Author Names
Romeo A, Parazza S, Boschi M, Nava T, Vanti C.
Reviewer Name
Kate Neville, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
This systematic review aimed at investigating the role of therapeutic exercise and/or manual therapy in the treatment of hip osteoarthritis (OA). Two independent reviewers (AR, CV) searched PubMed, Cinahl, Cochrane Library, PEDro and Scopus databases and a third one (SP) was consulted in case of disagreement. The research criteria were publication period (from May 2007 to April 2012) and publication language (English or Italian). Ten randomized controlled trials matched inclusion criteria, eight of which concerning therapeutic exercise and two manual therapy. Few good quality studies were found. At mid- and long-term follow-up land-based exercises showed insufficient evidence of effectiveness with respect to pain and quality of life, but positive results were found for physical function. Water exercises significantly reduced fall risk when combined with functional exercises. Programs containing progressive and gradual exposure of difficult activities, education and exercises promoted better outcomes, higher adherence to home program and increased amount of physical activity, especially walking. Manual therapy seemed to reduce pain and decrease disability at short-term. Less use of nonsteroidal anti-inflammatory drugs was statistically significant at long-term follow-up in patients treated with manual therapy. The relationship between clinical results and radiological grade of OA was not investigated. Encouraging results were found in recent literature for manual therapy and functional training. Further research is needed to elucidate this issue through high-quality trials, especially addressing the aspects that have not been thoroughly explored yet, for instance type, amount and scheduling of conservative treatment.
NIH Risk of Bias Tool
Quality Assessment of Systematic Reviews and Meta-Analyses
- Is the review based on a focused question that is adequately formulated and described?
- Yes
- Were eligibility criteria for included and excluded studies predefined and specified?
- Yes
- Did the literature search strategy use a comprehensive, systematic approach?
- Yes
- Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
- Yes
- Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
- Yes
- Were the included studies listed along with important characteristics and results of each study?
- Yes
- Was publication bias assessed?
- Yes
- Was heterogeneity assessed? (This question applies only to meta-analyses.)
- Yes
Key Finding #1
Manual therapy in conjunction with therapeutic exercise is supported as a key intervention for the management of osteoarthritis.
Key Finding #2
Patient adherence and daily physical activity are crucial to the success of the use of manual therapy and exercise as an intervention.
Key Finding #3
Exercise as an intervention decreased the use of NSAIDs and improved physical function, which decreases overall costs of healthcare for patients.
Key Finding #4
Joint mobilizations of specific dosages had short-term pain reduction and disability improvement, where unspecified dosages did not.
Please provide your summary of the paper
In this study, they utilized randomized control studies that included therapeutic exercise and/or manual therapy in patients with a diagnosis of Osteoarthritis. Studies that were included utilized outcome measures such as, pain intensity, function level, aerobic capacity, progression of disease, quality of life, pharmaceutical use, and cost. Using the PEDro Scale, studies had to score 7 out of 10 or higher to be included. Osteoarthritis (OA) is an extremely common condition that’s prevalence increases with age. Typically, oral non-steroidal anti-inflammatory agents are prescribed to manage OA symptoms, however, it is advised that patients enroll in an exercise regimen with manual therapy. Even with this information, patients are only prescribed manual therapy and therapeutic exercise 28% of the time. In this study they found that with known dosages of 800 N intensity of longitudinal traction joint mobilizations, that patient’s showed short-term reduction of pain and decreased disability. This could be consistent with the theory of a minimum joint distraction force of 400-600 N being necessary to create joint diastasis. This leads to the theory that manual therapy can reduce pain even without the help of exercise. Another study compared manual therapy to the whole kinetic chain of the lower extremity with exercise, with manual therapy of only the hip with exercise and found no significant difference between the group. There were multiple studies that included information on manual therapy that supported their utility and now makes it a cornerstone to rehabilitation of OA in the lower limb. Manual therapy is shown to reduce pain and increase function to in turn improve quality of life. These interventions are shown to also improve strength, range of motion, proprioception, balance, and heart health. By completing these interventions you are receiving benefits to the cardiovascular system, psychological conditions, and weight management. The findings of this study were limited in the connection of manual therapy and exercise to pain, moderate in connection to improvement of function, and booster sessions increased patient adherence to treatment. A limitation of this study was that only 6 of the randomized control trials had a sample size larger than 50 participants, which makes the other studies not considered statistically significant. Throughout this study, adherence to the exercise regimen with daily physical activity was the largest predictive factor of improved long-term outcomes. It is suggested in this study, that this topic be further examined with larger sample sizes in order to have good quality data to examine their limitations.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
In this study aspects of exercise were examined combined with manual therapy to see the benefits on patients with hip osteoarthritis. The overall consensus was that both manual therapy independently, and combined with exercise is beneficial for short-term symptom alleviation. However, it was noted that the combination of the two is the recommended form of intervention for this condition. This study will impact clinical practice due to its ability to prove there are benefits to manual therapy and that patients feel a decrease in symptoms. This will encourage clinicians to provide forms of manual therapy as interventions for osteoarthritis of the hip more widely in practice. With all of this said, there were a number of limitations to this study, implying more research needs to be done, especially to be able to apply manual therapy to other joints in the body.
