Author Names
Abbott, J. H., Robertson, M. C., Chapple, C., Pinto, D., Wright, A. A., Leon de la Barra, S., Baxter, G. D., Theis, J. C., Campbell, A. J
Reviewer Name
Abbrianna Robert
Reviewer Affiliations
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Objective: To evaluate the clinical effectiveness of manual physiotherapy and/or exercise physiotherapy in addition to usual care for patients with osteoarthritis (OA) of the hip or knee. Design: In this 2 2 factorial randomized controlled trial, 206 adults (mean age 66 years) who met the American College of Rheumatology criteria for hip or knee OA were randomly allocated to receive manual physiotherapy (n 1⁄4 54), multi-modal exercise physiotherapy (n 1⁄4 51), combined exercise and manual physiotherapy (n 1⁄4 50), or no trial physiotherapy (n 1⁄4 51). The primary outcome was change in the Western Ontario and McMaster osteoarthritis index (WOMAC) after 1 year. Secondary outcomes included physical performance tests. Outcome assessors were blinded to group allocation. Results: Of 206 participants recruited, 193 (93.2%) were retained at follow-up. Mean (SD) baseline WOMAC score was 100.8 (53.8) on a scale of 0e240. Intention to treat analysis showed adjusted re- ductions in WOMAC scores at 1 year compared with the usual care group of 28.5 (95% confidence interval (CI) 9.2e47.8) for usual care plus manual therapy, 16.4 (3.2 to 35.9) for usual care plus exercise therapy, and 14.5 (5.2 to 34.1) for usual care plus combined exercise therapy and manual therapy. There was an antagonistic interaction between exercise therapy and manual therapy (P 1⁄4 0.027). Physical performance test outcomes favoured the exercise therapy group. Conclusions: Manual physiotherapy provided benefits over usual care, that were sustained to 1 year. Exercise physiotherapy also provided physical performance benefits over usual care. There was no added benefit from a combination of the two therapies. Trial registration number: Australian New Zealand Clinical Trials Registry ACTRN12608000130369.
NIH Risk of Bias Score: 14/14
Key Findings of the Study:
- Usual care plus manual therapy showed clinically significant improvements in the self-reported primary outcome, the Western Ontario and McMaster osteoarthritis index (WOMAC).
- Usual care plus exercise therapy showed clinically significant improvements in all three physical performance measures (timed-up and go, 30-second sit to stand, and 40-meter self-paced walk test).
- Usual care plus a combination of manual and exercise therapy was found to be generally less effective or no more effective than each intervention alone.
Reviewer Summary:
This study found that usual care in addition to manual therapy for individuals with hip and knee OA provided self-reported improvements on the WOMAC at 1-year post intervention, and usual care in addition to exercise therapy provided improvements in physical performance measures. Manual therapy and exercise therapy in addition to usual care was less effective or no more effective than usual care alone. This particular finding may be the result of insufficient time spent on each intervention when they were both performed in session. The authors suggest that therapists spend adequate time on each intervention if used together. Interestingly, the results include participants that received joint replacements prior to the 1-year assessment. Therefore, it is suggested that the subgroup analysis excluding these participants is likely to be a more accurate representation of the intervention effects.
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 showed that manual therapy can improve self-reported outcomes, for individuals with hip and knee osteoarthritis (OA), in domains including pain, quality of life, and general health. These results can be used to encourage the use of manual therapy and conservative care for individuals with OA, to improve function and postpone surgical intervention.
