Manual or exercise therapy for long-standing adductor-related groin pain: A randomised controlled clinical trial – Duke Center of Excellence in Manual and Manipulative Therapy

Author Names

Weir, A.; Jansen, J.A.C.G.; van de Prot, I.G.L.; Van de Sande, H.B.A., Tol, J.L.; Backx, F.J.G.

Reviewer Name

Abigail Reichow, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Hypothesis: A multi-modal treatment program (MMT) is more effective than exercise therapy (ET) for the treatment of long-standing adductor-related groin pain. Study design: Single blinded, prospective, randomized controlled trial. Methods: Patients: Athletes with pain at the proximal insertion of the adductor muscles on palpation and resisted adduction for at least two months. Interventions: ET: a home-based ET and a structured return to running program with instruction on three occasions from a sports physical therapist. MMT: Heat, Van den Akker manual therapy followed by stretching and a return to running program. Primary outcome: time to return to full sports participation. Secondary outcome measures: objective outcome score and the visual analogue pain score during sports activities. Outcome was assessed at 0, 6, 16 and 24 weeks. Results: Athletes who received MMT returned to sports quicker (12.8 weeks, SD 6.0) than athletes in the ET group (17.3 weeks, SD 4.4. p 1⁄4 0.043). Only 50e55% of athletes in both groups made a full return to sports. There was no difference between the groups in objective outcome (p 1⁄4 0.72) or VAS during sports (p 1⁄4 0.12). Conclusions: The multi-modal program resulted in a significantly quicker return to sports than ET plus return to running but neither treatment was very effective.

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)?

Cannot Determine, Not Reported, or Not Applicable

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

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

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

Cannot Determine, Not Reported, or Not Applicable

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

Cannot Determine, Not Reported, or Not Applicable

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

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

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

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

Key Finding #1

Athletes receiving manual therapy interventions for adductor-related groin pain demonstrated quicker return to sport on average (12.8 weeks) when compared to athletes receiving exercise therapy (17.3 weeks).

Key Finding #2

There was no statistically significant difference in objective treatment outcome rating between the athletes who received manual therapy and the athletes who received exercise therapy interventions.

Key Finding #3

Both groups (manual therapy and exercise therapy) had significant improvements in pain score at 16 weeks from baseline. There was no significant difference in pain score between groups.

Key Finding #4

There was no significant difference in hip range of motion when compared to baseline following both treatments (manual therapy or exercise therapy) or between groups.

Please provide your summary of the paper

This study was a randomized controlled clinical trial that included two intervention groups: exercise therapy (ET) and mixed-modal treatment (MMT). ET has the highest level of evidence for the treatment of groin pain from previous studies. Athletes in the ET group received training on a home exercise program (HEP) which they performed three times a week for two weeks. At two weeks they returned to physical therapy to receive a progression of their HEP, and at six weeks they received a return to running program. Athletes in the MMT group received heat therapy, followed by Van Den Akker manual therapy, and stretching for two weeks. If no pain was experienced after the two weeks, these athletes then progressed to the return to running program. Both groups were assessed by a blinded physician at baseline and at 6 and 16 weeks following treatment. Time to return to sport, objective outcome rating, pain score using visual analog scale (VAS), and hip range of motion were assessed and used to determine outcomes of both intervention groups. The study found that athletes in the MMT group demonstrated quicker return to sport on average (12.8 weeks) when compared to athletes receiving ET (17.3 weeks). There was no statistically significant difference in objective treatment outcome ratings between the athletes who received MMT and the athletes who received ET. Additionally, both groups had significant improvements in pain score at 16 weeks from baseline yet there was no significant difference in pain score between groups. Finally, there was no significant difference in hip range of motion when compared to baseline following both treatments or between groups.

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

Adductor-related groin pain is a common complaint in athletes involving cutting, sprinting, and twisting motions such as soccer, football, and rugby to name a few. While many athletes recover quickly, chronic incidences of groin pain can cause significant delays in return to sport. This study aimed to determine the efficacy of both ET and MMT for the treatment of adductor-related groin pain in athletes. The results of this study show that both ET and MMT are effective treatments for groin pain in this population. Both groups showed significant reductions in pain score as well as overall return to sport and therefore, can be employed as treatments in this population. MMT did show quicker return to sport on average when compared to ET and therefore, could be used as the preferred treatment if time to return to sport is a major factor in the athlete’s treatment plan. However, athletes in the MMT group began the return to running program quicker than the ET group, which may account for the finding of earlier return to sport. Standardization of the transition to the return to running program between ET and MMT may provide more insight that will assist in better comparing return to sport in both groups. Further research should be done to include a control group as well as a group that receives both ET and MMT to determine the best course of treatment for these athletes.