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Effectiveness of local exercise therapy versus spinal manual therapy in patients with patellofemoral pain syndrome: medium term follow-up results of a randomized controlled trial

Author Names

Enfelsma, Y; Haverkamp, S; Scafoglieri, A; Tamminga, R; Van den Broeck, J; Van der Hoeven, H; Willems, S

Reviewer Name

Katherine Terkoski 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.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

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

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

Were study participants and providers blinded to treatment group assignment?

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

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

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

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

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

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

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

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

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

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

Key Finding #1

Spinal manual therapy is more effective than local exercise therapy in improving pain and function in patients with PFPS in the medium term.

Key Finding #2

There was no difference between the two groups in terms of maximal voluntary peak force.

Please provide your summary of the paper

This study aimed to investigate the difference between spinal manual therapy and local exercise therapy in treating patients with PFPS. Forty-three patients with PFPS were assigned randomly to a spinal manual therapy or local exercise group. Both groups received intervention sessions once a week for six weeks. All patients did home exercises additionally. Pain was measured using the visual analog scale, function was measured using the anterior knee pain scale, and MPFV was analyzed using a Biodex System 3 dynamometer. Patients were assessed before intervention, after the sixth intervention session, and six weeks after that for a follow up. The results showed that in the medium term, spinal manual therapy is more effective than local exercise therapy in improving pain and function in patients with PFPS.

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

The study offers a good direction for clinical management of PFPS, however, it can be improved upon. One thing the study stated is that spinal manipulations offer better long term benefits than local exercise therapy and should be utilized due to the chronic nature of PFPS. However, they only tracked the progress 6 weeks after intervention, which would not necessarily correlate with long term results. There appeared to be a few additional variables between the two groups besides what the study aimed to investigate. The exercise group received patellofemoral mobilizations while the manual therapy group did not. The manual therapy group received thoracic based home exercises while the home exercises for the other group were not specified. It cannot definitively be known whether these differences played a role in the results. While there are some gaps in this study, it appears that both spinal manual therapy and local exercise therapy can help reduce pain and function in patients with PFPS, with spinal manual therapy producing slightly better results. This study could be improved upon further with the addition of a control group receiving sham manual therapy and a group combining spinal manual therapy with local exercise therapy.

The effects of joint mobilization on individuals with patellofemoral pain: a systematic review

Author Names

Dhinu J Jayaseelan, David A Scalzitti, Geoff Palmer, Alex Immerman, and Carol A Courtney

Reviewer Name

Luke Vitale, SPT, CSCS

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective: To investigate and synthesize the effects of joint mobilization on individuals with patellofemoral pain syndrome. Data sources: Five electronic databases (CINAHL, the Cochrane Central Register of Controlled Trials, PubMed, Scopus, and SPORTDiscus) were used. Review methods: Each database was searched from inception to 1 November 2017. Randomized controlled trials investigating a manual therapy intervention, with or without co-interventions, for persons with patellofemoral pain were included. Two reviewers independently screened the retrieved literature and appraised the quality of the selected studies using the PEDro rating scale. A third reviewer was used in cases of discrepancy to create a consensus. Results: A total of 361 articles were identified in the search. Twelve randomized trials with a total of 499 participants were selected for full review. Within-group improvements in pain and function were noted for the manual therapy groups. Between-group improvements for short-term outcomes (three months or less) were greatest when joint mobilization was directed to the knee complex and used as part of a comprehensive approach. Conclusion: In the articles reviewed, joint mobilization appears to be most effective in improving pain and function when coupled with other interventions, although its discrete effect is unclear due to the reviewed studies’ design and reporting.

Keywords: Knee; manipulation; manual therapy; pain; patellofemoral.

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

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

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

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

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

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

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

Was publication bias assessed?

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

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

When joint mobilizations were used as co-interventions, short term improvements in pain and function were frequently reported.

Key Finding #2

Mobilization targeted to the knee resulted in significant improvements in pain and function when compared to spinal thrust mobilization, suggesting that localized treatment is more effective than proximal treatment directed to the spine.

Key Finding #3

Use of knee joint mobilization in isolation is not recommended based on the available data.

Please provide your summary of the paper

This systematic review found that manual therapy can have a positive effect on pain and function in the short term (3 months) for patients with Patellofemoral Pain Syndrome (PFPS). The authors investigated 12 randomized trials and found that manual therapy (MT) was most effective when it was targeted locally to the knee versus proximally at the spine, and when it was implemented as part of a comprehensive rehabilitation program. The studies that used MT in isolation compared to a control group did not show a significant improvement in either pain or function, which further supports the notion of MT being used implemented as a part of a comprehensive approach rather than treatment in isolation. The authors noted, however, that conclusions should be drawn with caution as there were some methodological, study quality, and data availability concerns with some of the trials selected for this review.

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

This paper supports the use of manual therapy/mobilization techniques for treatment of Patellofemoral Pain Syndrome (PFPS) only when it is included as a part of a comprehensive strategy. The authors do not suggest using mobilization as a standalone treatment based on the available data. Perhaps, capitalizing on the pain modulatory effects of manual therapy to then allow patients to perform exercises with less pain, through greater ROM, or both would be indicated. Furthermore, determining whether or not manual therapy/mobilization is received and perceived well by the patient will help the clinician determine if mobilization is included in their plan.

Shockwave Therapy Versus Dry Needling for the Management of Iliotibial Band Syndrome: A Randomized Clinical Trial

Author Names

Maghroori Razie, Karshenas Leila, and Khosrawi Saied

Reviewer Name

Luke Vitale, SPT, CSCS

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Iliotibial band syndrome (ITBS) is a common leading cause of lateral knee pain. Despite varieties of medical and non-medical treatments proposed for the management of ITBS, the best therapeutic approach for its treatment remained a significant question. The current study aims to compare the outcomes of dry needling (DN) versus shockwave therapy (SWT) in the management of ITBS. Materials and Methods: This randomized clinical trial was conducted on 40 patients diagnosed with ITBS. The patients were randomly divided into two treatment groups of DN (n=20) and SWT (n=20). Visual analog scale for the pain assessment, Lower Extremity Functional Scale (LEFS) for the function evaluation, and length of the iliotibial band were assessed at baseline, immediately after the cessation of the intervention, and within four weeks. Results: The two groups were similar regarding demographic characteristics (P0.05). Both approaches could efficiently lead to improved pain (P0.001) and promoted function based on LEFS (P0.001); however, iliotibial band length (ITBL) did not alter remarkably (P0.05). The groups were similar in terms of pain score, LEFS, and ITBL at all of the assessment intervals (P0.05), but the pain score within four weeks following the interventions that were significantly better in DN (P=0.023). Conclusion: Based on our results, DN, as well as SWT, could remarkably lead to an improvement in pain and function among patients resenting from ITBS; however, none of the approaches was superior over the other.

Keywords: Iliotibial Band Syndrome, Dry Needling, Extracorporeal Shockwave Therapy, Pain

NIH Risk of Bias Tool

Was the study question or objective clearly stated?

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

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

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

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

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

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

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

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

Cannot Determine, Not Reported, Not Applicable

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

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

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

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

SWT and DN both significantly reduced pain from baseline compared to cessation of treatment and at 4-week follow-up.

Key Finding #2

SWT and DN both significantly improved LE function as measured by the LEFS at cessation and 4-week follow-up compared to baseline.

Please provide your summary of the paper

Iliotibial Band Syndrome (ITBS) is commonly blamed for lateral knee pain, however consensus on the best treatment for ITBS is not always so clear. This study investigated the effects of dry needling (DN) versus shockwave therapy (SWT) on pain, lower extremity function, and IT band length. The authors found that DN and SWT significantly reduced pain from baseline, to immediately following the last treatment session, and 4 weeks following treatment. However, this paper did not find that either DN or SWT were significantly more effective than one another, i.e., neither one is superior. While this study provides interesting findings regarding possible treatment and/or pain management options for ITBS, there are limitations to the study. Firstly, there was no control group identified so we cannot determine if SWT or DN is superior to standard care or placebo. Further, the sample size used in this study was relatively small (40 participants). Finally, follow-up was limited to only 4 weeks after cessation of treatment, so it is unclear if these reductions in pain and improvement in function would persist past the follow-up period. The authors suggest that more studies need to be conducted with a longer follow-up period in order to generalize 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 use of DN may be useful in the treatment of ITBS. It has shown an ability to significantly reduce pain from ITBS as well as improve LE function when measured using the LEFS. Whether or not DN is warranted in your treatment plan will ultimately depend on your patient’s preferences, irritability, and level of comfort with DN. A possible benefit of DN would be a better tolerance to increased training volume in the running, hiking, and cycling population due to reduced pain following treatment. This could potentially allow patients to perform closer to baseline in their rehab or return to baseline quicker. However, as the authors mentioned, further studies need to be performed in order to make generalized statements.

Is Manual Therapy a Useful Tool When Treating Knee Osteoarthritis? | Article of The Week #54

Author Names

Buxton, S

Reviewer Name

Makayla Spade SPT

Reviewer Affiliation(s)

Duke school of medicine Doctorate of physical therapy

Paper Abstract

There is overwhelming evidence to suggest that exercise is the most effective treatment tool at physiotherapists disposal when it comes to managing knee osteoarthritis. But can manual therapy play a role in treatment too? Osteoarthritis is the most common chronic condition of the joints and most commonly occurrs in the knees and hips. This is reflected in the fact that OA in these joints is expected to be the 9th leading cause of years lived with disability by 2030.

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

Key Finding #1

Joint diseases such as osteoarthritis, which most commonly occurs in the hips and knees, are the most common chronic conditions. It is estimated that by 2030, OA in these joints will be the 9th most common cause of lifelong disability.

Key Finding #2

The use of manual therapy by physiotherapists is common, but evidence suggests that exercise is the best treatment for osteoarthritis of the knee.

Key Finding #3

The exercise program was applied to all groups of participants in all included studies, which may influence or inflate the benefits of manual therapy. Inclusion of studies was evaluated by using the Cochrane Manual for Systematic Reviews of Interventions. In addition to ROM and pain, WOMAC and sensation were also measured as outcome measures

Key Finding #4

Exercise is the best primary treatment for knee osteoarthritis according to best practice guidelines.

Please provide your summary of the paper

In the study of manual therapy in treating the knee has been found to be far less used and proven to improve OA. However, it is reported that functional or physical exercise has a better outcome when it comes to OA. OA in the joints is expected to be the 9th leading cause of lived years in disability. So, if that’s the case why are we wasting time on manual therapy when exercises do the trick? Well, manual therapy for patients with OA has been proven to help not only with pain management but ROM. With the participants picked, they were structured a plan for each patient while reporting outcome measures such as ROM, pain, WOMAC, sensation and overall function. Manual therapy was favored over electrotherapy but did not show greater results than the structured exercise plan.

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

My interpretation of this paper was that structured exercise plan for patients with OA showed and reported greater outcomes. However, manual therapy isnt so bad, patients approved of manual therapy for pain management and increasing ROM over the course of treatment. Patients get a sense of bonding, trusting and comfort when therapy hands are applied to the patients discomfort areas. Verbal feedback will also help with minimizing pain or reassuring patients improvement so therefor a patient is able to perform functional exercise with confidence. In conclusion, manual therapy isnt bad however it will not improve a runner back to running a marathon or a professional weight lifter back to finals but it is a start to relieving pain and increasing a limited ROM before building the muscle.

Efficacy of Tissue-Bone Homeostasis Manipulation on the Gait and Knee Function for Patients With Knee Osteoarthritis: A Randomized Controlled Trial

Author Names

Zhang, Z; Ding, Y; Tao, Y; Xu, H; Zhong, Y; Yang, K; Jiang, L

Reviewer Name

Hana Alvey, SPT, CPT

Reviewer Affiliation(s)

Duke University Doctor of Physical Therapy Program

Paper Abstract

Background: Knee osteoarthritis (KOA) was characterized by pain and limited joint function, which seriously affected the quality of life of patients. The vast majority of KOA was closely related to degeneration of the patellofemoral joint and abnormal patellar movement trajectory. Tissue-bone homeostasis manipulation (TBHM) could correct abnormal patellar movement trajectory on the basis of loosening soft tissue. However, there was little strong evidence to verify its efficacy on the patients with KOA. The study objective was to explore the efficacy of the TBHM on gait and knee function in the patients with KOA. Methods: Sixty KOA patients were randomly assigned to either the joint mobilization (n = 30) or TBHM (n = 30) group. The joint mobilization group received joint mobilization, while the TBHM group received TBHM. For two groups, the patients participated in 30 min rehabilitation sessions thrice per week for 12 weeks. The primary outcome was biomechanical gait outcomes during walking, including step length, step velocity, double support, knee range of motion (ROM), and knee adduction moment (KAM). The secondary outcomes were the Western Ontario and McMaster Index (WOMAC) and 36-Item short- form health survey (SF-36), which reflected improvements in knee function and quality of life, respectively. At baseline and 12 weeks, evaluations were conducted and compared between groups. Results: After a 12-week intervention, significant group differences were observed in KAM (p = 0.018), WOMAC-Pain (p = 0.043) and WOMAC-Stiffness (p = 0.026). A noteworthy finding was the presence of a significant interaction effect between group and time specifically observed in step velocity during gait (p = 0.046), WOMAC-Function (p = 0.013) and SF-36 (p = 0.027). Further analysis revealed a significant difference in step velocity (p = 0.034), WOMAC-Function (p = 0.025) and SF-36 (p = 0.042) during post-assessment between the two groups. Moreover, a significant time effect was observed across all outcomes of the two groups (p < 0.05). Conclusion: The TBHM intervention has better improved the gait, knee function, and quality of life in the patients with KOA.

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

Key Finding #1

Tissue-bone Homeostasis Manipulation (TBHM) increased step velocity, as well as improved other gait dynamics compared to joint mobilization.

Key Finding #2

TBHM decreased the knee adduction moment (KAM).

Key Finding #3

Both methods, TBHM and joint mobilization, improved patients’ WOMAC and SF-36 scores.

Please provide your summary of the paper

Knee osteoarthritis (KOA) is one of the most common conditions among older populations. KOA is caused by a complex interaction of many different variables, and it is thought that attaining equilibrium within the knee, including muscles, soft tissues, and the joint itself, would benefit in the load distribution of the knee and help with successful rehabilitation of KOA. The purpose of this research study was to investigate how tissue-bone homeostasis manipulation (TBHM) would impact gait dynamics and knee function for those with KOA, and compare these effects to joint mobilization to see if one is more effective than the other. TBHM is a manual therapy technique that focuses on restoring equilibrium to a joint. The TBHM techniques used in this study consisted of soft tissue release, press kneading of painful points, infrapatellar fat pad release, patellar mobilizations, and tibial internal and external rotation. The trial duration was 12 weeks, and both the TBHM and joint mobilization group received interventions three times a week for 12 weeks. Data was gathered before and after the 12 weeks. The primary outcomes measured were step length, step velocity, double support time, knee ROM, and knee adduction moment (KAM), which has a strong association with the functional disability of KOA patients. The secondary outcomes measured were WOMAC scores for pain, stiffness, and funtion and SF-36 scores. Though the results found that both groups benefitted from their respective interventions, those in the TBHM group had a significant increase in step velocity, a decreased KAM, lower WOMAC scores, and higher SF-36 scores when compared to the joint mobilization group. In conclusion, TBHM is beneficial and holds promise for KOA patients.

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

TBHM is a promising manual therapy technique that deserves further exploration of its effects on those with KOA. With so many people affected by OA, treatment methods like TBHM are worth researching into and implementing in the clinic, especially when there were no adverse events in this study. The outcomes of the TBHM group were more beneficial than the joint mobilization group. TBHM could be a great alternative treatment method to utilize with KOA patients, as opposed to less conservative methods. Future studies should have a longer follow-up time to see if the effects of TBHM last, and they could use MRI/CT data to analyze possible TBHM mechanisms.

Exercise, Manual Therapy, and Booster Sessions in Knee Osteoarthritis: Cost-Effectiveness Analysis From a Multicenter Randomized Controlled Trial

Author Names

Allyn Bove, Kenneth Smith, Christopher Bise, Julie Fritz, John Childs, Gerard Brennan, J Haxby Abbott, G Kelley Fitzgerald

Reviewer Name

Julie Bottarini, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background:

Limited information exists regarding the cost-effectiveness of rehabilitation strategies for individuals with knee osteoarthritis (OA).

Objective: The study objective was to compare the cost-effectiveness of 4 different combinations of exercise, manual therapy, and booster sessions for individuals with knee OA.

Design: This economic evaluation involved a cost-effectiveness analysis performed alongside a multicenter randomized controlled trial.

Setting: The study took place in Pittsburgh, Pennsylvania; Salt Lake City, Utah; and San Antonio, Texas.

Participants: The study participants were 300 individuals taking part in a randomized controlled trial investigating various physical therapy strategies for knee OA.

Intervention: Participants were randomized into 4 treatment groups: exercise only (EX), exercise plus booster sessions (EX+B), exercise plus manual therapy (EX+MT), and exercise plus manual therapy and booster sessions (EX+MT+B).

Measurements: For the 2-year base case scenario, a Markov model was constructed using the United States societal perspective and a 3% discount rate for costs and quality-adjusted life years (QALYs). Incremental cost-effectiveness ratios were calculated to compare differences in cost per QALY gained among the 4 treatment strategies.

Results: In the 2-year analysis, booster strategies (EX+MT+B and EX+B) dominated no-booster strategies, with both lower health care costs and greater effectiveness. EX+MT+B had the lowest total health care costs. EX+B costInline graphic, Picture1061 more and gained 0.082 more QALYs than EX+MT+B, for an incremental cost-effectiveness ratio ofInline graphic, Picture12,900/QALY gained.

Limitations: The small number of total knee arthroplasty surgeries received by individuals in this study made the assessment of whether any particular strategy was more successful at delaying or preventing surgery in individuals with knee OA difficult.

Conclusions: Spacing exercise-based physical therapy sessions over 12 months using periodic booster sessions was less costly and more effective over 2 years than strategies not containing booster sessions for individuals with knee OA.

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
- Yes
Was the method of randomization adequate (i.e., use of randomly generated assignment)?
- Yes
Was the treatment allocation concealed (so that assignments could not be predicted)?
- Cannot Determine, Not Reported, Not Applicable
Were study participants and providers blinded to treatment group assignment?
- Yes
Were the people assessing the outcomes blinded to the participants’ group assignments?
- Cannot Determine, Not Reported, 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?
- Cannot Determine, Not Reported, Not Applicable
Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
- Cannot Determine, Not Reported, 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)?
- Cannot Determine, Not Reported, Not Applicable
Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
- Yes
Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
- Cannot Determine, Not Reported, Not Applicable
Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
- Cannot Determine, Not Reported, Not Applicable
Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
- Yes

Key Finding #1

 Spacing exercise-based physical therapy sessions over 12 months using periodic booster sessions was cost-effective over 2 years compared to strategies not utilizing boosters.

Key Finding #2

Treatment groups that contained booster sessions were more cost effective and had better clinical effectiveness. 

Please provide your summary of the paper

This study was an economic evaluation of the cost effectiveness of four different combinations of physical therapy treatments for patients with knee osteoarthritis over a 2-year time span. The RCT used in this study divided patients into 4 treatment groups: exercise only, exercise plus booster sessions, exercise plus manual therapy, and exercise plus manual therapy and booster sessions. Manual therapy treatments and exercise interventions were kept similar across patient groups. Patients in the booster session groups received 8 visits over 9 weeks followed by 4 additional booster sessions that were spread out over the following year. All patients in the study received a total of 12 therapy sessions over the 2-year period. Effectiveness of treatment was measured in quality-adjusted life years (QALYs). The four treatment categories achieved similar positive results in clinical effectiveness. The greatest treatment effectiveness was achieved in the exercise and booster category, and the most cost effective strategy was the exercise, manual therapy, and booster group. The strategies that did not contain booster sessions were higher cost and less effective. The study concluded that treatment strategies that incorporate exercise and booster sessions, with or without manual therapy, have the greatest effectiveness and lowest health care utilization as opposed to non-booster groups. 

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

This study reveals the economic and clinical benefit of incorporating booster sessions in physical therapy treatment plans. Current payment models promote short episodes of care within a discrete time period. The implementation of booster sessions over a prolonged period of time could lead to better health outcomes and a reduction in healthcare costs. Other benefits of booster sessions are that they help motivate patients to continue their home exercise programs outside of the clinic, empowering patients to take a more active role in their personal health. Physical therapists should consider advocating for the adoption of a care model that utilizes booster sessions. 

The Combination of Exercise and Manual Therapy Versus Exercise Alone in Total Knee Arthroplasty Rehabilitation: A Randomized Controlled Clinical Trial

Author Names

Karaborkly Argut, S., Celik, D., Kilicoglu, O. I.

Reviewer Name

Ashleigh Conn, SPT

Reviewer Affiliation(s)

Duke School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background

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.

Objective

To investigate the effectiveness of an exercise program combined with manual therapy compared with an exercise program only for pain, ROM, function, quality of life, and patient satisfaction outcomes.

Design

A randomized controlled clinical trial.

Setting

Rehabilitation unit of a university hospital.

Participants

Forty-two patients (68.45 ± 6.3 years) scheduled for unilateral TKA as a treatment of severe osteoarthritis.

Interventions

Joint and soft tissue mobilizations in addition to exercise therapy were provided to the mobilization group (n = 21) while the control group received exercise therapy only (n = 21).

Main Outcome Measures

The outcome measures were 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).

Results

Improvements in pain outcomes were significantly higher in the mobilization group than in the control group (P = .001, F [3, 33] = 7.06) and the between-group difference in change score was 1.3 points (P = .001). Although the between-group difference in change score was 12.8° for knee flexion at 2 months (P = .001), the overall group-by-time interactions were not significant for flexion and extension ROMs (P = .175, F [3, 33] = 1.75 and P = .57, F [2, 34] = 0.56, respectively). Additionally, there were statistically meaningful group-by-time interactions on total WOMAC score (P = .006, F [2, 34] = 5.29), 10MWT (P = .002, F [3, 33] = 5.98), and SF-12 mental component summary (P = .01, F [2, 34] = 4.92) favoring the mobilization group. Also, patient satisfaction was higher in the mobilization group (P = .02).

Conclusions

A structured exercise program combined with manual therapy can be more beneficial in improving pain, function, and patient satisfaction compared to exercise program alone for postoperative TKA patients.

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 be determined

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

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

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

Structured exercise, along with manual therapy, can be used for postoperative TKA patients to reduce pain, increase function, and enhance quality of life. 

Key Finding #2

The mobilization group reported experiencing less stiffness compared to the control group, with a statistically significant difference proving the effectiveness of manual therapy for the postoperative TKA population. 

Key Finding #3

Participants in both the control group and the mobilization group exhibited improvements in knee flexion and extension range of motion. However, the mobilization group regained higher degrees of knee flexion range of motion than the control group.

Please provide your summary of the paper

This randomized clinical control trial investigates manual therapy as a treatment for postoperative unilateral total knee arthroplasty (TKA) patients who underwent surgery due to severe osteoarthritis. Forty-two participants were randomly assigned to either a control group, which received a structured exercise program, or a mobilization group, which received joint and soft tissue mobilizations combined with a structured exercise program. The study assessed primary outcomes of pain and knee flexion/extension range of motion (ROM), and secondary outcomes of function, quality of life, and patient satisfaction. Pain was evaluated through the numeric pain-rating scale (NPRS), while quality of life was assessed with the Short Form-12 (SF-12). The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), 10-meter walk test (10MWT), and 5-times sit to stand test (5SST) were given to determine the functional status of participants. Clinical outcomes were evaluated before surgery, at discharge, the second week, and the second month. Additionally, patient-reported outcomes were evaluated before surgery, the second week, and the second month.

Over the course of treatment, the study reflected more significant pain improvements, functional status enhancements, and patient satisfaction in the group receiving the structured exercise program along with manual therapy compared to the group receiving the structured exercise program only. Both groups gained knee flexion and extension ROM, and the group-by-time interaction effect was not significant. Higher degrees of knee flexion ROM were gained by the mobilization group. Lastly, reports of patient perceived stiffness were lower in the mobilization group. 

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

Considering functional limitations are a leading cause of morbidity in the geriatric populations and can largely dampen quality of life, it is crucial to focus on regaining function and decreasing pain following a total knee arthroplasty (TKA). This study highlights the multifactorial clinical benefits of physical therapists performing joint and soft tissue mobilizations in addition to using a structured exercise program when treating postoperative TKA patients. If the patient’s goals align, manual therapy is an important technique to consider when rehabilitating postoperative TKA patients to reduce pain, increase function, and enhance patient satisfaction. By increasing patient satisfaction, patient-therapist trust may be strengthened and patient buy-in is likely to rise. 

As always, it is essential to examine and understand the limitations of this study. This RCT did not follow up with patients beyond 2 months, did not blind the assessors, and measured knee ROM using an electronic goniometer and standardized scripts.

Knee Extension and Stiffness in Osteoarthritic and Normal Knees: A Videofluoroscopic Analysis of the Effect of a Single Session of Manual Therapy

Author Names

Taylor, AL; Wilken, JM; Deyle, GD; Gill, NW

Reviewer Name

Juliette Clavier, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Study Design

Descriptive biomechanical study using an experimental repeated-measures design.

Objective

To quantify the response of participants with and without knee osteoarthritis (OA) to a single session of manual physical therapy. The intervention consisted primarily of joint mobilization techniques, supplemented by exercises, aiming to improve knee extension.

Background

While manual therapy benefits patients with knee OA, there is limited research quantifying the effects of a manual therapy treatment session on either motion or stiffness of osteoarthritic and normal knees. Methods

The study included 5 participants with knee OA and 5 age-, gender-, and body mass index-matched healthy volunteers. Knee extension motion and stiffness were measured with videofluoroscopy before and after a 30-minute manual therapy treatment session. Analysis of variance and intraclass correlation coefficients were used to analyze the data.

Results

Participants with knee OA had restricted knee extension range of motion at baseline, in contrast to the participants with normal knees, who had full knee extension. After the therapy session, there was a significant increase in knee motion in participants with knee OA (P = .004) but not in those with normal knees (P = .201). For stiffness data, there was no main effect for time (P = .903) or load (P = .274), but there was a main effect of group (P = .012), with the participants with healthy knees having greater stiffness than those with knee OA. Reliability, using intraclass correlation coefficient model 3,3, for knee angle measurements between imaging sessions for all loading conditions was 0.99. Reliability (intraclass correlation coefficient model 3,1) for intraimage measurements was 0.97.

Conclusion

End-range knee extension stiffness was greater in the participants with normal knees than those with knee OA. The combination of lesser stiffness and lack of motion in those with knee OA, which may indicate the potential for improvement, may explain why increased knee extension angle was observed following a single session of manual therapy in the participants with knee OA but not in those with normal knees. Videofluoroscopy of the knee appears reliable and relevant for future studies attempting to quantify the underlying mechanisms of manual therapy. J Orthop Sports Phys Ther 2014;44(4):273–282. Epub 25 February 2014. doi:10.2519/jospt.2014.4710

Quality Assessment of Case-Control Studies

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

Yes

Was the study population clearly specified and defined?

Yes

Did the authors include a sample size justification?

Yes

Were controls selected or recruited from the same or similar population that gave rise to the cases (including the same timeframe)?

Yes

Were the definitions, inclusion and exclusion criteria, algorithms or processes used to identify or select cases and controls valid, reliable, and implemented consistently across all study participants?

Yes

Were the cases clearly defined and differentiated from controls?

Yes

If less than 100 percent of eligible cases and/or controls were selected for the study, were the cases and/or controls randomly selected from those eligible?

N/A

Was there use of concurrent controls?

Were the investigators able to confirm that the exposure/risk occurred prior to the development of the condition or event that defined a participant as a case?

N/A

Were the measures of exposure/risk clearly defined, valid, reliable, and implemented consistently (including the same time period) across all study participants?

Yes

Were the assessors of exposure/risk blinded to the case or control status of participants?

Yes

Were key potential confounding variables measured and adjusted statistically in the analyses? If matching was used, did the investigators account for matching during study analysis?

Yes

Key Finding #1

There was a statistically significant increase in knee extension range of motion in those with OA compared to the healthy control group after receiving a single manual therapy session.

Key Finding #2

In the healthy control group, there was higher knee stiffness at varying loads compared to the group with knee OA.

Please provide your summary of the paper

This study aimed to quantify the possible positive effects that manual therapy can have on patients with knee OA using videofluoroscopy. The researchers wanted to evaluate the changes in stiffness and knee range of motion after manual therapy intervention in knee OA. 5 participants with knee OA and 5 healthy controls that were age, gender, and BMI-matched were recruited for this study. The order of study intervention and experiment occurred as follows: 1. Baseline imaging measures were taken 2. manual therapy intervention was performed 3. imaging measures taken immediately after manual therapy 4. participant walks 5. third and final imaging session. Images were taken with the participants in supine with the knee bent to 45 degrees. A pneumatic pulley device was used in combination with Digital Motion X-ray fluoroscopic imaging. Measures of knee angle and stiffness were taken. The manual therapy intervention that each participant received consisted of a 30-minute session that was customized to the needs of participants with OA. Joint mobilization, soft tissue mobilization, and muscle stretching were performed. Researchers found that there was a significant increase in knee extension in those with OA compared to the healthy controls, which they explain is expected since patients with OA have a more limited knee extension range of motion at baseline. Although this study supports the use of manual therapy to gain range of motion in those with knee OA, researchers acknowledge that the sample might be too small to generalize to a greater population of patients with OA, and further research should be done to confirm this finding.

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

This study is useful in quantifying the positive effects that manual therapy intervention can have on individuals who suffer from pain and stiffness with knee OA beyond anecdotal evidence from patients. This helps provide evidence that manual therapy has a positive biological effect on an osteoarthritic knee and could help encourage clinicians to utilize this approach to treatment in similar patient groups. While this helps pave the way for manual therapy treatment of the osteoarthritic knee, more research on other osteoarthritic joints and with larger sample sizes should be done to confirm the results of this study.

The Effects of Manual Therapy in Pain and Safety of Patients With Knee Osteoarthritis: A Systematic Review and Meta-Analysis

Author Names

Zhu, B; Ba, H; Kong, L; Fu, Y; Ren, J; Zhu, Q; Fang, M

Reviewer Name

Lea Schneider, SPT, CSCS

Reviewer Affiliation(s)

Duke University School of Medicine

Paper Abstract

Background: Manual therapy (MT) is frequently used in combination with management of osteoarthritis of the knee, but there is no consensus on the exact efficacy of this treatment strategy. The purpose of this systematic review and meta-analysis was to evaluate the pain relief and safety of MT for treatment of knee osteoarthritis (KOA).

Methods: Randomized controlled trials evaluating MT in patients with KOA in major English and Chinese journals were searched in the following databases: Wanfang, China Science and Technology Journal Database (VIP database), China National Knowledge Infrastructure (CNKI), PubMed, Embase, Web of Science, and the Cochrane Library databases through June 2023. The methodological quality and quality of evidence of the included studies were assessed using Cochrane’s risk-of-bias 2 (ROB 2) tool and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. Data analysis was performed using Stata version 15.0 software. After use of Galbraith plots to exclude studies that could lead to heterogeneity, random effects models were used to analyze the remaining data and test the consistency of the findings. We used meta-regression to assess the effect of treatment period, patient age, and sex ratio on outcomes. Funnel plots and Egger’s test were used to evaluate publication bias. Sensitivity analyses were used to determine the reliability of the results.

Results: A total of 25 studies, with 2376 participants, were included in this review. The overall methodological quality of the included studies was limited. Our findings suggest that MT has a positive impact on pain relief outcomes in KOA patients. The meta-analysis showed that MT was superior to usual care (SMD = 2.04, 95% CI 0.94, 3.14, I2 = 96.3%; low evidence quality) and exercise (SMD = 1.56, 95% CI 0.41, 2.71, I2 = 96.3%; low evidence quality) for reducing pain. In terms of improvement in visual analogue scale (VAS) scores, MT treatment beyond 4 weeks (SMD=1.56, 95% CI 0.41, 2.71, I2 = 96.3%) may be superior to treatments less than or equal to 4 weeks (SMD = 1.24, 95% CI 0.56, 1.95, I2 = 94.7%). No serious adverse events associated with MT were reported

Conclusions: MT may be effective at reducing pain in patients with KOA and may be more effective after a 4-week treatment period. Compared with usual care and exercise therapy, MT may be superior at reducing KOA pain in the short term (9 weeks), but its long-term efficacy requires careful consideration of evidence-based outcomes.

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?

Yes

Was publication bias assessed?

Yes

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

Yes

Straight Connector 2, Shape

Key Finding #1

Manual therapy may be effective at reducing pain in patients with KOA in the short term (9 weeks). The pain relief effect of manual therapy in this patient population may be limited to certain activities, demonstrated by the variance in responses with the two pain scales used (the WOMAC and the VAS). Although the findings on VAS score improvements were statistically significant, there were no significant differences in WOMAC scores. This suggests that the analgesic effects of manual therapy do not extend into all aspects of patients’ daily lives, especially in situations such as walking, stair negotiation, sleeping, standing, sitting, and lying down.

Key Finding #2

Manual therapy appears to be safe for individuals with KOA. The meta-analysis of observed adverse events was musculoskeletal related (typically soreness), transient in nature, or mild to moderate severity. Thus, clinicians treating KOA patients may safely prioritize manual therapy for those seeking nonsurgical conservative treatment.

Please provide your summary of the paper

Although manual therapy is a widely used conservative treatment strategy, few studies have reported the efficacy of manual therapy alone for the treatment of knee osteoarthritis, leaving a lack of consensus about recommending manual therapy for this patient population. This study was conducted by performing a systematic review and meta-analysis to examine pain improvements following manual therapy treatment. A literature search was performed, and ultimately 5 English and 10 Chinese studies were included. The primary outcome was to examine if manual therapy compared with other therapies improved VAS score – the study found a significantly greater VAS score in those treated with MT, although the effect was considered small. When compared to other therapies (herbal application, oral analgesic, acupuncture, etc.), the VAS score in the MT group showed no significant improvements. However, MT treatments of ≥ 4 weeks may be superior to treatments of ≤ 4 weeks in terms of improvement in VAS scores. The secondary outcome examined the effect of MT compared with other therapies on the WOMAC pain score – they found that those treated with MT did not show statistically significant changes in WOMAC pain scores. Thus, MT was found to be potentially effective at reducing pain in KOA patients, and long-term treatment periods may be more effective. MT may be more advantageous than usual care and exercise therapy in patients with KOA despite limitations – further large sample, high-quality RCTs are needed in the future to further determine the beneficial effects of MT on KOA patients.

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 study suggest that MT as a stand-alone treatment may not produce satisfactory analgesic effects, especially in those who experience pain only in certain situations. However, clinicians may safely prioritize MT in anticipation of possible short-term improvements in pain in patients with KOA that are seeking nonsurgical, conservative treatment. MT may be effective after a 4-week treatment period and may be superior in reducing pain in the short-term; however, its long-term efficacy requires further consideration and study.

Are Manual Therapy or Booster Sessions Worthwhile in Addition to Exercise Therapy for Knee Osteoarthritis: Economic Evaluation and 2-Year Follow-Up of a Randomized Controlled Trial

Author Names

Pryymachenko, Y., Wilson, R., Sharma, S., Pathak, A., Haxby Abbott, J.

Reviewer Name

Leara Stanley, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background

Exercise therapy is known to be an effective intervention for patients with osteoarthritis, however the evidence is limited as to whether adding manual therapy or booster sessions are cost-effective strategies to extend the duration of benefits.

Objective

To investigate the cost-effectiveness, at 2-year follow-up of adding manual therapy and/or booster sessions to exercise therapy.

Design

2-by-2 factorial randomized controlled trial.

Methods

Participants with knee osteoarthritis were randomly allocated (1:1:1:1) to: exercise therapy delivered in consecutive sessions within 9 weeks (control group), exercise therapy distributed over 1 year using booster sessions, exercise therapy plus manual therapy delivered within 9 weeks, and exercise therapy plus manual therapy with booster sessions. The primary outcome was incremental cost-effectiveness from health system and societal perspectives interpreted as incremental net monetary benefit (INMB).

Results

Of 75 participants, 66 (88 %) were retained at 1-year and 40 (53 %) at 2-year follow-up. All three interventions were cost-effective from both the health system and societal perspectives (INMBs, at 0.5 × GDP/capita willingness to pay (WTP) threshold: $3278 (95%CI -3244 to 9800) and $3904 (95%CI -2823 to 10,632) respectively for booster sessions; $2941 (95%CI -3686 to 9568) and $2618 (95%CI -4005 to 9241) for manual therapy; $270 (95%CI -6139 to 6679) and $404 (95%CI -6097 to 6905) for manual therapy with booster sessions).

Conclusion

Manual therapy or booster sessions in addition to exercise therapy are cost-effective at 2-year follow-up. The evidence did not support combining both booster sessions and manual therapy in addition to exercise therapy.

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?

Were the people assessing the outcomes blinded to the participants’ group 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 there high adherence to the intervention protocols for each treatment group?

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

Yes

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

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

All three treatment groups (excluding the control) demonstrated higher quality adjusted life years (QALYs) and higher costs from the health system and societal perspectives over two years.

Key Finding #2

Exercise therapy alone showed worsening of OA after one year, however improvements occurred in condition at year two compared to baseline. Exercise therapy with booster sessions, with or without manual therapy, showed improvements across years one and two. Exercise therapy with manual therapy showed improvement at one-year follow-up, but these improvements were not maintained at year two.

Key Finding #3

Exercise therapy with manual therapy and exercise therapy with booster sessions were cost effective from both the health system and societal perspectives. Exercise therapy with booster sessions was cost-saving and dominated conventional exercise therapy from the societal perspective.

Please provide your summary of the paper.

The purpose of the randomized control trial was somewhat two-fold—first, to identify which intervention, manual therapy, booster sessions, or both, in addition to exercise therapy would be most effective in treating patients with knee osteoarthritis, and second, to determine the cost-effectiveness of adding manual therapy and/or booster physical therapy sessions to exercise therapy at 2-year follow-ups for patients with knee osteoarthritis. The 2×2 factorial design of the study distributed participants into four intervention groups: exercise therapy without booster sessions (control), exercise therapy with booster sessions, exercise therapy with manual therapy, and exercise therapy with manual therapy and booster sessions. Conventional exercise programs were provided to all participants, independent of treatment group allocation, with each group receiving 12 exercise sessions consisting of multimodal exercise protocols specific to their individual needs, including aerobic, strengthening, stretching, and neuromuscular control exercises. Clinical outcome measures used at two-year follow-ups were the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), numeric pain rating scale, 30-second chair rise, timed up and go, 40-meter self-paced walk test, global rating of change (GROC), and outcome measures in rheumatoid arthritis clinical trials. Quality adjusted life years (QALYs) from patient-reported HRQoL reports were used to determine effectiveness of each intervention group. Other outcomes measured were incremental cost-effectiveness ratios and incremental net-monetary benefits. Results from the study revealed that all intervention groups experienced an increase in QALYs and clinical outcomes in comparison to the control, however, exercise therapy in combination with manual therapy demonstrated the greatest increase, with a QALY gain of 0.15. Exercise therapy with booster sessions produced a QALY gain of 0.14 and exercise in conjunction with manual therapy and booster sessions produced gains of 0.07. Cost-effectiveness acceptability curves showed exercise therapy in combination with booster sessions and manual therapy were between 77%-88% more cost-effective at 0.5 x GDP/capita threshold, and 90% more cost-effective at higher willingness-to-pay thresholds. Based on one- and two-year follow-ups, the treatment group to demonstrate improvements and maintenance of those improvements during both assessments were participants receiving exercise therapy in combination with booster sessions. Limitations within this study include small sample size, preventing results to be extrapolated to larger populations. Additionally, the number of participants lost at the time of second follow-up limits significance of results, however, this was to be expected due to the longer duration of the study.

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

Osteoarthritis (OA) is one of the most common chronic conditions, impacting approximately 40% of individuals over the age of 45, and plays a large role in rising cases of disability. Osteoarthritis also contributes to higher healthcare costs, reduced productivity, and poorer health quality of life. As a first-line treatment for knee OA, clinical practice guidelines suggest exercise therapy, however, the benefits are typically regarded as modest and short-lived. Therefore, exercise therapy in conjunction with manual therapy or PT follow-up sessions, also known as booster sessions, have been suggested as additional treatments to enhance the lasting effects of exercise therapy on osteoarthritis. This study provides one review of the economic feasibility of providing exercise therapy treatments in conjunction with manual therapy, booster sessions, or both. While it is suggested to implement exercise therapy into a patient’s treatment plan for OA, if patients are only experiencing modest results, they are less likely to continue seeking PT services. However, combining exercise therapy with other interventions such as manual therapy or conducting sequential booster sessions for continued maintenance of the condition have shown to be beneficial in the treatment of osteoarthritis. Yet, finances may remain a barrier to patients receiving treatment. Therefore, sharing knowledge of the cost-effectiveness of additional treatments that serve as supplement to exercise therapies already provided should be one responsibility of physical therapists. Patient buy-in is a critical component in physical therapy treatment success. When a patient can play an active role and have some control in their recovery, their outcomes are generally more successful. Other factors that contribute to patient buy-in include knowledge and accessibility to resources, willingness to pay, and a better understanding of one’s condition. Although results from the study cannot be extrapolated to larger sample populations currently, they do highlight the cost-effectiveness and potential benefits of combining exercise therapy with other interventions in the treatment of chronic conditions such as knee OA. Coupling the physical benefits of physical therapy services with evidence of its cost-effectiveness, there is even greater proof of the necessity of PT as one of the frontline treatments for osteoarthritis and other chronic conditions contributing to disability.

Instrument-Assisted Soft Tissue Mobilization Increased Hamstring Mobility

Author Names

Doeringer, J., Ramirez, R., Colas, M.

Reviewer Name

Dillan Rowley, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Department of Physical Therapy

Paper Abstract

Context: Limited research reveals that the use of different soft tissue mobilization techniques increases tissue mobility in different regions of the body. Objective: The purpose of this study was to determine whether there is a difference between administering instrument-assisted soft tissue mobilization (IASTM) and therapeutic cupping (TC) on hamstring tightness. Design: Subjects attended one session wherein treatment and leg order were randomized before attending the session. A statistical analysis was completed using a 2 (intervention) × 2 (time) repeated-measures analysis of variance at α level ≤ .05. Participants: Thirty-three subjects between the age of 18–35 years old with bilateral hamstring tightness participated in this study. Interventions: The IASTM and TC were administered on different legs for 5 minutes and over the entire area of the hamstring muscles. One TC was moved over the entire treatment area in a similar fashion as the IASTM. Main Outcome Measures: The intervention measurements included soreness numeric rating scale, Sit-n-Reach (single leg for side being tested), goniometric measurement for straight-leg hip-flexion motion, and superficial skin temperature. The timeline for data collection included: (1) intervention measurements for the first randomized leg, (2) 5-minute treatment with the first intervention treatment, (3) intervention measurements repeated for postintervention outcomes, and (4) repeat the same steps for 1 to 3 with the contralateral leg and the other intervention. Results: There was a main effect over time for Sit-n-Reach, measurement (pre-IASTM—29.50 [8.54], postIASTM—32.11 [8.31] and pre-TC—29.67 [8.21], post-TC—32.05 [8.25]) and goniometric measurement (pre-IASTM—83.45 [13.86], post-IASTM—92.73 [13.20] and pre-TC—83.76 [11.97], post-TC—93.67 [12.15]; P < .05). Conclusion: Both IASTM and TC impacted hamstring mobility during a single treatment using only an instrument-assisted soft tissue mobilization technique without any additional therapeutic intervention. Keywords: hip flexion, range of motion, circulation, therapeutic modalities

Key Finding #1

Therapeutic cupping and instrument-assisted soft tissue mobilization can improve hamstring flexibility improving knee extension range of motion.

Key Finding #2

There is no significant difference between therapeutic cupping and instrument-assisted soft tissue mobilization in regard to how much range of motion is gained from each technique. Both improved range of motion.

Please provide your summary of the paper

33 subjects were involved in a study comparing the effects of instrument-assisted soft tissue mobilization (IASTM) and therapeutic cupping (TC) on range of motion and extensibility of the hamstrings. Every participant had both techniques done, one leg received on technique and the other leg received the other technique. The order and leg in which the techniques were done was randomized using a random number generator. The outcome measures used for assessing the extensibility of the hamstrings were pain on a 10 point scale during a bend and reach from a standing position down to the toes, a sit and reach in figure four seated position, hip flexion with a straight leg goniometric measurement, and temperature of the hamstrings. Each of these outcome measures were done before and after the intervention and were done in the same order both times to ensure consistency. The results depicted statistically significant improvement in range of motion in all assessments and a decrease in pain for the bend and reach for both interventions. TC showed an increase in temperature of the hamstrings hypothesized by the authors to indicate an increase in blood from to that area. Limitations that were noticed by the authors were that no other interventions or therapies were provided and the results were very short term with only one session provided. The authors mentioned other studies that show IASTM increased ROM more when compared to traditional stretching techniques.

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

This paper demonstrates the short term effectiveness of therapeutic cupping (TC) and instrument-assisted soft tissue mobilization (IASTM) on the flexibility of the hamstrings. The study did not look at long term effects however the test-retest model they used seemed to have an effect. These techniques could be beneficial for someone needing immediate or short term increases to their range of motion, however based on this study it is unclear the long term effects it would have. It could be beneficial to use these techniques in combination with other long duration stretching techniques to achieve plastic changes to the tissues being stretched.

Predictors of Outcome After Manipulation Under Anaesthesia in Patients With a Stiff Total Knee Arthroplasty

Author Names: L. Vanlommel, T. Luyckx, G. Vercruysse, J. Bellemans & H. Vandenneucker

Reviewer Name: Patrick Kunkel

Reviewer Affiliation(s): Duke DPT 2nd Year Student

Paper Abstract:

Purpose: Flexion in a stiff total knee arthroplasty (TKA) can be improved by manipulation under anaesthesia (MUA). Although this intervention usually results in an improvement in range of motion, the expected result is not always achieved. The purpose of this study is to determine which factors affect range of motion after manipulation in patients with a stiff total knee. Methods: After exclusion (n = 22), the data of 158 patients (138 knees) with a stiff knee after TKA who received a manipulation under anaesthesia between 2004 and 2014 were retrospectively analysed. Pre-, peri- and post-operative variables were identified and examined for their influence on flexion after the manipulation using Kruskal-Wallis and Mann-Whitney U tests and Spearman correlations. Results: After MUA, a mean improvement in flexion of 30.3° was observed at the final follow-up. Preoperative TKA flexion, design of TKA and interval between TKA procedure and MUA were positive associated with an increase in flexion after MUA. MUA performed 12 weeks or more after TKA procedure deteriorated the outcome. Conclusions: Three factors, pre-TKA flexion type of prosthesis and interval between TKA procedure and manipulation under anaesthesia, were found to have impact on flexion after TKA and MUA were identified. Results are expected to be inferior in patients with low flexion before TKA procedure or with a long interval (>12 weeks) between the TKA procedure and the manipulation under anaesthesia.

Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies

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

Yes

Was the study population clearly specified and defined?

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

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

Yes

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

Yes

Key Finding #1

An interval of more than 12 weeks was correlated with a significantly lower improvement in flexion after manipulation under anesthesia (MUA) compared to those manipulated early, implying that MUA should be performed as soon as possible after diagnosing stiffness after TKA.

Key Finding #2

Other factors, such as age, BMI, diagnosis and pre-op mechanical alignment that have been described as variables affecting flexion after TKA, did not have an influence on the results of manipulation under anesthesia.

Please provide your summary of the paper

This paper is a retrospective study on 138 patient with a stiff knee following a TKA who then received manipulation under anesthesia (MUA) from 2004 to 2014. The study analyzed 3 groups of factors that could potentially influence the outcome following MUA, pre-, peri-, and post-operative factors. Analyzing the group of variables on the influence of ROM, it was found that the length between TKA operation and receiving MUA correlated with the outcome of knee stiffness post TKA. Following MUA procedures, patients had a mean improvement of 30.3 degrees of flexion range observed at the final follow up. The degree of flexion before MUA was conversely correlated with the improvement in flexion at final follow-up. As such the preoperative TKA flexion level seems to be the highest achievable level of flexion to regain after MUA and indeed seems to be a realistic goal, as most patients reach this flexion degree, even after an initial slow post-operative rehabilitation and the need for a MUA. In this study, there was a significant decrease in flexion after MUA with prolonged intervals especially after 12 weeks. An interval of more than 12 weeks was correlated with a significantly lower improvement in flexion after MUA compared to those manipulated early, implying MUA should be performed prior to 12 weeks if knee stiffness is identified.

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

While reading this article, I felt this paper identified the importance for clinicians to identify knee stiffness in patients post-TKA as soon as possible. If clinicians can identify knee stiffness prior to 12 weeks and they can refer patients to receive MUA, they will have significantly improved outcomes in knee flexion ROM. Other perioperative variables regarding component positioning that were investigated in this study did not affect the results of MUA on flexion. Thus meaning that one of the important variables in final post-operative range of motion following MUA was the duration between receiving the TKA and MUA.

Clinical Hip Tests and a Functional Squat Test in Patients With Knee Osteoarthritis: Reliability, Prevalence of Positive Test Findings, and Short-Term Response to Hip Mobilization

Author Names

Cliborne, A., Wainner, R., Rhon, D., Judd, C., Fee, T., Matekel, R., Whitman, J.

Reviewer Name

Jessica Matsuoka, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Study Design: One group pretest-posttest exploratory design.

Objectives: Primary purposes of this study were to examine the short-term effect of hip mobilizations on pain and range of motion (ROM) measurements in patients with knee osteoarthritis (OA) and to determine the prevalence of painful hip and squat test findings in both patients with knee OA and asymptomatic subjects. The secondary purposes were to assess intrarater reliability and to determine whether fewer subjects experienced painful test findings following hip mobilization.

Background: Conservative intervention, including manual physical therapy applied to the lower extremity, has been shown to reduce impairments associated with knee OA.

Methods and Measures: One rater pair administered 4 clinical hip tests to 22 patients with knee OA (mean age, 61.2 years; SD, 6.1 years) and 17 subjects without lower extremity symptoms or known pathology (mean age, 64.0 years; SD, 7.9 years). Intrarater reliability was examined for each clinical test. Patients with knee OA and painful-hip and squat test findings received hip mobilizations. Pain and ROM responses for each test were dependent variables.

Results: Intraclass correlation coefficients for all tests were greater than 0.87. Composite and individual test pain scores and ROM scores improved significantly following hip mobilization. All clinical test findings were more frequent in the group with knee OA, except for those of the FABER test, and the number of subjects with painful test findings following hip mobilization was reduced for all tests except the hip flexion test.

Conclusions: Patients experienced increases in ROM, decreased pain, and fewer subjects had painful test findings immediately following a single session of hip mobilizations. Examination and intervention of the hip may be indicated in patients with knee OA. J Orthop Sports Phys Ther 2004;34:676-685.

Key Words: arthritis, lower extremity, manual therapy, provocation

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

Was the study question or objective clearly stated?

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

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

Yes

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

Yes

Key Finding #1: The interrater reliability for functional squat, hip scour, FABER, and hip flexion tests was excellent for ROM (ICC, >0.91) and good for assessing pain (ICC, >0.87).

Key Finding #2: FABER test is positive in many asymptomatic patients and may not be associated with knee OA.

Key Finding #3: Hip mobilization procedures had the largest mean reduction in pain following mobilization with the squat test (2.1 points) and the largest mean increase in ROM with hip flexion (8.2º).

Key Finding #4: The number of patients with painful findings following a single intervention session of hip mobilizations was decreased for all tests except the hip flexion tests. This may be because hip ROM also increased, which could have resulted in additional joint stress that prevented a decrease in pain response.

Please provide your summary of the paper

In this paper, the authors evaluated the short-term effects of hip mobilizations on pain and range of motion (ROM) measurements in patients with knee OA and aimed to determine the prevalence of painful hip and squat tests with knee OA and asymptomatic patients. The authors also aimed to assess interrater reliability and determine if participants exhibited less painful test findings following hip mobilizations. This study comprised a knee OA group (n=22; 11 male, 11 female) and an asymptomatic group (n=17; male 12, female 5). The participants in the knee OA group were enrolled based on the clinical criteria described by Altman et. al. (knee pain, >50, palpable bony enlargement, morning stiffness <30 minutes). Asymptomatic participants had to exhibit no knee pain or pain in any other lower extremity joints. 4 physical therapist students were responsible for data collection, 2 of which administered all test procedures. The more involved LE was tested in participants with knee OA and the dominant LE was assessed in asymptomatic participants. Pain levels (using numeric pain rating scale, NPRS) and ROM (using gravity inclinometer) were assessed for each testing procedure; functional squat, FAVER, hip flexion, and hip scour (only pain was assessed for this measure). All four tests were administered once in a random order and the examiner was blinded to goniometer and NPRS ratings, but not to the group in which they were testing. The examiner then repeated the 4 tests after a 2-minute rest period in the same order as the first round. Following this, participants with knee OA with ≥1 painful test finding were treated with one of the following hip mobilizations, at grade III or IV, based on test findings and location of the pain – caudal glide (CG), anterior-posterior (AP) glide, posterior-anterior (PA) glide, and PA glide with the hip in flexion, abduction, and external rotation (FAE). Overall, the authors found that hip mobilizations for patients with knee OA may be indicated due to improvements in pain and ROM measurements following this intervention and could be a beneficial component of intervention for patients with knee OA who have positive hip clinical tests.

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

Hip mobilizations in patients with positive hip clinical tests and knee OA may be a valid form of intervention to include in treatments to improve ROM measurements and NPRS (pain). Previous studies have found that manual therapy (including mobilizations), along with exercise, improves Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores (vs. placebo ultrasound intervention) over 8 weeks. This study is consistent with these findings and indicates that implementation of grade III and IV hip mobilizations can improve ROM and pain ratings in patients with knee OA. However, this study only looked at short-term findings immediately after mobilization, and due to the lack of a comparison group, no cause-and-effect relationship between hip mobilizations and pain and ROM can be made for sure. Future research should focus on evaluating this relationship in terms of cause-and-effect and developing a clinical prediction rule to determine which patients with knee OA respond best to hip mobilizations. This will allow this study’s findings to be implemented in the best, most effective way for patients.

Effects of Orthopaedic Manual Therapy in Knee Osteoarthritis: A Systematic Review and Meta-Analysis

Author Names

Anwer, S.; Alghadir, A.; Zafar, H.; Brismée, J.

Reviewer Name

Samantha Horan, SPT

Reviewer Affiliation(s)

Duke University Doctor of Physical Therapy

Paper Abstract

Objective: This systematic review aimed to evaluate the effects of orthopaedic manual therapy (OMT) on pain, improving function, and physical performance in patients with knee osteoarthritis (OA). Data sources: Four databases (PubMed, Web of Science, CENTRAL, and CINAHL) were searched. Study selection: Trials were required to compare OMT alone or OMT in combination with exercise therapy, with exercise therapy alone or control. Data extraction Data extraction and risk assessment were done by two independent reviewers. Outcome measures were visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score, WOMAC function score, WOMAC global score, and stairs ascending-descending time. Results: Eleven randomized controlled trials were included (494 subjects), four of which had a PEDro score of 6 or higher, indicating adequate quality. The results of the meta-analysis indicated that reduction of VAS score in OMT compared with the control group was statistically insignificant (SDM: −0.59; 95% CI: −1.54 to −0.36; P = 0.224). The reduction of VAS score in OMT compared with exercise therapy group was statistically significant (SDM: −0.78; 95% CI: −1.42 to −0.17; P = 0.013). The reduction of WOMAC pain score in OMT compared with the exercise therapy group was statistically significant (SDM: −0.79; 95% CI: −1.14 to −0.43; P = 0.001). Similarly, the reduction of WOMAC function score in OMT compared with the exercise therapy group was statistically significant (SDM: −0.85; 95% CI: −1.20 to −0.50; P = 0.001). However, the reduction of WOMAC global score in OMT compared with the exercise therapy group was statistically insignificant (SDM: −0.23; 95% CI: −0.54 to −0.09; P = 0.164). The reduction of stairs ascending-descending time in OMT compared with the exercise therapy group was statistically significant (SDM: −0.88; 95% CI: −1.48 to −0.29; P = 0.004). Conclusions: This review indicated OMT compared with exercise therapy alone provides short-term benefits in reducing pain, improving function, and physical performance in patients with knee OA.

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?

Yes

Was publication bias assessed?

Cannot Determine

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

Yes

Key Finding #1

More research can be done to find which combination of treatments (manual therapy, exercise therapy, electrotherapy, etc) can lead to the most long-term benefits for patients with knee osteoarthritis.

Key Finding #2

More research can be done on long-term effects/benefits of manual therapy on patients with knee osteoarthritis. These studies need to have a larger array of manual therapy techniques to find which have the most benefits.

Key Finding #3

Short-term benefits were found by using manual therapy techniques when it comes to improving pain levels, and function in patients with knee osteoarthritis.

Please provide your summary of the paper

This paper is a meta-analysis of 428 randomized controlled trials that looked at groups of adults over the age of 30 who have been diagnosed with knee OA to see if manual therapy alone or manual therapy in combination with exercise therapy lead to decreased pain and/or increased function as compared to a control group, an exercise therapy alone group, or an electrotherapy group. The results showed the reduction of VAS score with manual therapy as compared to the control group was statistically insignificant but was statistically significant when comparing manual therapy to exercise therapy. As well, there were statistically significant changes in WOMAC function score and WOMAC pain score with manual therapy when compared to the exercise therapy group. The WOMAC global score was insignificantly affected by manual therapy as compared to exercise therapy. There was statistically significant change in stair ascending-descending time with manual therapy as compared to the exercise therapy group. Most of the manual therapy techniques that these reviews included were joint mobilizations, mobilization supplementations, as well as some therapeutic massage. Overall, manual therapy is effective when it comes to decreasing overall pain scores and increasing functionality in these patients in the short-term. With that being said, the long-term effects are unknown, and more research needs to be done to find the best combination of treatments that will lead to the longest lasting benefits.

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 may be extremely helpful when it comes to deciding on a treatment plan for a patient with knee OA, especially when it comes to being able to provide short-term relief to patients. Oftentimes patients are hesitant to complete their exercises for therapy, but by introducing manual therapy for their OA, it may provide the patients the short-term relief that they may need to be willing to do their exercises and be more comfortable while they’re doing those. This study doesn’t necessarily lay out exactly what treatment will lead to the best results, but it shows the short-term benefits of manual therapy for pain and function which will be helpful in combination with exercise therapy as well for the patients. The addition of manual therapy may provide comfort for patients to be able to complete the remainder of their therapy.

Dynamic Soft Tissue Mobilization Versus Proprioceptive Neuromuscular Facilitation in Reducing Hamstring Muscle Tightness in Patients With Knee Osteoarthritis: A Randomized Control Trial

Nafees, K; Baig, A; Ali, S; Ishaque, F

Jessica Fullerton

Duke University, Doctor of Physical Therapy Program

Abstract:

Background: Knee osteoarthritis (KOA) considered as one of the most common degenerative diseases of synovial joint. KOA is mostly managed by physical therapy, focused on pain management, the range of motion and muscle strengthening but muscle flexibility is usually neglected. A study was conducted to evaluate the effectiveness of dynamic soft tissue mobilization (DSTM) in comparison with the proprioceptive neuromuscular facilitation (PNF) stretching in the management of hamstring tightness, reduction of pain intensity and improvement of physical functionality in KOA. Methods: Forty-eight patients with KOA were randomly allocated to group A receiving DTSM and group B receiving PNF stretching. The cryotherapy and isometric strengthening exercises were also given to both groups. Total treatment duration consisted of 4 weeks, 3 sessions per week and total 12 sessions per patient. Each treatment session comprised of 30 min. At baseline and post treatment, Active knee extension test (AKET), Visual analogue scale (VAS), and Knee Injury and Osteoarthritis Outcome Score (KOOS) were used to assess hamstring flexibility, pain intensity level and physical functional capability respectively. The continuous variables were shown as mean and standard deviations. For the comparison of outcome within and between groups, paired sample and independent t-test was applied. Considerable p value was less than 0.05. Results: The between group analysis of VAS, right AKE test, and left AKE test showed non-significant (p>0.05) mean difference as 0.2 (95% CI= -0.29, 0.70), 1.79 (95% CI= -1.84, 4.59), 1.78 (95% CI= -1.6, 5.19) respectively. KOOS domains of symptom, pain, ADLs, sports and recreational, and quality of life had also non-significant (p>0.05) mean difference as 1.12 (95% CI= -4.05, 6.3), -5.12 (95% CI= -12.71, 2.46), -2.55 (95% CI= -7.47, 2.38), -2.7 (95% CI= -9.72, 4.3), and −0.68 (95% CI= -7.69, 6.36) respectively. Significant (p<0.001) improvement was shown in both groups for all outcome measures after 12 sessions.

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?

Not reported

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

Not reported

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?

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: PNF and DSTM are equally effective in increasing hamstring flexibility, pain reduction and functional mobility in patients with knee OA.

Key Finding: The decrease in pain sensitivity with PNF may be attributed to autogenic inhibition of the tight hamstring muscle.

Key Finding: Muscular and ligamentous tightness should be addressed in physical therapy for patients with knee OA as knee OA significantly affects hamstring muscle tightness

Paper Summary:

This study looked to investigate if there is a difference between dynamic soft tissue mobilization and proprioceptive neuromuscular facilitation on hamstring flexibility in patients with knee OA. The results showed that both treatments were equally beneficial for hamstring flexibility, pain reduction and functional mobility in terms of AKET, VAS, and KOOS. With both groups receiving cryotherapy and isometric strengthening, I think there is some limitation in determining whether results could be attributed to PNF and DSTM. Despite this, the study refers to multiple other studies resulting in similar results which further make me believe these results are reliable, but other studies show that DSTM is more effective when compared to PNF. With the use of AKET, VAS, and KOOS, there was a proper amount and use of outcome measures to assess the effectiveness of these treatment methods. DSTM suggests reciprocal inhibition of leads to relaxation of the previously tight hamstring muscle due to increase blood circulation and decrease pain. The decrease in pain sensitivity with PNF may be attributed to autogenic inhibition of the tight hamstring muscle. Decreases in pain scores on the VAS scale for DSTM and PNF were greater than the minimally clinically relevant difference. Further research done on this topic can help determine whether there is a true difference between PNF and DSTM in effectiveness of treating patients with KOA but shows the clinical importance of incorporating treatments to decrease hamstring muscle tightness which is typically neglected when treating this population.

Clinical Interpretation:

This study shows the effectiveness of PNF and DSTM have on increasing hamstring flexibility, reducing pain and improving functional mobility in knee OA patients. This study suggests physical therapists often neglect muscular and ligamentous tightness when treating KOA patients despite knee OA’s effect on increasing hamstring tightness. This study offers insight and treatment options on treating hamstring tightness. Since this study incorporates multiple treatments, these can be applied to physical therapy treatments with patients. While pain levels vary from patient to patient, it might be beneficial to test whether PNF or DSTM works best for your patient while still including cryotherapy and isometric quadriceps and hip adductor strengthening. Since PNF and DSTM were equally effective in this study, the use of either of these treatments should prove effective for KOA patients with hamstring tightness. This study can impact clinical practice by maximizing treatment effect and decreasing KOA burden with the implementation of DSTM and/or PNF in physical therapy treatment sessions. This study also provides a base for further research to be conducted.

Effectiveness of Maitland and Mulligan Mobilization Methods for Adults With Knee Osteoarthritis: A Systematic Review and Meta-Analysis

Author’s Names

Li, L., Hu, X., Di, Y., Jiao, W.

Reviewer’s Names

Sarah Freeman SPT

Abstract

Abstract BACKGROUND As a serious global problem, knee osteoarthritis (KOA) often leads to pain and disability. Manual therapy is widely used as a kind of physical treatment for KOA. AIM To explore further the efficacy of Maitland and Mulligan mobilization methods for adults with KOA. METHODS We searched PubMed, the Cochrane Library, EMbase, Web of Science and Google Scholar from inception to September 20, 2020 to collect studies comparing Maitland and Mulligan mobilization methods in adults with KOA. The quality of the studies was assessed using the Physiotherapy Evidence Database Scale for randomized controlled trials. Data analyses were performed using Review Manager 5.0 software. RESULTS A total of 341 articles were screened from five electronic databases (PubMed, the Cochrane Library, EMbase, Web of Science and Google Scholar) after excluding duplicates. Ultimately, eight trials involving 471 subjects were included in present systematic review and meta-analysis. The mean PEDro scale score was 6.6. Mulligan mobilization was more effective in alleviating pain [standardized mean difference (SMD) = 0.60; 95% confidence interval (CI): 0.17 to 1.03, P = 0.007; I2 = 60%, P = 0.020) and improving Western Ontario and McMaster Universities function score (SMD = 7.41; 95%CI: 2.36 to 12.47, P = 0.004; I2 = 92%, P = 0.000). There was no difference in the effect of the two kinds of mobilization on improving the range of motion (SMD = 9.63; 95%CI: -1.23 to 20.48, P = 0.080; I2 = 97%, P = 0.000). CONCLUSION Mulligan mobilization technique is a promising intervention in alleviating pain and improving function score in KOA patients. Keywords: Mulligan mobilization, Maitland mobilization, Manipulation, Manual therapy, Knee osteoarthritis, Meta-analysis.

Key Point 1:

Based on the results from the meta analysis and systematic review, the Mulligan Mobilization technique was found to be a well supported, beneficial alternative to the maitland method for alleviating pain and improving WOMAC function scores, with the Mulligan method being associated with slightly better WOMAC scores compared to the Maitland method.

Key Point 2:

From the meta-analyses and systematic review, there was no overwhelming evidence to suggest that the Mulligan method or the Maitland method were superior in regards to increasing overall knee ROM. Although the Mulligan method was found to result in long term improvements in some of the reviewed studies, the subject participants did not undergo any exclusion criteria so the validity of the results are poor due to the participant’s having a wide range of pain complaints and orthopedic/ demographic backgrounds. 

Key Point 3:

The majority of reports that were reviewed in this analysis did not incorporate exclusion criterias or hone in on particular subject demographics and pain locations, so therefore, some of the results could be skewed due to confounding variables. 

Paper Summary:

The purpose of this article was to perform a thorough review and meta analysis of previous randomized control trial studies comparing the benefits of the Maitland and Mulligan mobilization methods in adults with knee osteoarthritis. Due to the high prevalence of knee osteoarthritis globally, the authors of this systematic review felt it imperative to dissect through the literature and determine if there was a clinically significant difference between the two manual therapy techniques in order to provide clinicians a more direct path for patient treatment sessions. Variables that were typically found in previous studies and used to compare the two methods included changes in ROM, alleviation of pain, and changes in the WOMAC outcome measure scores. While the Mulligan method was shown to be associated with slightly better WOMAC scores, there was no clinically significant difference between the two methods in terms of improving ROM, and both methods were shown to help alleviate pain associated with knee Osteoarthritis. The results from this review support the idea that the Mulligan method is an appropriate and beneficial alternative to the Maitland method in the treatment of adults with knee osteoarthritis, and that neither manual therapy approach is drastically superior to the other. The author’s of this article screened out duplicate studies and biased studies utilizing the PEDro scale, ultimately resulting in only 10 studies being included out of an original 341. This provided a limitation of a small sample size, making the results harder to generalize for the greater population.

Clinical Importance:

This article is clinically important as it is, as the author’s state in their conclusion, the first systematic review and meta analysis comparing these two manual therapy techniques and their impact on patients with knee osteoarthritis. This is important as this will help provide scientific evidence and support to clinicians aiming to treat patients with knee OA, and will allow them the opportunity to choose the mobilization methods they feel are right for them as they are both shown to be beneficial with neither one outweighing the other. The results from this review are also clinically significant because it reinforces the notion that there is no singular correct way to treat a patient’s condition or ailment, and that further research would need to be conducted to help support the choice to consistently perform one method over another. The limitations and discussions within this review also highlight the importance of needing further studies on this topic that limit confounding variables and have subjects with more demographic and pain similarities to allow for the results to be more conclusive and reliable.

Instrument Assisted Soft Tissue Mobilization (IASTM) Versus Stretching: A Comparison in Effectiveness on Hip Active Range of Motion, Muscle Torque and Power in People With Hamstring Tightness

Author Names: Ahmad Osailan , Abdulaziz Jamaan, Khalid Talha, Mshari Alhndi

Reviewer Name: Hannah Dougherty, SPT

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

Paper Abstract: Background: Instrument-assisted soft tissue mobilization (IASTM) is a new technique that has been known to be effective in reducing muscle tightness in athletics. However, little is known about its effect on the range of motion, muscle power, and torque compared to manual stretching among non-athletics. Thus, the study was aimed to compare the effectiveness between IASTM and manual stretching in improving hip flexion active range of motion (ROM), muscle torque and power on hamstring muscle complex (HMC) tightness in one session. Method: Twenty-three young male college students with unilateral hamstring tightness measured via straight leg raising (SLR) test (<65°) were randomly assigned to one of two groups. Twelve participants received the application of IASTM (group 1), and eleven received manual stretching (group 2). Hip flexion active ROM was measured via goniometer, the torque & power of the hamstring muscle were measured using Human isokinetic dynamometer, before and after both interventions. (ISRCTN17693345). Results: There was no significant difference in the improvement of hip flexion active ROM (69.6 ± 6.6 vs 72.5 ± 7.9, p = .34), HMC torque (63.7 ± 14.5 vs 53.2 ± 16.3, p = .14), and HMC power (47.8 ± 11.8 vs 40.9 ± 16.3, p = .34) between group 1 and group 2 respectively. When a comparison was made within each group, significant improvements in hip active flexion ROM was found in both groups (p’s < .001), and HMC power was significantly improved in group 1 (p = .04) but not in group 2. Conclusion: The current study findings demonstrate that IASTM was as effective as manual stretching in improving hip flexion active ROM, muscle torque and power among non-athletic people with HMC tightness. Keywords: Hamstring muscle complex; IASTM; Isokinetic testing; Muscle power; Stretching.

Quality Assessment of Controlled Intervention Studies

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

a. Yes (1)

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

a. Yes (1)

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

a. Yes (1)

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

a. Yes (1)

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

a. Cannot Determine / Unknown (3)

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

a. Yes (1)

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

a. Cannot Determine (3)

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

a. Cannot Determine (3)

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

a. Cannot Determine (3)

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

a. Yes (1)

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

a. Yes (1)

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?

a. No (2)

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

a. Yes (1)

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?

a. Yes (1)

Key Finding #1

The study showed no statistically significant difference when the outcome measures were compared against each other.

Key Finding #2

When comparisons were made within groups, both interventions significantly improved hip active ROM.

Key Finding #3

When comparisons were made within groups, HMC power was significantly improved in the IASTM group only. No improvements were made in torque.

Key Finding #4

The explanation for improved torque and power could be due to mechanical advantage of IASTM and the targeted breakdown of scar tissue and myofascial adhesions.

Please provide your summary of the paper

In the article by Osailan and colleagues, they explored the interrelatedness of instrument-assisted soft tissue mobilization (IASTM) and stretching on hip flexibility by assessing hip flexion range of motion as well as hamstring muscle torque and power. The paper outlines the importance of injury prevention and promotion of optimal alignment and normal forces to limit the onset of adverse complications due to hamstring muscle complex (HMC) tightness. Their study was directed to determine the immediate effects of IASTM compared to manual stretching techniques and its possible improvement of HMC tightness. The researchers hypothesized that IASTM will produce better results in terms of hip flexion active range of motion, HMC torque and muscle power when compared to just manual stretching. The study included 23 non-athlete male participants in college that presented with shortened hamstrings, and a straight leg raise test of <65 degrees with no history of prior hamstring injury. The participants were randomly assigned to two groups, one receiving IASTM and one receiving manual stretching. Hip flexion range of motion was measured in the supine position using the SLR test and a goniometer while torque and power were measured with a human isokinetic dynamometer. Participants in the IASTM received the treatment technique over the affected area for two minutes. Participants in the manual stretching group received treatment in the supine position for 30 seconds with a 30 second rest break. This continued for three minutes and was repeated three times per session. Overall, post-treatment objective results showed no significant difference in outcome measures between hip flexion ROM, HMC torque and power after intervention between both groups. When comparisons were made within groups, participants from both groups made significant improvements in hip ROM. Also, within groups, participants in the IATSM group only made significant improvements in HMC power compared to the manual stretching group. Finally, there was no significant improvement in HMC torque in either group when compared individually. Despite the inconsistencies, “both share the concept of improving muscles structural properties and surrounding fascia by releasing the tension with the muscle structures.”(Osailan et al., 2021). Each intervention has its positive benefits on hamstring tightness and flexibility as studied over a short period and would be worthwhile to study in a long-term trial. Both methods of reducing HMC tightness could be utilized to effectively reduce impairments and improve body structure alignment and overall function.

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 both methods are effective treatments for reducing hamstring muscle complex tightness. However, I do believe the mechanical advantages of IASTM may be more beneficial depending on the patient population. Compared to broad muscle stretching with a manual technique, IASTM can be more focused to one area or to an area that is more affected with targeted focus on palpable adhesions or scar tissue. I believe further evaluation of these techniques needs to be conducted within a more diverse population of active individuals, including both males and females.

Efficacy of Quadriceps Vastus Medialis Dry Needling in a Rehabilitation Protocol After Surgical Reconstruction of Complete Anterior Cruciate Ligament Rupture

Author Names

Velázquez-Saornil, J., Ruíz-Ruíz, B., Rodríguez-Sanz, D., Romero-Morales, C., López-López, D., & Calvo-Lobo, C.

Reviewer Name

Joyel Edgecombe, SPT

Reviewer Affiliation(s)

Doctor of Physical Therapy Program, Duke University

Paper Abstract

Background: Several new rehabilitation modalities have been proposed after anterior cruciate ligament (ACL) reconstruction. Among these, trigger point dry needling (TrP-DN) might be useful in the treatment of myofascial pain syndrome associated with ACL reconstruction to reduce pain intensity, increase knee flexion range and modify the mechanical properties of the quadriceps muscle during late-stage rehabilitation. To date, this is the first randomized clinical trial to support the use of TrP-DN in the early rehabilitation process after ACL reconstruction. The aim of this study was to determine the pain intensity, range of motion (ROM), stability, and functionality improvements by adding quadriceps vastus medialis TrP-DN to the rehabilitation protocol (Rh) provided to subacute ACL reconstructed patients. Methods: This randomized, single-blinded, clinical trial (NCT02699411) included 44 subacute patients with surgical reconstruction of complete ACL rupture. The patients were randomized into 2 intervention groups: Rh (n = 22) or Rh + TrP-DN (n = 22). Pain intensity, ROM, stability, and functionality were measured at baseline (A0) and immediately (A1), 24 hours (A2), 1 week (A3), and 5 weeks (A4) after the first treatment. Results: Comparing statistically significant differences (P ≤ .001; Eta = 0.198-0.360) between both groups, pain intensity (at A1), ROM (at A1, A2, and A3), and functionality (at A2, A3, and A4) were increased. Nevertheless, the rest of measurements did not show significant differences (P > .05). Conclusion: Quadriceps vastus medialis TrP-DN in conjunction with a rehabilitation protocol in subacute patients with surgical reconstruction of complete ACL rupture increases ROM (short-term) and functionality (short- to mid-term). Although there was an increase in pain intensity with the addition of TrP-DN, this was not detected beyond immediately after the first treatment. Furthermore, stability does not seem to be modified after TrP-DN.

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)?

Not specified

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

Not specified

Were study participants and providers blinded to treatment group assignment?

Not specified

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

Not specified

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

Not specified

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?

Not specified

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

Not specified

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

Not specified

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

Not specified

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?

Not specified

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

Not specified

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

Not specified

Key Finding #1

The authors found that supplementing the rehabilitation protocol of surgically reconstructed ACL rupture patients with quadriceps vastus medialis TrP-DN increases ROM (short-term) and functionality (short- and mid-term) and an immediate increase in pain intensity accompanies this.

Key Finding #2

Both intervention groups showed statistically significant differences (P < .001) with a large effect size (Eta2 coefficient from 0.962 to 0.980) between different measurement moments for VAS and WOMAC reductions, as well as ROM and SEBT increases. 

Key Finding #3

The Local Twitch Response (LTRs) number obtained during TrP-DN did not influence the outcome measurements.

Please provide your summary of the paper

The study aimed to evaluate the mid-term effects of incorporating trigger point dry needling (TrP-DN) of the quadriceps vastus medialis into a rehabilitation protocol following surgical reconstruction of a complete anterior cruciate ligament (ACL) rupture. The researchers conducted a single-blinded randomized controlled trial (RCT) involving 44 patients aged 18–55 years in the subacute phase of recovery from unilateral ACL reconstruction, confirmed by MRI.

Outcome measures included pain intensity (assessed using the Visual Analog Scale [VAS]), range of motion (ROM, measured with a universal goniometer), stability (evaluated using the Star Excursion Balance Test [SEBT]), and functionality (assessed with the Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]). Participants were randomly divided into two groups: one receiving the rehabilitation protocol plus TrP-DN (Rh + TrP-DN group; n = 22) and the other receiving the rehabilitation protocol alone (Rh group; n = 22).

Both groups demonstrated statistically significant improvements across different time points, with large effect sizes for reductions in VAS and WOMAC scores and increases in ROM and SEBT scores. The number of local twitch responses (LTRs) elicited during TrP-DN did not influence the outcomes.

The findings indicate that supplementing a standard rehabilitation protocol with TrP-DN for quadriceps vastus medialis enhances short-term ROM and both short- and mid-term functionality in patients recovering from ACL reconstruction. Although TrP-DN caused an immediate increase in pain intensity after the first session, this effect was transient and not observed in subsequent treatments. Importantly, stability did not appear to be significantly affected by the addition of TrP-DN.

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

The paper highlights that incorporating trigger point dry needling (TrP-DN) of the quadriceps vastus medialis into a rehabilitation protocol after surgical reconstruction of a complete anterior cruciate ligament (ACL) rupture can significantly improve short-term range of motion (ROM) and both short- and mid-term functionality. I believe this approach would be highly beneficial in clinical practice when combined with other modalities, ensuring appropriate interventions are in place to manage post-treatment pain associated with TrP-DN. While the authors acknowledge several limitations that warrant further investigation, this technique shows great promise for patients recovering from ACL reconstruction.

A Comparison of Two Manual Therapy Approaches and Electrotherapy Modalities for Patients With Knee Osteoarthritis: A Randomized Three-Arm Clinical Trial

Author Names
Kaya Mutlu, E., Ercin, E., Razak Ozdıncler, A., Ones, N.
Reviewer Name
Abby Frazier, SPT
Reviewer Affiliation(s)
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 benefit 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

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?
No
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)?
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?
No

Key Finding #1
Patients receiving the MWM or PJM intervention demonstrated a greater increase in functional score, greater increase in flexion and extension ROM, and greater increase in quadriceps muscle strength compared to those receiving the electrotherapy group at the 1-year follow-up.
Key Finding #2
Participants receiving MWMs or PJM demonstrated a greater decrease in pain at rest, during activity and at night compared to those receiving electrotherapy from baseline to after the treatment and the 1-year follow-up.
Key Finding #3
There were no significant differences between the MWM and PJM groups at the end of treatment and at the 1-year follow-up.

Please provide your summary of the paper
Osteoarthritis (OA) is the most common degenerative joint disorder, and the primary goals for treatment of this condition are to reduce pain and disability. This study aimed to assess the long term effects between two manual therapy techniques and electrotherapy on function, pain, ROM, and strength in individuals with bilateral knee OA. Participants were randomized into one of three groups, mobilization with movement (MWM), passive joint mobilization (PJM), or electrotherapy. Along with each of the three treatments, the groups participated in a standardized exercise program and home exercise program, which they were advised to continue for one year beyond the treatment period. The outcome measures assessed were the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Aggregated Locomotor Function test (ALF), pain using pressure pain threshold and visual analog scale, ROM, and muscle strength with a hand-held dynamometer. Each measure was assessed at baseline, after the treatment (12 sessions), and one year later. The study discovered that manual therapy, MWM or PJM interventions, resulted in higher scores on the WOMAC and ALF, an increase in flexion and extension ROM, and an increase in quadriceps muscle strength when compared to the electrotherapy group at the 1-year follow-up. Additionally, the MWM and PJM groups had a greater decrease in pain at rest, during activity, and at night when compared to the electrotherapy
group at the end of the intervention period and at the 1-year follow-up. Overall, implementation of manual therapy with exercise provided greater benefits than utilization of electrotherapy with exercise in individuals with knee OA. Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented. This study provides strong evidence of both the short- and long-term beneficial effects of manual therapy when compared to the use of electrotherapy in individuals with knee OA. It is important to note that these findings were a result of manual therapy in combination with exercise interventions, not manual therapy alone. So, when treating in the clinic, it would be essential to prescribe exercise as well as utilize manual therapy to see positive long-term results. Additionally, the results of this study highlight the lack of a need to perform electrotherapy modalities on patients with knee OA.
Based on these results, the primary thing clinicians must consider with patients with knee OA whether manual therapy is being implemented at all, not which type of manual therapy is used. Further research may be warranted to discover an ideal manual therapy technique for patients with knee OA; however, considering this study, it is most important to ensure the patient receives any type of manual therapy, along with exercise. Lastly, the study outlines an effective treatment plan for individuals with knee OA, including exercise with aerobic, active range of motion, strength and stretching components, manual therapy, and a consistent home exercise program, that clinicians can utilize and administer to this patient population

Manual Therapy With Cryotherapy Versus Kinesiotherapy With Cryotherapy for Knee Osteoarthritis: A Randomized Controlled Trial

Author Names: Pawel Lizis, PhD, DPT; Grzegorz Manko, PhD, DPT; Wojciech Kobza, PhD, BMed; Barbara Para, PhD, BMed

Reviewer Name: Haven Higgins

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

Paper Abstract Objective:

Context: Manual therapy and kinesiotherapy are used for knee osteoarthritis (OA). Yet, a clear evidence of the effects of manual therapy versus kinesiotherapy on knee OA is limited. The addition of cryotherapy to manual therapy or to kinesiotherapy may enhance the health benefits in patients with knee OA.

Objective: The study intended to evaluate the efficacy of manual therapy combined with cryotherapy versus kinesiotherapy combined with cryotherapy for patients with knee OA.

Design: The research team designed a randomized, controlled trial.

Setting: The study occurred in the Physiotherapy Outpatient Department of the Regional Hospital (Sandomierz, Poland).

Participants: The participants were 128 females and males with knee OA, aged 40 to 80 y, who were patients in the department at the hospital.

Intervention: The participants were randomly assigned to an intervention group that received manual therapy combined with cryotherapy, the MT-C group (n = 64), or to a control group, which received kinesiotherapy combined with cryotherapy, the KIN-C group (n = 64). The participants in both groups received 10 treatments, 2 per wk for 5 wk.

Outcome Measures: The primary outcome was measured using a visual analog scale pain ratings. The secondary outcome measured the quality of life using the Western Ontario and McMaster Universities questionnaire, knee extension, and flexion range of motion using the goniometer, and functional capacity using the 6-min walk test.

Results: After the treatments, the intervention group had significantly lower scores than the control group for pain, as well as significantly higher scores for quality of life, range of motion of the affected knee, and functional capacity.

Conclusion: The patients achieved better health benefits from manual therapy when it was combined with cryotherapy. (Altern Ther Health Med. 2019;25(4):40-45).

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?

Not reported

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

Not reported

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

The manual therapy group had significantly lower scores than the kinesiotherapy group for pain severity on the VAS.

Key Finding #2

The manual therapy group had significantly better scores than the kinesiotherapy group on the WOMAC.

Key Finding #3

Knee ROM in flexion and extension improved significantly more in the manual therapy group than the kinesiotherapy group.

Key Finding #4

The manual therapy group had significantly better scores than the kinesiotherapy group for functional capacity on the 6-MWT.

Please provide your summary of the paper

This randomized controlled trial compared the effects of manual therapy combined with cryotherapy (MT-C) to kinesiotherapy combined with cryotherapy (KIN-C) on patients with knee osteoarthritis. The manual therapy intervention consisted of tibiofemoral distraction, anterior tibial glide, posterior tibial glide, medial and lateral tibia rotation mobilization, and patellofemoral glides. The kinesiotherapy intervention included a warm up, stretching, strengthening, functional task-oriented training, and endurance exercise. The MT-C and KIN-C received the same cryotherapy before each session. Both groups attended 2 sessions per week over 5 weeks. Outcome measures including pain, quality of life, knee flexion and extension ROM, and functional capacity were measured pre intervention and 7 days post intervention. The MT-C group had significantly decreased pain and significantly increased QOL, knee ROM, and functional capacity when compared to the KIN-C group. This study suggests that manual therapy may be a better option than kinesiotherapy when combined with cryotherapy to treat patients with knee osteoarthritis.

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 with cryotherapy is beneficial for patients with knee OA as it reduces pain, and increases QOL, knee ROM, and functional capacity. It also may be a preferable treatment to kinesiotherapy for patients with knee OA. However, this study only looked at effects in the short term, so it cannot be said with certainty that manual therapy with cryotherapy is more beneficial than kinesiotherapy with cryotherapy in the long term. Further research should look at the use of both manual and kinesiotherapy with cryotherapy and compare it to only manual therapy with cryotherapy.

Joint Mobilization Enhances Mechanisms of Conditioned Pain Modulation in Individuals With Osteoarthritis of the Knee

Author Names
Courtney, Carol et al.
Reviewer Name
Jacob Lane, PT, DPT
Reviewer Affiliation(s)
Duke University Hybrid Orthopedic Residency Program

Paper Abstract
Abstract Study Design An experimental laboratory study with a repeated-measures crossover design.
Background Treatment effects of joint mobilization may occur in part by decreasing excitability of central nociceptive pathways. Impaired conditioned pain modulation (CPM) has been found experimentally in persons with knee and hip osteoarthritis, indicating impaired inhibition of central nociceptive pathways. We hypothesized increased effectiveness of CPM following application of joint mobilization, determined via measures of deep tissue hyperalgesia.
Objective To examine the effect of joint mobilization on impaired CPM.
Methods An examination of 40 individuals with moderate/severe knee osteoarthritis identified 29 (73%) with impaired CPM. The subjects were randomized to receive 6 minutes of knee joint mobilization (intervention) or manual cutaneous input only, 1 week apart. Deep tissue hyperalgesia was examined via pressure pain thresholds bilaterally at the knee medial joint line and the hand at baseline, postintervention, and post-CPM testing. Further, vibration perception threshold was measured at the medial knee epicondyle at baseline and post-CPM testing.
Results Joint mobilization, but not cutaneous input intervention, resulted in a global increase in pressure pain threshold, indicated by diminished hyperalgesic responses to pressure stimulus. Further, CPM was significantly enhanced following joint mobilization. Diminished baseline vibration perception threshold acuity was enhanced following joint mobilization at the knee that received intervention, but not at the contralateral knee. Resting pain was also significantly lower following the joint intervention.
Conclusion Conditioned pain modulation was enhanced following joint mobilization, demonstrated by a global decrease in deep tissue pressure sensitivity. Joint mobilization may act via enhancement of descending pain mechanisms in patients with painful knee osteoarthritis. J Orthop Sports Phys Ther 2016;46(3):168–176. Epub 1 Jan 2016. doi:10.2519/jospt.2016.6259

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)?
○ Cannot Determine, Not Reported, or Not Applicable
● 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)?
○ No
● Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
○ Cannot Determine, Not Reported, or Not Applicable
● Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
○ Cannot Determine, Not Reported, or Not Applicable
● Was there high adherence to the intervention protocols for each treatment group?
○ 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?
○ Cannot Determine, Not Reported, or Not Applicable
● Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
○ Cannot Determine, Not Reported, or Not Applicable
● Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
○ Cannot Determine, Not Reported, or Not Applicable

Key Finding #1
In individuals with chronic knee OA, a joint mobilization intervention resulted in a global decrease in pain sensitivity and improvement of impaired descending pain inhibition, indicating that joint mobilization may aid in facilitating central inhibitory mechanisms.
Key Finding #2
Diminished baseline vibratory perception threshold was enhanced following joint mobilization at the knee that received interventions indicating
hypoesthesia to vibratory stimulus

Please provide your summary of the paper
The study “Joint Mobilization Enhances Mechanisms of Conditioned Pain Modulation in Individuals With Osteoarthritis of the Knee” investigates the
effects of knee joint mobilization on pain modulation in individuals with knee osteoarthritis. Researchers aimed to assess whether joint mobilization could enhance Conditioned Pain Modulation (CPM), a mechanism that helps the body regulate pain. Participants were randomly assigned to receive either joint mobilization or a control intervention which consisted of hands on cutaneous input during the first session and were provided the second input during the second session. The second session was performed one week following the first session. Patients’ pressure pain thresholds, vibration perception, and resting pain levels were measured before and after treatment. Findings revealed that joint mobilization significantly improved CPM, indicating a more effective pain-inhibitory response. Additionally, participants who received mobilization experienced increased pressure pain thresholds, reduced resting pain, and improved sensory function compared to the control group. These results suggest that joint mobilization may be a valuable intervention for managing pain sensitivity and enhancing the body’s natural pain regulation mechanisms in individuals with knee osteoarthritis.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Despite demonstrating that joint mobilizations significantly enhance Conditioned Pain Modulation (CPM), pressure pain thresholds, and resting pain, this study lacks key methodological details necessary for a comprehensive NIH risk of bias assessment, making it difficult to fully evaluate its validity and reliability. Important aspects such as randomization procedures, allocation concealment, blinding, and dropout rates were not clearly reported, raising concerns about potential biases that could influence the study’s findings. Without a more transparent methodology, the strength of the evidence supporting joint mobilization as an effective intervention for knee osteoarthritis remains uncertain. Additionally, the study only compared manual therapy to cutaneous input, without assessing how manual therapy might interact with exercise interventions, which are commonly used in clinical practice for managing knee osteoarthritis. The integration of manual therapy with targeted exercise programs could provide greater functional benefits and long-term symptom relief, making it an important area for future research. Despite these limitations, the study’s findings highlight the potential of joint mobilization as a non-invasive treatment option for pain management in knee osteoarthritis. Other high-quality, well-controlled studies are needed to explore its effectiveness in combination with other therapeutic approaches. With additional supporting evidence to bolster the results of this study, joint mobilization highlighted in this study could become a valuable, evidence-based intervention for improving pain modulation and function in individuals with knee OA.

What Really Happens When We Use Manual Therapy? A Fresh Look at the Mechanisms Behind Hands-On Approaches
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