by the LEFS and FAAM Sports sub-scale, however these changes were not found to be clinically significant based on the MCID score.

Key Finding #3

None of the ROM measurements at the ankle, knee, and hip of the injured limb were found to be significantly different pre- to post intervention.

Please provide your summary of the paper

This study highlights that the use of a manual therapy technique, Aquastretch may have benefits in improvement of ROM, special tests and muscle length, and functional tests in recreational athletes. While the study was aimed at researching whether this technique would improve ROM and functional activities in an injured lower extremity limb, it found no statistical evidence of improvement. However, the study did find statistical evidence in improvement of ROM at the ankle, knee, and hip of the uninjured limb. In addition, this study resulted in statistically significant differences for three of the eight special test or muscle length measurements and three of the 5 functional tests, again in the uninjured limb. Due to this study only including a one time session of Aquastretch, additional studies will need to be performed that implements several sessions and over a period of time to determine whether or not this technique will improve function on an injured limb.

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

Clinically, I believe Aquastretch can be a good alternative for patients with injuries and degenerative joint disease to improve their ROM and functional activity level without placing excessive stress on their body. The results from this study shows the potential for this technique to be helpful in improving these factors. Evidence supporting this was that there was statistically significant differences pre and post intervention for the LEFS and FAAM Sports sub-scale, however these differences were not clinically significant. I would be interested in additional studies being implemented that contain multiple session of this technique, and evaluation of improvement over a period of time to determine its efficacy.

The immediate effect of lumbopelvic manipulation on EMG of vasti and gluteus medius in athletes with patellofemoral pain syndrome: A randomized controlled trial

Author Names

Motealleh A, Gheysari E, Shokri E, Sobhani S

Reviewer Name

Jaydee Dillon, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

The purpose of this study was to evaluate the immediate effect of lumbopelvic manipulation on EMG activity of vastus medialis, vastus lateralis and gluteus Medius as well as pain and functional performance of athletes with patellofemoral pain syndrome. Twenty-eight athletes with patellofemoral pain syndrome were randomly assigned to two groups. One group received a lumbopelvic manipulation at the side of the involved knee while the other group received a sham manipulation. EMG activity of the vasti and gluteus Medius were recorded before and after manipulation while performing a rocking on heel task. The functional abilities were evaluated using two tests: step-down and single-leg hop. Additionally, the pain intensity during the functional tests was assessed using a visual analog scale. The onset and amplitude of EMG activity from vastus medialis and gluteus medius were, respectively, earlier and higher in the manipulation group compared to the sham group. There were no significant differences, however, between two groups in EMG onset of vastus lateralis. While the scores of one-leg hop test were similar for both groups, significant improvement was observed in step-down test and pain intensity in the manipulation group compared to the sham group. Lumbopelvic manipulation might improve patellofemoral pain and functional level in athletes with patellofemoral pain syndrome. These effects could be due to the changes observed in EMG activity of gluteus medius and vasti muscles. Therefore, the lumbopelvic manipulation might be considered in the rehabilitation protocol of the athletes with patellofemoral pain syndrome.

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

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?

Cannot Determine, Not Reported, or Not Applicable