Author Names
Runge N, Aina A, May S.
Reviewer Name
Jaimie Legault, SPT
Reviewer Affiliation(s)
Duke University School of Medicine- Doctor of Physical Therapy Division
Paper Abstract
OBJECTIVE: To evaluate if there was an additional benefit of combining manual therapy (MT) and exercise therapy over exercise therapy alone on pain and function in patients with hip or knee osteoarthritis. DESIGN: Intervention systematic review LITERATURE SEARCH: We (1) searched 4 databases from inception to June 20, 2021; (2) hand searched a reference list of included trials and relevant systematic reviews; and (3) contacted 2 researchers in the field. STUDY SELECTION CRITERIA: We included randomized controlled trials that compared MT and exercise therapy to similar exercise therapy programs alone in patients with hip or knee osteoarthritis. DATA SYNTHESIS: The data were combined using random-effects meta-analyses where appropriate. The certainty of evidence for each outcome was judged using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. RESULTS: We included 19 trials. There was very low to moderate certainty of evidence that MT added benefit in the short term for pain, and combined pain, function, and stiffness (WOMAC global scale), but not for performance-based function and self-reported function. In the medium term, there was low- to very-low-certainty evidence that MT added benefit for performance-based function and WOMAC global score, but not for pain. There was high-certainty evidence that MT provided no added benefit in the long term for pain and function. CONCLUSION: There was very low to moderate certainty of evidence supporting MT as an adjunct to exercise therapy for pain and WOMAC global scale, but not function in patients with knee or hip osteoarthritis in the short term. There was high certainty of evidence of no benefit for additional MT over exercise therapy alone in the long term.
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
The benefit of manual therapy with exercise for short- and medium-term OA pain was found to have very-low to low evidence, respectively. Additionally, there is high certainty that there’s no benefit of manual therapy with exercise when compared to exercise alone for long term pain.
Key Finding #2
When analyzing self-reported function, low to very-low certainty evidence was found to support no benefit in the short to medium term, respectively. These results were determined by comparing exercise alone to exercise with manual therapy in both hip and knee OA populations. There were no articles included that studied self-reported function in the long term.
Key Finding #3
Performance based function was studied utilizing the timed up and go (TUG) outcome measure. At a short term follow up, moderate certainty evidence was found that manual therapy with exercise showed no benefit when compared to exercise alone. At medium-term follow up, very-low certainty evidence discovered additional benefit. It’s important to note that this was concluded based on only one trial within the systematic review and meta-analysis. At long-term follow up, high certainty evidence from 3 trials revealed no additional benefit of manual therapy to exercise.
Key Finding #4
Mixed findings were discovered when analyzing results of the WOMAC global scale among various studies. Including additional benefit with moderate certainty evidence at short-term and very-low certainty evidence at medium-term. But at long term, there was high-certainty evidence of no long-term benefit. The article notes that they were unable to determine if this finding was clinically significant.
Please provide your summary of the paper
This systematic review with meta-analysis studies the use of manual therapy in conjunction with exercise therapy in patients with diagnosed hip or knee osteoarthritis. The manual techniques are defined as joint mobilizations, manipulations, soft tissue techniques, and stretches. The focus of this study was to analyze the benefits of manual techniques and exercise therapy versus exercise alone. Additionally, the benefits of each primary outcome were analyzed at short, medium, and long-term periods of time. The previously mentioned time frames were defined as follows: short-term being up to 4 weeks, medium-term being 4 weeks to 6 months, and long-term being greater than 6 months. The overall conclusion of this article was that there is minimal evidence to support additional benefit of manual therapy for individuals with hip or knee OA. This conclusion was determined based on analysis of pain, self-reported function, performance-based function, and WOMAC global scale. Limitations included variable dosage and type of manual intervention among the studies included. While statistical analysis was able to conclude very little to no significant benefit of manual therapy within this population, it’s difficult to determine if type, frequency, and dosage of manual therapy intervention would play a role in altering the results of the study. Additionally, there were only two studies included that solely studied manual techniques and hip OA. So it is difficult to differentiate hip versus knee benefits within this article alone.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
From this, we can conclude that there is very little to no statistical findings supporting the use of manual therapy in conjunction with exercise for patients with hip or knee OA. The results of this study would allow clinicians to focus on other modalities with stronger supporting evidence when treating this population. Ultimately, this would increase the clinicians time efficiency and increase the patient’s likelihood to progress.
