Author Names

Hoeksma, HL, Dekker, J, Ronday, HK, Breedveld, FC and Van den Ende, CHM

Reviewer Name

Sara Zilvetti LAT, ATC, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

 

Paper Abstract

Objective. To investigate whether manual therapy has particular benefit in subgroups of patients defined on the basis of hip function, range of joint motion, pain and radiological deterioration. Methods. The study was performed in the out-patient clinic of physical therapy of a large hospital. Data on 109 patients with OA of the hip (clinical ACR criteria) participating in a randomized clinical trial on the effects of manual therapy were used. The outcomes for hip function (Harris hip score), range of joint motion (ROM) and pain (VAS) were compared for specific subgroups. Subgroups were assigned by the median split method. The interaction effect between subgroup and treatment was tested using multiple regression analysis. Results. No differences were observed in the effect of manual therapy in specific subgroups of patients defined on the basis of baseline levels of hip function, pain and ROM. On the basis of radiological grading of osteoarthritis (OA), we found that patients with severe radiological grading of OA had significantly worse outcome on ROM as a result of manual therapy than patients with mild or moderate radiological grading of OA. Conclusion. A significant interaction effect was found for only 1 out of 12 hypotheses investigated. Therefore, we conclude that there is no evidence for the particular benefit of manual therapy in subgroups of patients.

 

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
  1. Was the method of randomization adequate (i.e., use of randomly generated assignment)?
  • Cannot Determine
  1. Was the treatment allocation concealed (so that assignments could not be predicted)?
  • No
  1. Were study participants and providers blinded to treatment group assignment?
  • No?
  1. Were the people assessing the outcomes blinded to the participants’ group assignments?
  • Cannot Determine
  1. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
  • No
  1. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
  • Yes
  1. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
  • Cannot Determine
  1. Was there high adherence to the intervention protocols for each treatment group?
  • Cannot Determine
  1. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
  • Cannot Determine
  1. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
  • Yes
  1. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
  • No
  1. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
  • Yes
  1. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
  • Yes

 

Key Finding #1

There were no relevant differences between the studied groups in the prognostic variables age, sex, duration of complaints, radiological deterioration, hip function, pain and ROM.

Key Finding #2

In comparison with exercise therapy, patients with severe radiological deterioration who were treated with manual therapy had a significantly lower outcomes with respect to ROM than patients with mild or moderate radiological deterioration.

Key Finding #3

The evidence did not show that manual therapy has particular benefit in specific subgroups of patients as only one our of 12 interactions was shown to be significant.

Key Finding #4

While manual therapy does not have benefit for specific subgroups, in general manual therapy should be the first treatment of choice for all patients compared with exercise therapy.

 

Please provide your summary of the paper

While there is previous research supporting the use of manual therapy in the treatment of hip osteoarthritis (OA), this study explored if certain clinical presentations of OA would have benefits of manual therapy. These subgroups were hip function, hip range of motion, pain, and radiological deterioration. Each subgroup had two groups of patients being assessed, a manual therapy group, which included stretching of the surrounding hip musculature and manipulations of the hip, and an exercise group with the exercise program tailored to each patient. Upon review of the data, there was no significant findings supporting the use of manual therapy for these subgroups. However, the patients that received manual therapy had better results than those that completed an exercise program which indicates that manual therapy is a good modality to include while treating patients with hip 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 has some limitations regarding the patients who were selected. They did not account for patient demographics, age, or comorbidities which can all impact the study outcomes. Furthermore, each exercise program was stated to be “tailored to each patient” which decreases the standardization of the study. Specific explanations of how the exercise programs were modified were not given which makes the study hard to replicate Even with these limitations, the study supported previous literature which shows manual therapy can be an effective technique to include in the treatment of patients with hip OA.