Knee

Author Names

Alkhawajah, H; Alshami, A

Reviewer Name

Taylor Doherty, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background

Few studies have investigated the effects of mobilization with movement (MWM) in patients with knee osteoarthritis (OA) compared to other procedures. Sham procedures are generally more appropriate control than using no or usual treatments. Moreover, studies investigating the widespread hypoalgesic effects of MWM in patients with knee OA are lacking. The aim was to investigate the effect of MWM on function and pain in patients with knee OA compared to sham MWM.

Methods

This is a randomized double-blind (patients and assessor) controlled trial. Forty adult patients with knee OA of grade II and above were recruited to receive either MWM treatment or sham MWM for the knee. The outcome measures included the following: a visual analogue scale (VAS) for pain, the pressure pain threshold (PPT) test, the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index, the timed up and go (TUG) test, knee strength and knee range of motion (ROM). The measurements were taken at baseline, immediately after intervention and 2 days later.

Results

Compared with sham MWM, MWM resulted in greater immediate improvement in pain [mean difference (95% CI): − 2.2 (− 2.8, − 1.6)], PPT at both the knee [176 (97, 254)] and shoulder [212 (136, 288)], TUG time [− 1.6 (− 2.1, − 1.1)], knee flexor strength [2.0 (1.3, 2.7)] and extensor strength [5.7 (4.1, 7.2)] and knee flexion ROM [12.8 (9.6, 15.9)] (all, p < 0.001) but not knee extension ROM [− 0.8 (− 1.6, 0.1)] (p = 0.067). After 2 days of intervention, patients who received MWM also demonstrated a greater improvement in pain [− 1.0 (− 1.8, − 0.1)], PPT at the shoulder [107 (40, 175)], TUG time [− 0.9 (− 1.4, − 0.4)], knee flexor strength [0.9 (0.2, 1.7)] and extensor strength [2.9 (2.1, 3.9)] and knee flexion ROM [8.3 (4.7, 11.9)] (all, p ≤ 0.026). However, WOMAC scores and knee extension ROM showed no evidence of change at any stage after intervention (p ≥ 0.067).

Conclusions

MWM provided superior benefits over sham MWM in terms of local and widespread pain, physical function (walking), knee flexion and extension muscle strength and knee flexion ROM for at least 2 days in patients with knee OA.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Yes

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Yes

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Yes

12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

• Yes

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

• Yes

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

• Yes

Key Finding #1

Mobilization with movement (MWM) resulted in clinically relevant reductions in pain in patients with knee OA immediately and after 2 days when compared to patients who completed the same movements without mobilization.

Key Finding #2

MWM resulted in significantly improved knee flexion ROM immediately upon intervention in patients with knee OA when compared with patients who completed the same movements without mobilization.

Key Finding #3

MWM resulted in significantly improved quadriceps strength up to 1 year follow-up in patients with knee OA when compared to patients who completed the same movements without mobilization.

Key Finding #4

MWM resulted in a clinically significant average of 1.6 second reduction in TUG time in patients with knee OA when compared with patients who performed the same movements without mobilization.

Please provide your summary of the paper

This study was a randomized double-bind controlled trial looking at the short-term differences in pain levels, physical function, strength, and ROM in patients with knee OA receiving mobilization with movement (MWM) compared with those performing the same movements without manual mobilization. The participants assigned to the MWM group received tibiofemoral glides in all directions to determine which glide was most effective for their pain levels and ROM. That glide was then performed during intervention while the participant flexed and extended his or her knee in open chain with no resistance for three sets of 10 repetitions. In the sham group, the same rep and set scheme was performed with one hand on the tibia and one on the femur with no mobilization applied. Outcome measures were then taken immediately after intervention and 2 days later. These outcome measures include the Visual Analog Scale (VAS), Pressure Pain Threshold (PPT), WOMAC, Timed up and Go, Knee ROM, and motor activity of the knee extensors and flexors. Overall, MWM resulted in significant short-term local and widespread hypoalgesic effects on the knee, increased knee flexion ROM, improved physical function, and improved strength of the knee extensors and flexors.

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

I believe that this paper shines a positive light on performing MWM in the clinic to relieve pain and improve function in the short term for patients with knee OA. However, I do not think the results of this paper can be extrapolated to the long-term  in this patient population, which may discourage clinicians from finding value in utilizing MWM on patients with knee OA. Personally, for patients with high pain levels and inadequate function, I think MWM can be valuable to produce short-term improvements and improve quality of life for those with knee OA. Of course the goal of PT is to produce long-term sustainable results for patients upon discharge, but MWM should still be considered to treat patients in the short term based on patients’ subjective pain reports and before exercise to improve exercise tolerance.

Author Names

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

Reviewer Name

Natalia Engel, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

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

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

7. Was publication bias assessed?

• Yes

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

• Cannot Determine, Not Reported, Not Applicable

Key Finding #1

Manual therapy applications combined with therapeutic exercises are associated with reduced pain and increased functionality in the short term.

Key Finding #2

The positive effect of manual therapy on pain reduction and ROM/functionality improvements in patients with knee OA can be attributed to neurophysiological adaptations in the peripheral and central nervous systems.

Key Finding #3

Although there are positive short term effects of manual therapy, the long term cannot yet be determined.

Please provide your summary of the paper

The results demonstrated that manual therapy has a positive short-term effect on pain and function in patients with knee OA. The study examined roughly 150 studies that implemented manual therapy on patients to assess its effectiveness. In almost all of the studies reviewed, participants were divided into intervention without a control group; although some variations existed among the interventions, the systematic review compared manual therapy technique interventions compared to other interventional methods. Through the systematic review, the results demonstrated that manual therapy has a positive effect on patient pain levels, ROM, and functionality. The reduction in pain and increase in ROM and functionality can be attributed to neurophysiological changes occurring in the nervous system. The peripheral system after manual therapy treatment leads to reduced blood and serum cytokine levels and changes in inflammatory and pain-relief mediators, and the central system responds by altering supraspinal inhibitory pain mechanisms that modulate pain from the higher centers. It is reasonable to assume that manual therapy in patients with knee OA can potentially enhance the mechanical properties of the affected structures of the knee joint through these neurophysiological changes. However, the long term effects of manual therapy for patients with knee OA could not be determined through this systematic review.

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 systematic review positively support the use of manual therapy for achieving short term benefits of pain reduction, increased ROM, and increased function in patients with knee OA. Although the long term benefits cannot be determined, this strategy can be implemented early on in order to hopefully achieve greater participation and self-efficacy from patients. If the patients are able to experience a small amount of positive change early on, they will be more likely to invest in their therapy and overall improvement of function.

Author Names

Cuesta-Barriuso R, Gómez-Conesa A, López-Pina, J A.

Reviewer Name

Razan Mazin Fayyad, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Haemophilic arthropathy is characterized by joint restrictions. One of the most affected joints in haemophilia patients is the knee. The aim of the study is to evaluate the effectiveness of manual therapy and passive muscle stretching exercises for reducing the frequency of hemarthrosis and pain and improving joint health and range of motion in patients with haemophilic knee arthropathy. Twenty eight patients with haemophilic knee arthropathy were randomized to an experimental group or to a control group (without intervention). Manual therapy sessions included joint traction and gliding manoeuvers, in addition to passive muscle stretching. The intervention included one 60-minute with two weekly sessions over a 12-week period. We evaluated the frequency of knee hemarthrosis (self-reporting), joint health (Hemophilia Joint Health Score), range of motion (goniometry) and perceived knee pain (visual analogue scale). A baseline evaluation was performed at the end of the intervention and after a 12-week follow-up period. The results showed that the frequency of hemarthrosis dropped significantly in the experimental group compared to the control group (F = 11.43; P < .001). Compared to the control group, the experimental group had consistently better results in the variables for joint health (F = 13.80; P < .001), range of motion in knee flexion (F = 24.29; P < .001) and loss of extension (F = 8.90; P < .001), and perceived pain (F = 49.73; P < .001). In conclusion, manual therapy using joint traction and gliding manoeuvers, in addition to passive muscle stretching, reduces the frequency of hemarthrosis in patients with haemophilia. Manual therapy with passive muscle stretching exercises improves joint health, range of motion and perceived joint pain.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

• No

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

• Yes

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

• Yes

Key Finding #1

At baseline, no differences were found between the study groups in any of the measured variables

Key Finding #2

Manual therapy using traction and joint sliding techniques showed significant improvements in the frequency of hemarthrosis, joint health, knee flexion and loss of extension, and perceived pain

Key Finding #3

Manual therapy was shown to maintain these improvements after six months of treatment

Please provide your summary of the paper

There is a high prevalence of haemophilic knee arthropathy in patients with haemophilia. Despite that, only a few studies looked into the efficacy of manual therapy applied to this condition. To fill this gap, this study evaluated the safety and effectiveness of manual therapy using traction and joint sliding techniques and passive muscle stretching in patients with haemophilic knee arthropathy. An experienced physical therapist was blinded to patient allocation to each study group and conducted all the evaluations, reducing bias. Further, no adverse events were reported during the study. One of the study’s major limitations is the low sample size. Additionally, the secondary study variables focused on assessing musculoskeletal outcomes, which are of great importance. However, other measures, such as functional independence and quality of life, were not investigated. Although the results showed support and improvement once manual therapy techniques were used, further randomized clinical trials with a larger sample size and measured outcomes would be necessary to validate these results.

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

From the results of this study, various manual therapy mobilization techniques, such as traction and joint sliding can be implemented in the treatment plan of patients with haemophilic knee arthropathy. The study provides a further understanding of how these techniques reduce the frequency of hemarthrosis as well as improve joint health in these patients. Further studies would be necessary to validate the results and allow for these exercises to be implemented on a regular basis.

Author Names

Mutlu E K, Ercin E, Ozdincler A R, Ones N.

Reviewer Name

Razan Mazin Fayyad, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

A broad spectrum of physical therapy exercise programs provides symptom relief and functional benefit for patients with knee OA. Manual physical therapy, including tailored exercise programs provide relatively higher level benefits that persists to one year. It is currently unknown if there are important differences in the effects of different manual physical therapy techniques for patients with knee OA and there are virtually no studies comparing manual physical therapy and electrotherapy modalities. The aim of the study was to compare long-term results between three treatment groups (mobilization with movements [MWMs], passive joint mobilization [PJM], and electrotherapy) to determine which treatment is most effective in patients with knee OA. A single-blind randomized clinical trial with parallel design was conducted in patients with knee OA. Seventy-two consecutive patients (mean age 56.11 ± 6.80 years) with bilateral knee OA were randomly assigned to one of three treatment groups: MWMs, PJM, and electrotherapy. All groups performed an exercise program and received 12 sessions. The primary outcome measures of the functional assessment were the Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) and Aggregated Locomotor Function (ALF) test scores. The secondary outcome measures were pain level, measured using a pressure algometer and a visual analogue scale (VAS), range of motion (ROM), measured using a digital goniometer, and muscle strength, evaluated with a handheld dynamometer. Patients were assessed before treatment, after treatment and after 1 year of follow-up. Patients receiving the manual physical therapy interventions consisting of either MWM or PJM demonstrated a greater decrease in VAS scores at rest, during functional activities, and during the night compared to those in the electrotherapy group from baseline to after the treatment (p < 0.05). This improvement continued at the 1-year follow-up (p < 0.05). The MWMs and PJM groups also showed significantly improved WOMAC and ALF scores, knee ROM and quadriceps muscle strength compared to those in the electrotherapy group from baseline to 1-year follow-up (p < 0.05). In the treatment of patients with knee OA, manual physical therapy consisting of either MWM or PJM provided superior benefit over electrotherapy in terms of pain level, knee ROM, quadriceps muscle strength, and functional level.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

• Yes

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

• Yes

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

• Yes

Were study participants and providers blinded to treatment group assignment?

• Yes

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

• Yes

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

• Yes

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

• No

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

• No

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

• Yes

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

• Yes

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

• Yes

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

• Yes

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

• Yes

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

• No

Key Finding #1

No significant differences were observed in the level of function, ROM, and muscle strength between the three groups from baseline to end of treatment

Key Finding #2

Manual therapy in the form of MWM or PJM intervention showed a greater increase in functional score, flexion and extension ROM, and quadriceps muscle strength compared to electrotherapy at the 1-year follow-up

Key Finding #3

MWM or PJM intervention demonstrated a greater decrease in pain at rest, during activity, and at night compared to electrotherapy from baseline to after treatment. This improvement continued after 1-year follow-up

Please provide your summary of the paper

Managing osteoarthritis (OA), a degenerative joint disorder characterized by increasing joint pain, stiffness, and limitation in ROM, has focused on controlling pain and reducing the disability. Studies have shown that manual therapy in combination with exercise has important benefits for patients with knee OA. However, few studies compare the benefit level with the use of different manual therapy techniques. With that, this paper aimed to investigate the effect of two manual therapy interventions, MWM and PJM, in comparison to electrotherapy in the long-term management of knee OA. Participants were blinded and randomized to the three groups using a web service. The interventions were performed by the same experienced physical therapist to reduce bias. In addition, a decent percentage of the participants were followed-up for one year. Even though the primary outcome measured the level of function, the second outcome measured pain, ROM, and muscle strength, all of which are highly important in the management of OA. Although the results showed support and improvement of manual therapy techniques over electrotherapy, further studies need to be conducted to validate the results. This study contains several limitations, including the inability to ensure that patients performed the home exercises correctly and adhered to them since this information was provided verbally, and the lack of intention-to-treat analysis that could have led to an overestimation of the results.

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 suggest that the addition of manual treatment interventions, such as MWM or PJM, to standardized exercise programs, proves to be more beneficial than electrotherapeutic modalities in treating the dysfunction associated with knee OA. In addition, these results add another level of support for the benefit of manual therapy to the previously reported studies. This study provides further understanding of the use of techniques, such as sustained manual glides and knee flexion and extension, to reduce pain and improve the ROM in those patients. Currently, manual therapy has been incorporated into the therapy plan of knee OA patients. Further studies with larger study groups and an intention-to-treat analysis would be beneficial to validate these results.

Author Names

Bruun-Olsen, V., Heiberg, K., & Mengshoel, A.

Reviewer Name

Miranda Frohlich, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Purpose. Continuous passive motion is frequently used post-operatively to increase knee range of motion after total knee arthroplasty in spite of little conclusive evidence. The aim of this study was to examine whether continuous passive motion (CPM) as an adjunct to active exercises had any short time effects (after one week and three months) on pain, range of motion, timed walking and stair climbing.  Method. A randomized controlled trial was conducted. A total of 63 patients undergoing primary TKA were randomly assigned into an experimental group receiving CPM and active exercises and a control group receiving active exercises only. Outcomes were assessed by goniometer, visual analogue scale (VAS), timed ‘Up and Go’ test (TUG), timed 40 m walking distance and timed stair climbing.  Results. There were no statistical differences between the treatment groups for any outcome measures either at one week or after three months. For the whole group, a significant and 50% reduction in pain score was found after three months (p < 0.01 ). Compared with before surgery, a significantly impaired knee flexion range of motion (p < 0.01 ) and a significantly decreased number of patients able to climb stairs were found after three months (p < 0.01).  Conclusion. CPM was not found to have an additional short-time effect compared with active physiotherapy. After three months considerable pain relief was obtained for the whole group, the patients preoperative ROM was not restored and the number of patients able to climb stairs had decreased.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

• Yes

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

• Yes

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

• Yes

Were study participants and providers blinded to treatment group assignment?

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

• Yes

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

• Yes

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

• Yes

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

• Yes

Key Finding #1

The focus of treatment was on improving mobility for which ROM was the primary outcome variable measured in the study.

Key Finding #2

All patients in the study followed an exercise programme with a local physiotherapist following discharge from the hospital, however, the outpatient treatment was not standardized.

Key Finding #3

Both groups had a statistically significant (p < 0.01)  reduction in pain intensity after 3 months than at baseline (before surgery).

Key Finding #4

Continuous passive motion (CPM) does not seem to provide an additional effect of clinical relevance above active physiotherapy exercises on knee ROM.

Please provide your summary of the paper

This RCT investigated the effects of continuous passive motion (CPM) as an addition to active exercises in early rehabilitation following a total knee arthroplasty (TKA). The experimental group received CPM and active exercises while the control group only received active exercises. The short term effects were evaluated at 1 week and 3 months to measure pain, range of motion (ROM), timed walking, and stair climbing. The outcome measures utilized were reliable and consisted of a visual analogue scale (VAS), goniometer, timed ‘Up and Go’ test (TUG), timed 40m walking distance, and timed stair climbing.

The findings of this study showed no additional benefit of CPM on short-term effects of pain, knee ROM, or walking ability compared with active exercises alone for patients in the postoperative period following a TKA. All patients did not recover their baseline ROM within 3 months post-surgery; and there were more patients unable to climb stairs compared to the baseline of patients able to climb stairs 3 months post-surgery. Both groups had a statistically significant reduction in pain intensity after 3 months than at baseline. Furthermore, there was no association found between ROM and walking ability for either group.

With regards to the limitations of this study, the authors note good external validity, however, they did not incorporate a standardized out-patient treatment which could have been of benefit for better implication in clinical practice and future studies. Overall, these findings reveal the underlying need for more research on functional recovery post-op a TKA.

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

I believe the study provided strong evidence on the lack of additional benefit that continuous passive motion (CPM) has above active exercises alone for patients post-op TKA. The study has adequate external validity, it acknowledged it’s weaknesses (e.g. ceiling effect regarding TUG outcome measure), and indicated other factors (strength, balance, motivation, and level of anxiety) which could have influenced some of the findings. Specifics were given with regards to the administration of CPM and types of active exercises which gives clinicians the ability to replicate these techniques in clinical practice. I am curious if incorporating a standard out-patient treatment would have changed patient outcomes. Overall, I think the results of this study are vital to note and have the ground to prompt further research in considering a new approach to treatment and functional recovery following a TKA.

Author Names

Pfluegler G, Borkovec M, Kasper J, McLean S.

Reviewer Name

Megan Hayden, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Anterior knee pain (AKP) is often associated with persistent hip muscle weakness and facilitatory interventions may be beneficial for managing patients with AKP (pwAKP). Physiotherapists often employ passive oscillatory hip joint mobilizations to increase hip muscle function. However, there is little information about their effectiveness and the mechanisms of action involved.   Objectives: To investigate the immediate effects of passive hip joint mobilization on eccentric hip abductor/external rotator muscle strength in pwAKP with impaired hip function.  Design: A double-blinded, randomized, placebo-controlled crossover design.  Method: Eighteen patients with AKP participated in two sessions of data collection with one week apart. They received passive hip joint mobilization or placebo mobilization in a randomized order. Eccentric hip muscle strength was measured immediately before and after each intervention using a portable hand-held dynamometer.   Results: An ANCOVA with the sequence of treatment condition as the independent variable, the within-subject post-treatment differences as the dependent variable and the within- subject pre-treatment differences as the covariate was conducted. Patients showed a significant mean increase in eccentric hip muscle strength of 7.73% (p = 0.001) for the mobilization condition, compared to a mean decrease of 4.22% for the placebo condition. Seventeen out of eighteen participants reported having no pain during any of the strength testing.   Conclusion: These data suggest that passive hip joint mobilization has an immediate positive effect on eccentric hip abductor/external rotator muscle strength in pwAKP with impaired hip function, even in the absence of current pain.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

• Yes

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

• Yes

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

• Yes

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

• No

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• No

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

• Yes

12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

• Yes

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

• Yes

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

• Yes

Key Finding #1

Hip joint mobilizations demonstrated immediate improvements in gluteal strength for patients with AKP.

Key Finding #2

The study determined that grade 4 mobilizations showed immediate improvements in strength; the effects of grade 3 or 5 were not examined.

Key Finding #3

Outcomes were based on immediate effects only, not long-term effects.

Please provide your summary of the paper

This research study examined the overarching idea that treating neighboring joints is also important in a plan of care. Reduced hip strength can lead to malalignment of the entire lower extremity and lead to pain and structural damage, so this study was examining the effects of manual therapy at the hip level for those experiencing knee pain. Strength was measured first via the clam exercise outcome measure, followed by either grade 1 mobilizations (placebo group) or grade 4 (experimental). Finally, each patient’s strength was re-tested via the clam exercise to examine the immediate effects of the mobilizations on hip strength.

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

Overall, this study shows the immediate, positive effect of a grade 4 manipulation on hip strength in those with AKP. Due to the immediate effects of the treatment, it may be best utilized prior to engaging in therapeutic exercises to ensure adequate muscle fiber recruitment and enhance strength gains. The study does not include a comparison of therapeutic exercise to mobilizations, therefore it is necessary to consider other treatments in addition to manual therapy in the plan of care.

Author Names

Jansen MJ, Viechtbauer W, Lenssen AF, Hendriks EJ, de Bie RA

Reviewer Name

Megan Hayden, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Question: What are the effects of strength training alone, exercise therapy alone, and exercise with additional passive manual mobilization on pain and function in people with knee osteoarthritis compared to control? What are the effects of these interventions relative to each other? Design: A meta-analysis of randomized controlled trials. Participants: Adults with osteoarthritis of the knee. Intervention types: Strength training alone, exercise therapy alone (combination of strength training with active range of motion exercises and aerobic activity), or exercise with additional passive manual mobilization, versus any non-exercise control. Comparisons between the three interventions were also sought. Outcome measures: The primary outcome measures were pain and physical function. Results: 12 trials compared one of the interventions against the control. The effect size on pain was 0.38 (95% CI 0.23 to 0.54) for strength training, 0.34 (95% CI 0.19 to 0.49) for exercise, and 0.69 (95% CI 0.42 to 0.96) for exercise plus manual mobilization. Each intervention also improved physical function significantly. No randomized comparisons of the three interventions were identified. However, meta-regression indicated that exercise plus manual mobilizations improved pain significantly more than exercise alone (p = 0.03). The remaining comparisons between the three interventions for pain and physical function were not significant. Conclusion: Exercise therapy plus manual mobilization showed a moderate effect size on pain compared to the small effect sizes for strength training or exercise therapy alone. To achieve better pain relief in patients with knee osteoarthritis physiotherapists or manual therapists might consider adding manual mobilization to optimize supervised active exercise programs.

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

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

• Yes

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

• Yes

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

• Yes

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

• Cannot Determine, Not Reported, Not Applicable

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

• Yes

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

Was publication bias assessed?

• No

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

• Cannot Determine, Not Reported, Not Applicable

Key Finding #1

There is no way to determine which program is superior because no study directly compared the effect of all 3; this systematic review had to rely on indirect comparisons.

Key Finding #2

Exercise therapy combined with mobilizations was found to have a moderate effect on both pain and function in those with knee OA.

Key Finding #3

The addition of manual therapy in exercise programs may address connnective tissue damage thereby having a positive effect on hyperalgesia experienced by those with knee pain due to OA.

Please provide your summary of the paper

This systematic review of 12 randomized control trials was an indirect comparison of strength training, exercise training, or exercise with mobilizations to a control of no exercise on both pain and function in those with knee OA. The authors reviewed articles that only examined programs with supervised interventions, and no home exercise program. The primary outcome measures used to measure pain and function were the WOMAC, Lequesne Index, and VAS. Because no study compared all three interventions in one trial, a mixed-effects meta-regression model was used to make the indirect comparison. They found that overall, all 3 intervention groups showed improvements in function and pain; however, the experimental group that utilized both exercise and manual therapy had the greatest effect size.

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

There is not enough evidence to assume that one therapeutic technique is superior to another. Physical therapists should create unique plans of care that incorporate strength training, aerobic exercise, and active ROM exercises in addition to manual therapy. These programs should be based on the preferences of both the patient and physical therapist in order to create a program where the patient feels they have the most autonomy in order to see the most success.

Author Names

Scafoglieri A, Van den Broeck J, Willems S, Tamminga R, van der Hoeven H, Engelsma Y, Haverkamp S.

Reviewer Name

Kimberlyn Hayes, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Increasing evidence has shown benefits of spinal manipulations in patients with patellofemoral pain syndrome (PFPS). There is scarcity regarding medium term effects of spinal manual therapy on outcome measures in PFPS patients. Therefore, the aim of the present study was to compare the effectiveness of local exercise therapy and spinal manual therapy for knee pain, function and maximum voluntary peak force (MVPF) velocity of the quadriceps in PFPS patients.  Methods: Forty-three patients with PFPS were randomly assigned to a local exercise or spinal manual therapy group. The local exercise group received six sessions (one session per week) of supervised training of the knee-and hip muscles with mobilization of the patellofemoral joint. The spinal manual therapy group received six interventions (one intervention per week) of high velocity low thrust manipulations at the thoracolumbar region, sacroiliac joint, and/or hip. All patients were also asked to do home exercises. Maximum, minimum and current pain were measured using the visual analogue scale. Function was assessed with the anterior knee pain scale (AKPS) and MPFV was recorded using a Biodex System 3 dynamometer. Patients were assessed before intervention, after 6 weeks of intervention and after 6 weeks of follow-up. Between-group differences at assessments were analysed by way of analysis of covariance with Bonferroni correction.  Results: Pain and functionality improved more following spinal manipulative therapy than local exercise therapy. After 6 weeks of intervention the between-group difference (local versus spinal) for maximal pain was 23.4 mm [95% CI: 9.3, 37.6; effect size (ES): 1.04] and – 12.4 [95% CI: – 20.2, – 4.7; ES: 1.00] for the AKPS. At 6 weeks of follow-up the between-group difference for maximal pain was 18.7 mm [95% CI: 1.4, 36.0; ES: 0.68] and – 11.5 [95% CI: – 19.9, – 3.3; ES: – 0.87] for the AKPS.  Conclusions: This study suggests that spinal manual therapy is more effective than local exercise therapy in improving pain and function in patients with PFPS in the medium term. We suggest for future research to investigate whether combining local exercise therapy and spinal manual therapy is more effective than either single intervention on its own. This clinical trial study was approved by the Medical Ethics Committee METC Z under registration number NL57207.096. and registered retrospectively in ClinicalTrials.gov PRS with registration ID number NCT04748692 on the 10th of February 2021.  Keywords: Effectiveness; Exercise; Manipulation; Medium term; Patellofemoral pain syndrome; Randomized controlled trial.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

• Yes

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

• Yes

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

• Yes

Were study participants and providers blinded to treatment group assignment?

• No

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

• 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)?

• Yes

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

• Yes

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

• Yes

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Yes

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

• Yes

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

• Yes

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

• No

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

• Yes

Key Finding #1

Spinal manual therapy of the thoracolumbar, sacroiliac, and/or hip region was found to be more effective in improving pain and function in patients with patellofemoral pain syndrome than local exercise.

Key Finding #2

Among the spinal manual therapy group, a minimal clinically important difference (MCID) of 23mm was found for maximum pain and an MCID of 12 points for the anterior knee pain scale (AKPS) were found following 6 weeks of intervention.

Key Finding #3

The improvements seen in pain and function, as well as the MCID in maximum and for the AKPS were still present for 6 weeks following the last treatment.

Please provide your summary of the paper

The goal of this study was to determine the effectiveness of local exercise therapy compared to spinal manual therapy on patellofemoral pain syndrome (PFPS). A randomized controlled trial was conducted using pain, score on anterior knee pain scale (AKPS), and maximum voluntary peak force (MVPF) of the quadriceps muscle group as quantitative variables. Researchers found a minimal clinically important difference in maximum pain and score on the AKPS after 6 weeks of treatment. These improvements continued to be present in patients even 6 weeks following their final intervention session. They suggest further research to determine whether combining local exercise therapy with spinal manual therapy may have greater effects on pain and function in patients with PFPS than either treatment alone.

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

I interpreted this paper as evidence supporting ideas that pain and dysfunction in some areas of the body may impact pain and dysfunction in other ares. It is important to assess a patient holistically in order to determine the true cause or their dysfunction or how it may be negatively impacting other areas of the body.

Author Names

Pollard, H., Ward, G., Hoskins, W., Hardy, K.

Reviewer Name

Jada Holmes SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Knee osteoarthritis is a highly prevalent condition with a significant socioeconomic burden to society. It is known to effect sufferers through pain, loss of function and changes in health related quality of life. Management typically involves pharmacologic and/or exercise based therapy approaches to reduce pain. Previous studies have shown multimodal treatment approaches incorporating manual therapy to be efficacious. The aim of this study is to determine if a manual therapy technique knee protocol can alter the self reported pain experienced by a group of chronic knee osteoarthritis sufferers in a randomised controlled trial. Methods: 43 participants with a chronic, nonprogressive history of osteoarthritic knee pain, aged between 47 and 70 years were randomly allocated following a screening procedure to an intervention group (n=26; 18 men and 8 women, mean age 56.5 years) or a control group (n=17; 11 men and 6 women, mean age 54.6 years). Participants were matched for present knee pain intensity measured on a visual analogue scale. The intervention consisted of the Macquarie Injury Management Group Knee Protocol whilst the control involved a non-forceful manual contact to the knee followed by interferential therapy set at zero. Participants received three treatments per week for two consecutive weeks with a follow up immediately after the final treatment. Post-treatment Participants completed 11 questions including present knee pain intensity and feedback regarding their response to treatment utilizing a visual analogue scale. Results were analysed using descriptive statistics. Results: Prior to the intervention, there was no significant differences in age or present knee pain intensity. Following treatment, the intervention group reported a significant decrease in the present pain severity (mean 1.9) when compared to the control group (mean 3.1). Response to treatment questions indicated that compared to the control group, the intervention group felt the intervention had helped them (intervention mean 7.0; control mean 3.4), felt it decreased their knee symptoms such as crepitus (intervention mean 6.0; control mean 3.4) and improved their knee mobility (intervention mean 6.4; control mean 3.4) and their ability to perform general activities (intervention mean 6.5; control mean 3.8). Importantly the MIMG Knee Protocol intervention group reported no adverse reactions during treatment. Conclusions: A short-term manual therapy knee protocol significantly reduced pain suffered by participants with osteoarthritic knee pain and resulted in improvements in self-reported knee function immediately after the end of the 2 week treatment period.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

• Yes

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

• Yes

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

• Yes

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

• No

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• No

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

• Yes

12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

• No

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Yes

Key Finding #1

The MIMG manual therapy knee protocol outlined in this research demonstrated significant short-term relief of self-reported pain and dysfunction in participants with knee osteoarthritis.

Key Finding #2

No participants in either group reported adverse effects/discomfort with intervention.

Key Finding #3

In light of these findings, it is recommended that further research be conducted to determine the utility of this protocol in patients not achieving satisfactory pain management with traditional approaches of exercises and medication for knee osteoarthritis.

Key Finding #4

Further research should also focus on the duration of the clinical effects as measured by the reduction of symptoms in medium and long-term objective measures of pain and disability.

Please provide your summary of the paper

This study shows that MIMG knee protocol as an intervention method for knee OA was statistically significant in changing short-term knee pain for patients that met the criteria of this study. Most research has looked at treating knee OA with medical treatment or physical therapy, but not many have looked into the efficacy of manual therapy in treating this condition. Studies that do look at the effects of manual therapy on treatment of knee OA often look at a multi-faceted approach to treatment, whereas this study looks only at 1 type of treatment (i.e., manual therapy). The MIMG protocol is a non-invasive myofascial mobilization that is beneficial to patients by stretching the joint to make it more mobile. However, the effects of this method of treatment are only short-term.

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

Manual therapy can be used a treatment modality that helps provide short-term relief from pain in patient with knee OA. Along with physical activity, PTs can add this to their list of treatments they provide to their patients that present with knee OA in clinic.

Author Names

Pinto, D., Robertson, M. C., Abbott, J. H., Hansen, P., & Campbell, A. J.

Reviewer Name

Jada Holmes, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective: To evaluate the cost effectiveness of manual physiotherapy, exercise physiotherapy, and a combination of these therapies for patients with osteoarthritis of the hip or knee. Methods: 206 Adults who met the American College of Rheumatology criteria for hip or knee osteoarthritis were included in an economic evaluation from the perspectives of the New Zealand health system and society alongside a randomized controlled trial. Resource use was collected using the Osteoarthritis Costs and Consequences Questionnaire. Quality-adjusted life years (QALYs) were calculated using the Short Form 6D. Willingness-to-pay threshold values were based on one to three times New Zealand’s gross domestic product (GDP) per capita of NZ$ 29,149 (in 2009). Results: All three treatment programmes resulted in incremental QALY gains relative to usual care. From the perspective of the New Zealand health system, exercise therapy was the only treatment to result in an incremental cost utility ratio under one time GDP per capita at NZ$ 26,400 (–$34,081 to $103,899). From the societal perspective manual therapy was cost saving relative to usual care for most scenarios studied. Exercise therapy resulted in incremental cost utility ratios regarded as cost effective but was not cost saving. For most scenarios combined therapy was not as cost effective as the two therapies alone. Conclusions: In this study, exercise therapy and manual therapy were more cost effective than usual care at policy relevant values of willingness-to-pay from both the perspective of the health system and society.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Yes

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

• Yes

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

• Yes

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Yes

12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

• Yes

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

• No

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

• Yes

Key Finding #1

The MOA Trial exercise physiotherapy and manual physiotherapy programs were cost effective relative to usual care within policy-relevant ranges of WTP per QALY from the perspectives of the New Zealand health system and society.

Key Finding #2

Early intervention to treating OA closer to initial symptom development could help slow the progression and prolong how long before the usual method of care (ex. joint replacement) is implemented.

Please provide your summary of the paper

This study shows that manual therapy or exercise therapy in addition to usual care was highly cost effective relative to usual care alone when considering the analyses from the cost perspective of both. The most cost-effective treatment in the perspective of the New Zealand healthcare system is exercise therapy, while the most cost-effective treatment from a social perspective is manual therapy. Both of these perspectives are made according to the estimates from the QALY outcome (quality-adjusted life years). Because of how delayed action is between the initial presentation of OA and its actual treatment, a recommendation for change could be in order to try and implement treatment for OA sooner rather than later to try and delay the progression of pain and disability.

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

Exercise and manual therapy are more cost-effective treatments than the usual care for treating OA, which usually includes a joint replacement surgery at some point. A recommendation or policy change that can be made is for PTs to be allowed to intervene and treat hip or knee OA preventatively. If treatment can start earlier, closer to when the initial symptoms present, then the progression of the pain and disability can be potentially slowed.

Author Names

Abbott, J. H., Chapple, C. M., Fitzgerald, G. K., Fritz, J. M., Childs, J. D., Harcombe, H., & Stout, K.

Reviewer Name

Jada Holmes, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper 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 measures 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).

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

• Yes

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

• Yes

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

• Yes

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

• No

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

• Yes

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

• Cannot Determine, Not Reported, or Not Applicable

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

• No

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

• Yes

Key Finding #1

Distributing supervised exercise therapy sessions over the course of 1 year, in the form of 8 initial sessions in the first 2 months, then 4 booster sessions at 5, 8, and 11 months, improved outcomes at 1 year compared with delivery of 12 consecutive sessions of supervised exercise therapy within 2 months, without additional therapist contact time.

Key Finding #2

The addition of 12 sessions of individually tailored manual therapy to 12 sessions of supervised exercise therapy, delivered over 2 months, also improved outcomes at 1 year, while also requiring additional therapist time.

Key Finding #3

However, providing manual therapy distributed over 12 months using booster sessions in addition to supervised exercise therapy did not provide incremental benefit at 1 year compared with delivery of 12 consecutive sessions of supervised exercise therapy alone, and required additional therapist time.

Key Finding #4

Further research is required to establish the incremental benefits of booster sessions and/or manual therapy in addition to exercise therapy.

Please provide your summary of the paper

This study shows that providing manual therapy or booster sessions (which includes sessions of supervised therapy provided at time intervals separated from the consecutive sessions of the initial episode of care, with intervening periods of no supervised therapy provision) paired with exercise therapy had more benefits than just exercise therapy alone. Overall results showed the decreased pain disability gauged 1-year post-trial was attributed to these results [after 12 sessions of manual therapy on top of exercise therapy]. Similarly manual therapy paired with exercise therapy and standard care for treating knee OA also was more beneficial than just standard medical care for OA. When looking specifically at time spent doing each intervention, the study shows that keeping exercise and manual therapy intervention times the same poses additional benefits.

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

Although there are added benefits to a PT providing exercise and manual therapy, time must be a considered factor when making the decision to implement both interventions. This could require the PT to have more sessions with the patient (i.e. time with the patient) to be able to provide both types of therapy to the same degree and get the additional benefits mentioned in this study.

Author Names

Pollard, H.; Ward, G.; Hoskins, W; Hardy, K.

Reviewer Name

Natalie Hosmer, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Knee osteoarthritis is a highly prevalent condition with a significant socioeconomic burden to society. It is known to effect sufferers through pain, loss of function and changes in health related quality of life. Management typically involves pharmacologic and/or exercise based therapy approaches to reduce pain. Previous studies have shown multimodal treatment approaches incorporating manual therapy to be efficacious. The aim of this study is to determine if a manual therapy technique knee protocol can alter the self reported pain experienced by a group of chronic knee osteoarthritis sufferers in a randomised controlled trial. Methods: 43 participants with a chronic, non-progressive history of osteoarthritic knee pain, aged between 47 and 70 years were randomly allocated following a screening procedure to an intervention group (n=26; 18 men and 8 women, mean age 56.5 years) or a control group (n=17; 11 men and 6 women, mean age 54.6 years). Participants were matched for present knee pain intensity measured on a visual analogue scale. The intervention consisted of the Macquarie Injury Management Group Knee Protocol whilst the control involved a non-forceful manual contact to the knee followed by interferential therapy set at zero. Participants received three treatments per week for two consecutive weeks with a follow up immediately after the final treatment. Post-treatment Participants completed 11 questions including present knee pain intensity and feedback regarding their response to treatment utilizing a visual analogue scale. Results were analysed using descriptive statistics. Results: Prior to the intervention, there was no significant differences in age or present knee pain intensity. Following treatment, the intervention group reported a significant decrease in the present pain severity (mean 1.9) when compared to the control group (mean 3.1). Response to treatment questions indicated that compared to the control group, the intervention group felt the intervention had helped them (intervention mean 7.0; control mean 3.4), felt it decreased their knee symptoms such as crepitus (intervention mean 6.0; control mean 3.4) and improved their knee mobility (intervention mean 6.4; control mean 3.4) and their ability to perform general activities (intervention mean 6.5; control mean 3.8). Importantly the MIMG Knee Protocol intervention group reported no adverse reactions during treatment. Conclusions: A short-term manual therapy knee protocol significantly reduced pain suffered by participants with osteoarthritic knee pain and resulted in improvements in self-reported knee function immediately after the end of the 2 week treatment period.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

• Yes

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

• Yes

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

• Cannot Determine, Not Reported, or Not Applicable

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

• No

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Yes

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Yes

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

• No

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

• No

12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

• Cannot Determine, Not Reported, or Not Applicable

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

• No

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

• Yes

Key Finding #1

There was a significant difference between groups for those who received the Macquarie Injury Management Group Knee Protocol (MIMG).

Key Finding #2

Short term outcomes were measured (immediately following 2 weeks of treatment).

Key Finding #3

Co-occurring treatment methods were not considered when looking at outcomes.

Please provide your summary of the paper

This study examined the effect of manual therapy on pain and functionality in participants with knee osteoarthritis. The study found a significant difference in pain reduction in individuals who received manual therapy. However, there were limitations identified that decrease the reliability and validity of this study. The authors do not identify exclusion criteria for the participants. For this reason, we cannot confidently say that manual therapy resulted in the reduction of pain because we do not know what other treatments these participants were receiving in addition to manual therapy. Additionally, this study only looks at short-term outcomes. While this study does a good job of presenting manual therapy as a plausible option for treatment of knee OA, additional studies should further investigate whether manual therapy provides long term relief. Additionally, further exclusion criteria should be implemented to ensure that any effect produced is produced by manual therapy.

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 proposes manual therapy as a plausible treatment option for short term relief in individuals with knee osteoarthritis. More research will need to be done on the long term effects of manual therapy in individuals with knee osteoarthritis, but it is useful to know that manual therapy can provide short term relief, especially if you have a patient who presents to your clinic flared up.

Author Names

Zago, J., Amatuzzi, F., Rondinel, T., Matheus, J.P.

Reviewer Name

Hannah Koch, 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

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

• Yes

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Yes

Key Finding #1

There was a statistically significant decrease in patient reported pain outcomes in both the osteopathic manipulative treatment and exercise program groups, when compared with the control group. However, there was no statistically significant difference in the amount of pain decreased when comparing the two intervention groups, indicating they are equally effective in pain reduction.

Key Finding #2

The study demonstrated that there was an increase in functionality, evaluated through the LKSS questionnaire, in both the osteopathic manipulation treatment and exercise program groups. The effect size of this improvement indicates that both interventions experiences clinically revenant improvements in patients’ functionality from baseline.

Key Finding #3

The data suggests that exercise program intervention produces a significant and relevant effect size improvement in hip extension range of motion when compared to the control group. This discovery was only in the exercise program group and not in the osteopathic manipulation treatment group. This indicates that if improvement in hip extension range of motion is an intended effect of treatment, the exercise program intervention may be more beneficial in accomplishment of this goal.

Please provide your summary of the paper

This paper is the first randomized control trial to compare the effects that osteopathic manipulative treatments and exercise programs have on runners with Patellofemoral Pain Syndrome.The osteopathic manipulation treatments included myofascial release and thrust manipulations. The exercise program group based their protocol on previous literature regarding PFPS. This included a variety of exercises targeting the lower extremities for strength and flexibility. The study evaluated the treatments’ effects on pain and functionality, plantar pressure in middle foot, posterior thigh flexibility and hip range of motion. Participants in the study were required to attend 6 sessions of a 40 minute treatment, twice a week for 3 weeks. An interval of 48 hours was required between each treatment session.  The overall results of the study indicate that both treatment options were effective in reducing the patient’s pain and increasing functional mobility, when compared to the control group. This indicates that if the overall goal of physical therapy for a runner with PFPS is to reduce pain and increase function, then both treatment options are viable. However, there are additional benefits to be gained from the exercise program treatment. The exercise program group experienced greater improvements in plantar pressure in middle foot, dynamic knee valgus, and hip extension range of motion: factors that are believed to be linked to Patellofemoral Pain Syndrome. The paper recognizes the need to continue to investigate this topic with subsequent studies, specifically looking at the effects of combining osteopathic manipulative treatment and exercise programs.

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 supports the use of both osteopathic manipulative treatments and an exercise program targeting the lower extremities for strength and flexibility in the treatment of Patellofemoral Pain Syndrome in runners. This paper helps to grow the literature supporting that conservative treatment options are effective and clinically relevant in treating runners with PFPS. Since there is no significant difference in decreases in pain levels or increases in functionality between the two treatment groups, this gives physical therapists and their patients the ability to use either treatment techniques when treating PFPS. This is beneficial because it allows patients and therapists the autonomy to choose between two research backed treatment options.

There are areas for research growth in the topic. Future research is indicated to compare the effects of the individual treatments being administered independently versus being paired together in order to identify optimal treatment strategies for this patient population. Further research may identify if there is a difference in treatment outcomes between the combined versus independent treatments, influencing future treatment approaches.

Additionally, the population studied consists of runners. Future research should analyze each treatment’s effects on the patient’s ability to return to running at previous volume and intensity levels when comparing the overall treatment effectiveness, which is not a factor evaluated in this study. Research should also address the long term effects of each treatment. Considering the exercise program produced significant improvements in plantar pressure in middle foot, dynamic knee valgus, and hip extension range of motion, it may be beneficial to evaluate if patients continue to experience these benefits overtime.

Overall, this research demonstrates that an exercise program and osteopathic manipulative treatments are both plausible treatment options of PFPS in runners. This may influence clinical care by increasing the usage of these conservative methods and overall improving patients pain levels and functionality. This study helps to identify areas of exploration in research needed to progress the understanding and knowledge of physical therapy’s place in the treatment of Patellofemoral Pain Syndrome in runners.

Author Names

Lilly, S, Seeber, GH, Smith, MP, McGaugh, JM, James, CR, Brismée, JM, & Sizer, PS

Reviewer Name

Emma Kosbab, LAT, ATC, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Anterior knee pain during knee extension may be related to a meniscal movement restriction and increased meniscal load during function. One method of treatment involves the use of manual posterior mobilization of the tibia to specifically target the meniscotibial interface of the knee joint.  Purpose: The purpose of this study was to measure motion at a cadaveric medial meniscus anterior horn during a posterior tibial mobilization.  Study Design: Prospective, multifactorial, repeated–measures laboratory study.  Methods: Eight unembalmed cadaveric knee specimens were mounted in a custom apparatus and markers were placed in the medial meniscus, tibia and femur. The tibia was posteriorly mobilized in two randomized knee positions (0 degrees and 25 degrees) using three randomly assigned loads (44.48N, 88.96N, and 177.93N). Markers were photographed and digitally measured and analyzed.  Results: All load x position conditions produced anterior displacement of the meniscus on the tibia, where the displacement was significant [t (7) = -3.299; p = 0.013] at 0 degrees loaded with 177.93N (mean 0.41±0.35 mm). The results of 2(position) x 3(load) repeated measures ANOVA for meniscotibial displacement produced no significant main effects for load [F (2,14) = 2.542; p = 0.114) or position [F (1,7) = 0.324, p= 0.587]. All load x position conditions produced significant posterior tibial and meniscal displacement on the femur. The 2(position) x 3(load) repeated measures ANOVA revealed a significant main effect for load for both femoral marker displacement relative to the tibial axis [F (2,14) = 77.994; p < 0.001] and meniscal marker displacement relative to the femoral marker [F (2,14) = 83.620; p < 0.001].  Conclusion: Use of a mobilization technique to target the meniscotibial interface appears to move the meniscus anteriorly on the tibia. It appears that this technique may be most effective at the end range position.  Level of Evidence: 2 (laboratory study)  Keywords: Anterior knee pain, Knee, Meniscus

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

• No

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Yes

12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

• Cannot Determine, Not Reported, or Not Applicable

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Cannot Determine, Not Reported, or Not Applicable

Key Finding #1

The greatest anterior displacement of the medial meniscus occurred during condition three (0deg 0N-0deg 177.93N).

Key Finding #2

Femur displacement, relative to tibial axis, was present during all conditions, and significantly effected by load (not significant for position x load or position alone).

Key Finding #3

Load produced a significant effect on meniscal femoral displacement, whereas position x load and position alone did not have such effect.

Key Finding #4

Tibial angle moved into more knee extension more with greater load intensity, regardless of position. In addition, with the higher loads (all but 44.48N), more movement into extension occurred at 25 degrees than 0 degrees

Please provide your summary of the paper

This study presents details of how the inert tissues (tibia, femur, and medial meniscus) of the knee joint move in reponse to a posterior tibial mobilization with various joint angle and force combinations performed on 8 cadavers. The study is limited by the scale and transferability to live subjects. Authors of the study suggest, based on the findings, that the most effective position for moving the meniscus with a posterior mobilization would be 0 degrees and using force less that 177.93N.

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 study is limited as a laboratory study on cadavers, it can be helpful in directing further studies on effectiveness of manual techniques by directing which conditions would be most likely to achieve meniscal movement. Noting that force was the greatest indicator of displacement across findings, it seems logical that in human trials, force will be a key to improving clinical indicators of a successful intervention and would be likely that even greater forces may be required when considering non-cadaver subjects.

Author Names

Coelho, B; Rodrigues, H; Almeida, G; Joao, S

Reviewer Name

Adrienne Maniktala, LAT, ATC, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Context: Restriction in ankle dorsiflexion range of motion (ROM) has been previously associated with excessive dynamic knee valgus. This, in turn, has been correlated with knee pain in women with patellofemoral pain (PFP). Objectives: To investigate the immediate effect of 3 ankle mobilization techniques on dorsiflexion ROM, dynamic knee valgus, knee pain, and patient perceptions of improvement in women with PFP and ankle dorsiflexion restriction. Design: Randomized controlled trial with 3 arms. Setting: Biomechanics laboratory. Participants: A total of 117 women with PFP who display ankle dorsiflexion restriction were divided into 3 groups: ankle mobilization with anterior tibia glide (n = 39), ankle mobilization with posterior tibia glide (n=39), and ankle mobilization with anterior and posterior tibia glide (n=39). Intervention(s): The participants received a single session of ankle mobilization with movement technique. Main Outcome Measures: Dorsiflexion ROM (weight-bearing lunge test), dynamic knee valgus (frontal plane projection angle), knee pain (numeric pain rating scale), and patient perceptions of improvement (global perceived effect scale). The outcome measures were collected at the baseline, immediate postintervention (immediate reassessment), and 48 hours postintervention (48 h reassessment). Results: There were no significant differences between the 3 treatment groups regarding dorsiflexion ROM and patient perceptions of improvement. Compared with mobilization with anterior and posterior tibia glide, mobilization with anterior tibia glide promoted greater increase in dynamic knee valgus (P = .02) and greater knee pain reduction (P = .02) at immediate reassessment. Also compared with mobilization with anterior and posterior tibia glide, mobilization with posterior tibia glide promoted greater knee pain reduction (P < .01) at immediate reassessment. Conclusion: In our sample, the direction of the tibia glide in ankle mobilization accounted for significant changes only in dynamic knee valgus and knee pain in the immediate reassessment.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Yes

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

• Yes

12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

• Yes

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

• Yes

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

• No

Key Finding #1

The direction of the glide in the mobilization with movement did not influence the amount of dorsiflexion range of motion.

Key Finding #2

The anterior tibia glide produced a greater dynamic knee valgus movement compared to the anterior and posterior tibia glide in the immediate reassessment. Demonstrating that ankle mobilization might not decrease the excessive dynamic knee valgus.

Key Finding #3

Both anterior tibia glide and the posterior tibia glide demonstrated greater decreases in knee pain in the immediate reassessment compared to the anterior and posterior tibia glide.

Please provide your summary of the paper

There has been a connection demonstrated between limited ankle dorsiflexion ROM and excessive dynamic knee valgus. The limited dorsiflexion ROM creates more tibial internal rotation and more hip internal rotation and adduction, leading to excessive dynamic knee valgus that places more stress on the joint. This finding has then been connected to women with PFP. This study believed that since the tibia moves anterior during dorsiflexion in a closed kinetic chain, an ankle mobilization with an anterior tibia glide should improve dorsiflexion ROM, but since no other trial had compared different directions of the glides, they decided to test them all. The results of the study determined that there was no difference in the improvement of dorsiflexion ROM between the different glides.

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

The information in this study can be correlated to clinical practice because they determined that all directions improved dorsiflexion ROM, as well as the directions that improved knee pain. Some limitations of the study would be that they only analyzed a single session of this treatment, nor did they include an inactive treatment group as a control to determine if the observed changes were from the treatment or something else like the outcome measures. A future study looking at the treatment over a course of time, the use of a control group, as well as a home exercise plan to see how improvement would change with additional interventions would help to solidify this study’s findings.

Author Names

Deyle, G., Henderson, N., Matekel, R., Ryder, M., Garber, M., Allison, S

Reviewer Name

Marc Moreno-Takegami

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Few investigations include both subjective and objective measurements of the effectiveness of treatments for osteoarthritis of the knee. Beneficial interventions may decrease the disability associated with osteoarthritis and the need for more invasive treatments.  Objective: To evaluate the effectiveness of physical therapy for osteoarthritis of the knee, applied by experienced physical therapists with formal training in manual therapy.  Design: Randomized, controlled clinical trial.  Setting: Outpatient physical therapy department of a large military medical center.  Patients: 83 patients with osteoarthritis of the knee who were randomly assigned to receive treatment (n = 42; 15 men and 27 women [mean age, 60 +/- 11 years]) or placebo (n = 41; 19 men and 22 women [mean age, 62 +/- 10 years]).  Intervention: The treatment group received manual therapy, applied to the knee as well as to the lumbar spine, hip, and ankle as required, and performed a standardized knee exercise program in the clinic and at home. The placebo group had subtherapeutic ultrasound to the knee at an intensity of 0.1 W/cm2 with a 10% pulsed mode. Both groups were treated at the clinic twice weekly for 4 weeks.  Measurements: Distance walked in 6 minutes and sum of the function, pain, and stiffness subscores of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). A tester who was blinded to group assignment made group comparisons at the initial visit (before initiation of treatment), 4 weeks, 8 weeks, and 1 year.  Results: Clinically and statistically significant improvements in 6-minute walk distance and WOMAC score at 4 weeks and 8 weeks were seen in the treatment group but not the placebo group. By 8 weeks, average 6-minute walk distances had improved by 13.1% and WOMAC scores had improved by 55.8% over baseline values in the treatment group (P < 0.05). After controlling for potential confounding variables, the average distance walked in 6 minutes at 8 weeks among patients in the treatment group was 170 m (95% CI, 71 to 270 m) more than that in the placebo group and the average WOMAC scores were 599 mm higher (95% CI, 197 to 1002 mm). At 1 year, patients in the treatment group had clinically and statistically significant gains over baseline WOMAC scores and walking distance; 20% of patients in the placebo group and 5% of patients in the treatment group had undergone knee arthroplasty.  Conclusions: A combination of manual physical therapy and supervised exercise yields functional benefits for patients with osteoarthritis of the knee and may delay or prevent the need for surgical intervention.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

• No

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

• Yes

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

• Yes

Key Finding #1

Patients with osteoarthritis of the knee who were treated with manual physical therapy and exercise experienced clinically and statistically significant improvements in self-perceptions of pain, stiffness, and functional ability and the distance walked in 6 minutes.

Key Finding #2

At 1 year, improved performance in the 6-minute walk test was maintained in the treatment group, indicating that the objective gains in functional performance persisted in the absence of supervised exercise and treatment.

Key Finding #3

The greater overall improvement compared with results of previous studies may be due to the manually applied treatment, which allowed the therapist to focus treatment on the specific structures that produced pain and limited function for each patient.

Please provide your summary of the paper

In this randomized, controlled clinical trial, 83 patients with knee osteoarthritis were randomly assigned to receive manual therapy and exercise treatment in physical therapy, while the placebo group had subtherapeutic ultrasound to the knee. Both groups were treated twice a week for one month. Outcome measures used to determine effectiveness of the treatements were the 6 minute walk test and the Western Ontario and McMaster Universities Osteoarthritis Index. Clinically and statistically significant improvements in the 6 MWT and WOMAC scores were seen in the treatment group and not the placebo group, both at the one month and 2 month mark. The trial concluded that a combination of manual therapy and supervised exercise yields greater functional benefits for patients with knee osteoarthritis as seen with the decrease in their pain and stiffness and increased distance walked in the 6 minute walk test.

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

As stated in the article, arthritis is the most common cause of disability in the United States. However, with the use of skilled manual therapy along with therapeutic exercise, people suffering from knee osteoarthritis may be able to avoid surgical interventions and manage their pain through physical therapy. This study also demonstrated that it does not take a long amount of time to achieve the benefits of manual therapy and exercise. In this specific trial, the benefits of treatment were achieved in eight clinic visits. That said, this trial did not report if any of the positive effects were sustained after 1 year. Further research may be required to determine which factors are involved in maintaining the long-term positive effects from manual physical therapy and exercise.

Author Names

Xu, Q. et. al.

Reviewer Name

Marc Moreno-Takegami, Physical Therapy Student

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Knee osteoarthritis (KOA) is the most common form of arthritis, leading to pain disability in seniors and increased health care utilization. Manual therapy is one widely used physical treatment for KOA. Objective: To evaluate the effectiveness and adverse events (AEs) of manual therapy compared to other treatments for relieving pain, stiffness, and physical dysfunction in patients with KOA. Study Design: A systematic review and meta-analysis of manual therapy for KOA. Methods: We searched PubMed, EMBASE, the Cochrane Library, and Chinese databases for relevant randomized controlled trials (RCTs) of manual therapy for patients with KOA from the inception to October 2015 without language restrictions. RCTs compared manual therapy to the placebo or other interventional control with an appropriate description of randomization. Two reviewers independently conducted the search results identification, data extraction, and methodological quality assessment. The methodological quality was assessed by PEDro scale. Pooled data was expressed as standard mean difference (SMD), with 95% confident intervals (CIs) in a random effects model. The meta-analysis of manual therapy for KOA on pain, stiffness, and physical function were conducted. Results: Fourteen studies involving 841 KOA participants compared to other treatments were included. The methodological quality of most included RCTs was poor. The mean PEDro scale score was 6.6. The meta-analyses results showed that manual therapy had statistically significant effects on relieving pain (standardized mean difference, SMD = -0.61, 95% CI -0.95 to -0.28, P= 76%), stiffness (SMD = -0.58, 95% CI -0.95 to -0.21, P = 81%), improving physical function (SMD = -0.49, 95% CI -0.76 to -0.22, P = 65%), and total score (SMD = -0.56, 95% CI -0.78 to -0.35, P = 50%). But in the subgroups, manual therapy did not show significant improvements on stiffness and physical function when treatment duration was less than 4 weeks. And the long-term information for manual therapy was insufficient. Limitations: The limitations of this systematic review include the paucity of literature and inevitable heterogeneity between included studies. Conclusion: The preliminary evidence from our study suggests that manual therapy might be effective and safe for improving pain, stiffness, and physical function in KOA patients and could be treated as complementary and alternative options. However, the evidence may be limited by potential bias and poor methodological quality of included studies. High-quality RCTs with longterm follow-up are warranted to confirm our findings.

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

Was publication bias assessed?

• Yes

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

• Yes

Key Finding #1

Eleven studies demonstrated that manual therapy significantly helps to relieve pain and stiffness, and significantly helps to improve physical function for greater than 4 weeks.

Key Finding #2

Regarding the long-term effect of manual therapy on osteoarthritis, only 3 studies were reported and long-term outcomes of manual therapy on OA need to be further explored.

Please provide your summary of the paper

This systematic review and meta-analysis investigated the effectiveness and adverse events of manual therapy compared to other treatments for relieving pain, stiffness, and physical dysfunction in patients with knee osteoarthritis. In total, fourteen studies involving 841 participants with knee osteoarthritis were reviewed. The meta-analyses results showed that manual therapy had a statistically significant effect on relieving pain, and stiffness, and improving physical function and total score. These findings suggest that manual therapy is an effective treatment for knee osteoarthritis, specifically for those experiencing pain, stiffness, and deficits in physical function as a direct result of their osteoarthritis. However, further research needs to be conducted to find the long-term effects of manual therapy.

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

As stated in the article, knee osteoarthritis is the most common form of arthritis and is one of the leading causes for pain disability, especially in the older population. Manual therapy is a form of treatment that can relieve those primary symptoms of pain and stiffness that are experienced by a majority of the population suffering with knee osteoarthritis. In many cases, manual therapy is a much more preferable form of treatment when compared to other interventions i.e. pharmacological treatment. However, it seems as if manual therapy is at its most effective when combined with strength and mobility exercise. Therefore, it is important to stress compliance to a home exercise program in order to achieve the best results when treating patients for knee osteoarthritis with manual therapy.

Author Names

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

Reviewer Name

Courtney Mueller, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

STUDY DESIGN: A factorial randomized controlled trial. OBJECTIVES: To investigate the addition of manual therapy to exercise therapy for the reduc-tion of pain and increase of physical function in people with knee osteoarthritis (OA), and whether “booster sessions” compared to consecutive ses-sions 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. Par-ticipants 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 Ontar-io and McMaster Universities Osteoarthritis Index (WOMAC score; 0-240 scale) at 1-year follow-up. Secondary outcome measures 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 exer-cise therapy over a year in the form of booster ses-sions was more effective than providing 12 consec-utive 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. Epub28 Sep 2015. doi:10.2519/jospt.2015.6015 KEY WORDS:arthralgia, OA, physical therapy techniques, randomized controlled trial

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

• Yes

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

• Yes

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

• Yes

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

• No

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

• No

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

• Yes

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

• Yes

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Yes

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

• Yes

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

• Yes

12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

• Cannot Determine, Not Reported, or Not Applicable

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

• Yes

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

• Yes

Key Finding #1

Patients who received manual therapy in addition to exercise therapy had greater benefits in regards to pain and self-reported disability than those who received just exercise interventions.

Key Finding #2

Patients who received booster sessions of exercise therapy over the course of a year had better outcomes than those who received consecutive exercise therapy sessions.

Please provide your summary of the paper

This paper sought to evaluate the treatment effects of manual therapy and the delivery of care through booster sessions in those with knee osteoarthritis. The main findings included the increased benefit of manual therapy in conjunction with exercise therapy and of booster sessions to provide exercise therapy as follow up care over a longer period of time. However, in the combined exercise therapy and manual therapy booster session group, there was a lessened treatment effect. The study noted a smaller sample size in this study compared to other studies previously performed and that their results conflict with other research being done in the same field. Further research was recommended to provide more evidence to back the effectiveness of manual therapy and booster sessions.

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 can be applicable for those with knee osteoarthritis who have struggled to see improvement from continuous physical therapy exercise interventions. It provides some backing to the use of manual therapy to address pain and self-reported disability and to the expansion of care to cover a longer period of time with booster sessions. This allows for the patient and therapist to use shared decision making to create a treatment plan that is best for the patient and their goals by providing the team options for care that can be individualized and successful. Options could include receiving only exercise therapy, receiving both exercise and manual therapy, having continuous physical therapy visits, and having booster sessions.

Author Names

Rehman, Mubarra; Riaz, Huma

Reviewer Name

Courtney Mueller, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Abstract Objective: To compare the effect of mobilisation with movement and Mulligan knee taping on anterior knee pain, hamstring flexibility and physical performance of the lower limb. Methods: The randomised controlled trial was conducted from July to December, 2019, at the physical therapy department of Sahat Clinic, Rawalpindi, Pakistan, and comprise participants of both genders having patellofemoral pain who were randomised into mobilisation with movement group A and Mulligan knee taping group B. Both the groups were treated for 2 days per week for 2 consecutive weeks. Outcome was measured using the numeric pain rating scale, the Kujala pain rating scale, the active knee extension test and the time-up-and-go test. Assessments were taken at baseline, and at 2nd and 6th weeks post-intervention. Data was analysed using SPSS 21. Results: Of the 34 participants, there were 17(50%) in each of the two groups. Overall, there were 6(17.6%) males and 28(82.4%) females with a mean age of 31.17±7.22 years. Group A showed significant improvement (p<0.0001) in terms of pain, while group B had better hamstring flexibility (p<0.0001). Both the groups showed a significant difference (p<0.0001) for all outcome variables post-intervention. Conclusion: Mobilisation with movement was found to be more effective in the treatment of patellofemoral pain and associated knee functional performance. Keywords: Anterior knee pain syndrome, Patellofemoral pain syndrome, Musculoskeletal manipulations, Manual therapy, Physical therapy techniques. (JPMA 71: 2119;2021)  DOI: https://doi.org/10.47391/JPMA.04-658

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

• Yes

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

• Yes

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

• Yes

Were study participants and providers blinded to treatment group assignment?

• No

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

• No

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

• Cannot Determine, Not Reported, or Not Applicable

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

• Yes

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

• Yes

Key Finding #1

Patients that received mobilization with movement showed greater improvements in pain and functional activities involving the knee.

Key Finding #2

Patients that received mobilization with movement demonstrated improved hamstring flexibility when measuring active knee extension, but not as significantly as in those that received Mulligan taping.

Please provide your summary of the paper

This paper sought to evaluate the effects of mobilization with movement and Mulligan knee taping on anterior knee pain, hamstring flexibility and functional performance. The mobilization with movement group received straight leg raise with traction and tibial gliding techniques, while the Mulligan taping group received taping to their anterior knee. Both groups were prescribed home exercise programs consisting of hamstring stretching and quadricep and vastus medialis oblique strengthening. Mobilization with movement was found to improve pain and functional movement involving the knee and Mulligan taping was found to improve hamstring flexibility.

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

Depending on the individual needs of the patient, this study provides some validation for the use of mobilization with movement and Mulligan knee taping to improve limitations that present with patellofemoral pain syndrome. It is key to note that a stretching and strengthening program was implemented along with these interventions and could contribute to some of the effects seen. Overall, a multimodal approach can be used to help improve the symptoms and quality of life of those with PFPS.

Author Names

Espí-López, G. V., Arnal-Gómez, A., Balasch-Bernat, M., & Inglés, M.

Reviewer Name

Hope Reynolds, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objectives: The purpose of this study was to conduct a review of randomized controlled trials (RCTs) to determine the treatment effectiveness of the combination of manual therapy (MT) with other physical therapy techniques. Methods: Systematic searches of scientific literature were undertaken on PubMed and the Cochrane Library (2004-2014). The following terms were used: “patellofemoral pain syndrome,” “physical therapy,” “manual therapy,” and “manipulation.” RCTs that studied adults diagnosed with patellofemoral pain syndrome (PFPS) treated by MT and physical therapy approaches were included. The quality of the studies was assessed by the Jadad Scale. Results: Five RCTs with an acceptable methodological quality (Jadad ≥ 3) were selected. The studies indicated that MT combined with physical therapy has some effect on reducing pain and improving function in PFPS, especially when applied on the full kinetic chain and when strengthening hip and knee muscles. Conclusions: The different combinations of MT and physical therapy programs analyzed in this review suggest that giving more emphasis to proximal stabilization and full kinetic chain treatments in PFPS will help better alleviation of symptoms.

NIH Risk of Bias Tool

Systematic Reviews

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

• Yes

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

• Yes

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

• No

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

• Yes

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

• Yes

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

• Yes

7. Was publication bias assessed?

• Cannot Determine, Not Reported, Not Applicable

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

• Cannot Determine, Not Reported, Not Applicable

Key Finding #1

Manual therapy interventions, including patellar mobilizations, PNF, and stretching, led to improvements in knee motion and pain in adults diagnosed with PFPS.

Key Finding #2

Stronger improvements, however, in pain reduction, mobility, and function, were found in participants treated with combined hip strengthening and stretching exercises.

Key Finding #3

When manual therapy treatments addressed the full kinetic chain of the lower limb instead of solely local treatments to the knee, participants experienced longer-term decreased pain noted at a 2-month follow-up.

Key Finding #4

Lumbopelvic manipulations were not found to affect quadriceps activation in those with PFPS.

Please provide your summary of the paper

This systematic review looked at the effectiveness of manual therapy when combined with other physical therapy techniques, mainly strengthening. The findings suggest that manual therapy provides a conservative yet effective treatment option for PFPS, reducing pain and improving functional mobility of the knee joint. However, manual therapy combined with strengthening that both address the full kinetic chain of the lower limb produces greater and longer-term improvements in pain relief and function. There are some limitations of the review though, including that the studies examined utilized dissimilar protocol designs and they mainly investigated the immediate effects of manipulation techniques. Therefore, further investigation into the long-term effects of combined manual therapy and other physical therapy techniques as well as a more standardized protocol are needed.

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

While manual therapy has been shown to be effective in reducing pain and improving function of the knee joint in adults diagnosed with PFPS, greater improvements are obtained by combining manual therapy of the knee with strengthening and manual techniques addressing the full kinetic chain of the lower limb, focusing on the muscles around the knee and hip. The exact protocol that is the most beneficial requires further research.

Author Names

Fitzgerald, G. K., Fritz, J. M., Childs, J. D., Brennan, G. P., Talisa, V., Gil, A. B., Neilson, B. D., & Abbott, J. H

Reviewer Name

Abbrianna Robert

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective: (1) Do treatment effects differ between participants receiving manual therapy (MT) with exercise compared to subjects who don’t, (2) are treatment effects sustained better when participants receive booster sessions compared to those who don’t over a one year period in subjects with knee osteoarthritis (KOA)? Design: Multi-center, 2 x 2 factorial randomized clinical trial. 300 participants with knee OA were randomized to four groups: exercise-no boosters (Ex), exercise-with boosters (Ex+B), manual therapy+exercise-no boosters (MT+Ex), manual therapy+exercise-with boosters (MT+Ex+B). The primary outcome was the Western Ontario and McMaster osteoarthritis index (WOMAC) at 1 year. Secondary outcomes included knee pain, physical performance tests, and proportions of participants meeting treatment responder criteria. Results: There were no differences between groups on the WOMAC at 1 year or on any performance-based measures. Secondary analyses indicated a) better scores on the WOMAC and greater odds of being a treatment responder at 9 weeks for participants receiving MT, b) greater odds of being a treatment responder at 1 year for participants receiving boosters. Exploratory interaction analysis suggested knee pain decreases for participants receiving boosters and increases for participants not receiving boosters from 9 weeks to 1 year. Conclusions: MT or use of boosters with exercise did not result in additive improvement in the primary outcome at 1 year. Secondary outcomes suggest MT may have some short term benefit, and booster sessions may improve responder status and knee pain at 1 year. However, the role of booster sessions remains unclear in sustaining treatment effects and warrants further study. Clinical trials: gov (NCT01314183).

NIH Risk of Bias Score: 11/14

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

• Yes

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

• Yes

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

• Yes

Key Finding #1

There was no difference between treatment groups on the Western Ontario and McMaster osteoarthritis index (WOMAC) at 1 year.

Key Finding #2

Combining manual therapy with exercise showed some short-term improvement (9 weeks) in WOMAC scores.

Key Finding #3

Booster sessions may improve responder status based on the Osteoarthritis Research Society International responder criteria (OARSI).

Reviewer Summary:

This study placed participants into 4 groups: exercise no booster sessions, exercise with booster sessions, manual therapy and exercise no booster sessions, and manual therapy and exercise with booster sessions. The primary outcome measure used was the WOMAC and secondary outcomes included the timed-up and go, 30-second chair rise, and the 40-meter walk test. This study found no differences, on the WOMAC, between groups at the 1-year follow-up. However, they did find some short-term improvements at the 9-week session in the WOMAC for participants receiving manual therapy. This suggests that there may be positive short-term effects associated with manual therapy as compared to exercise alone. Interestingly, they found that booster sessions at 5-, 8-, and 11-months improved responder status on the OARSI which shows that booster sessions may help sustain therapeutic effects. Further studies are needed to investigate the effectiveness of booster sessions that include manual therapy.

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 did not find a difference between groups on their primary outcome at the 1-year follow-up, but there was an improvement at the 9-week session. This may suggest that manual therapy is more beneficial in the short-term and needs to be maintained over time, but further research is needed on the effects of manual therapy in booster sessions.

Author Names

Fatimah, I., Waqqar, S.

Reviewer Name

Alli Shaw, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective: To determine the effects of tibiofemoral joint mobilisation on pain and range of motion in patients with patellofemoral pain syndrome.

Methods: The randomised control trial was conducted at the Lady Reading Hospital and Hayatabad Medical Complex, Peshawar, Pakistan, from July to December 2019, and comprised patellofemoral pain syndrome patients of either gender aged 25-35 years with anterior knee pain for at least one month. The subjects were randomly allocated control group A and experimental group B. Group A received 6 stretching and strengthening exercises of hip and knee muscles with hot pack, while group B additionally received tibiofemoral joint mobilisation. There were 3 sessions per week over 4 weeks for both the groups. Numeric pain rating scale, Kujala scale, algometer and goniometer were used to assess pain and range of motion at baseline and at the end of the last session. Data was analysed using SPSS 20.

Results: Of the 60 individuals initially assessed, 52(86.6%) were enrolled; 26(50%) in each of the two groups. The overall mean age of the sample was 29.63±3.25 years. The experimental group B showed significant improvement in pain, range of motion and pressure pain threshold (p<0.05) compared to the control group A. Group B also showed significant improvement in terms of functional activities (p<0.05). Except patellar instability and weight-bearing activities, the groups showed no significant difference (p>0.05).

Conclusion: Tibiofemoral joint mobilisations with hip and knee stretching and strengthening exercises were found to be more effective in reducing pain, and increasing range of motion as well as pressure pain threshold.

Clinical Trial Number: Identifier: NCT04225000:https://clinicaltrials.gov/ct2/show/NCT04225000

Keywords: Kujala anterior knee pain scale, Numerical pain rating scale, Patellofemoral pain syndrome, Pressure pain threshold, Tibiofemoral mobilisation. (JPMA 71: 2506; 2021) DOI: https://doi.org/10.47391/JPMA.04-585

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

• Yes

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

• Yes

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

• Yes

Were study participants and providers blinded to treatment group assignment?

• Cannot Determine, Not Reported, or Not Applicable

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)?

• Yes

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

• Yes

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Yes

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

• Yes

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

• Yes

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

• Yes

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

• Yes

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

• Yes

Key Finding #1

Tibiofemoral joint anterior-posterior grade II or III mobilizations are an effective treatment modality for the treatment and management of patellofemoral pain syndrome (PFPS).

Key Finding #2

Efficacy of mobilizations was defined as improvements in pain levels, range or motion, and ability to functionally participate. Overall pain level reduction, range of motion improvement, and an improved ability to complete functional activities in patients with PFPS were all outcomes reported secondary to the implementation of these mobilizations.

Key Finding #3

There was no significant difference found in in 2 variables of one pain rating scale: the Kujala Anterior Knee pain Scale (AKPS). Pain with weight-bearing and patellar instability were not significantly reduced with the use of these mobilizations.

Key Finding #4

Tibiofemoral joint mobilizations should not be used in isolation but should be used in conjunction with other physical therapy modalities such as strengthening and stretching.

Please provide your summary of the paper

Manual therapy is one of many modalities utilized in the treatment of patellofemoral pain syndrome (PFPS). By stimulating surrounding structures, joint mobilizations may contribute to pain reduction and targeted muscle activation. While PFPS is thought to be a pathology of the patellofemoral joint, mobilization at the nearby tibiofemoral joint may benefit individuals with PFPS. The goal of this randomized control trial (RCT) was to assess the efficacy of tibiofemoral joint mobilization as a treatment for PFPS. The authors noted that at the time, there were no reported RCTs that looked at these specific variables. PFPS patients were recruited using a non-probability purposive sampling technique. Exclusion criteria included, but was not limited to, patients with a history of knee surgery, arthritis, and patellar subluxation or dislocation. Patients were randomized into a control and experimental group. Both groups received treatment three times per week over four weeks. Both groups received specific hip and knee stretches and exercises as well as a hot pack. However, in addition to this treatment, patients in the experimental group received tibiofemoral joint mobilizations. The specific mobilizations used were an anterior-posterior (AP) grade II or II tibial glide of the tibiofemoral joint with the patient in supine and knee in a certain degree of flexion depending on amount of available range of motion. Pain intensity and knee joint range of motion were the primary outcome measures used to determine the efficacy of the mobilization. Results revealed a significant difference between the experimental and control groups in the following: overall numerical pain rating scale (NRPS), overall pressure-pain threshold (PPT), overall Kujala Anterior Knee Pain Scale (AKPS), range of motion, and functional activities. There was no significant difference in 2 variables of the AKPS: weight- bearing and patellar instability.

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

The findings of this research suggest that TFJ anterior-posterior grade II or III mobilizations are an effective treatment modality for the treatment and management of PFPS and should be used in conjunction with other modalities such as strengthening and stretching. However, one should be cautious when reading these results because the study took place over a 4-week span; therefore, one cannot assume that the benefits are long lasting. An additional mentioned limitation was that physical levels of patients with PFPS was not accounted for as a confounding variable. Lastly, the use of a universal goniometer as the sole measurement for range of motion introduces an inherent level of error due to measurement error. There was no comment about standardization of these measurements.

Author Names

Karaborklu Argut S, Celik D, Kilicoglu OI.

Reviewer Name

Makayla Spade

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Total knee arthroplasty (TKA) is one of the most commonly performed orthopedic surgeries in the lower extremity. However, patient dissatisfaction and functional disability are mostly experienced because of pain and limited range of motion (ROM). Although manual therapy is commonly implemented to improve ROM and modulate pain in the management of musculoskeletal disorders, there is a lack of evidence about its clinical effectiveness on postoperative TKA rehabilitation.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

• Yes

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

• Yes

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

• Yes

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Cannot Determine, Not Reported, or Not Applicable

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

• Yes

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

• No

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

• Cannot Determine, Not Reported, or Not Applicable

Key Finding #1

Joint and soft tissue mobilizations, with the addition to exercise therapy, are found to improve function, pain, and patient satisfaction versus just exercise programs alone for postoperative TKA patients.

Key Finding #2

Despite a between-group difference in knee flexion change score of 12.8° at 2 months, there were no group-by-time interactions significant for both flexion and extension ROMs.

Key Finding #3

When considering patient satisfaction, the mobilization group responded higher compared to the controlled group.

Key Finding #4

Outcome measurements were used along all participants such as numeric pain-rating scale, knee ROMs, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, 10-meter walk test (10MWT), 5-times sit to stand test (5SST), and Short Form-12 (SF-12).

Please provide your summary of the paper

Many tend to look manual therapy as the reward of the hard work. However, this Randomized Controlled Clinical Trial shows beneficial factors from manipulation after exercise program. The key strength of this clinical trial (low risk of bias) are the outcome measures reported by therapist and patient themselves. Although group-by-time did not show a significant change of flexion and extension ROM. This could indicate guarding or fear, however, reports on total WOMAC score, 10MWT, and SF-12 mental component summary showed meaningful stats in the mobilized group.

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

Patients who have an exercise program with additional manual therapy tend to have better outcome measures. Trials shows that patients ROM shows no significant change, however, this could be due to fear, guarding and simple if the measurement was taken before or after the session. In clinical practice, this could cause a placebo effect or long term manual therapy. It is common to use manual therapy to increase range of motion and modulate pain in the management of musculoskeletal disorders, but there is limited evidence that manual therapy can facilitate recovery after TKA surgery.

Author Names

Salamh, P., Cook, C., Reiman, M., Sheets, C.

Reviewer Name

Emily Stadnick

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Manual therapy (MT) is a commonly used treatment for knee osteoarthritis (OA) but to date only one systematic review has explored its effectiveness. The purpose of the present study was to perform a systematic review and meta-analysis of the literature, to determine the effectiveness and fidelity of studies using MT techniques in individuals with knee OA. Relevant studies were assessed for inclusion. Effectiveness was measured using effect sizes, and methodological bias and treatment fidelity were both explored. Effect sizes were calculated using standardized mean differences (SMD) based on pooled data depending on statistical and clinical heterogeneity, as well as risk of bias. The search captured 2,969 studies; after screening, 12 were included. Four had a low risk of bias and high treatment fidelity. For self-reported function, comparing MT with no treatment resulted in a large effect size (standardized mean difference [SMD] 0.84), as did adding MT to a comparator treatment (SMD 0.78). A significant difference was found for pain when adding MT to a comparator treatment (SMD 0.73). The findings in the present meta-analytical review support the use of MT versus a number of different comparators for improvement in self-reported knee function. Lesser support is present for pain reduction, and no endorsement of functional performance can be made at this time.

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

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

• Yes

7. Was publication bias assessed?

• Yes

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

• Yes

Key Finding #1

Manual therapy appears moderately effective for improved function, specifically as an adjunct to another treatment and versus comparators of no treatment or other treatments

Key Finding #2

With some reservations, use of manual therapy is supported for pain

Key Finding #3

Based on the research findings, manual therapy cannot be supported as a mechanism to improve functional performance

Please provide your summary of the paper

This meta-analysis and systematic review looked at 12 studies about the use of manual therapy for patients with knee osteoarthritis. The researchers used PRISMA guidelines during the research process and created a list of inclusion to deem the study fit for review. They analyzed the literature bias using a modified version of the Downs and Black checklist and examined treatment fidelity, using a modified, unvalidated scale based on a scale from Borelli et al. (2005). Manual therapy was concluded effective and statistically significant with a moderate to large effect size when included with another treatment, versus no treatment, and versus other treatments. Although functional performance was not improved with manual therapy, manual therapy should be considered for use for patients with knee osteoarthritis to improve function and possibly relieve pain.

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

Clinicians should consider using manual therapy for patients with knee osteoarthritis who want to gain more independence in function. Only two studies within the paper examined pain effects with manual therapy and the results were variable, so further research is needed to determine the effects of MT on pain relief for knee OA. More research should also be conducted to determine whether manual therapy can be effective in treating pain and improving function and functional performance in other knee pathologies.