Abbott JH, Robertson MC, Chapple C, et al. Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee: a randomized controlled trial. 1: clinical effectiveness

Centre for Musculoskeletal Outcomes Research, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand. Electronic address: .
Osteoarthritis and Cartilage (Impact Factor: 4.66). 01/2013; 21(4). DOI: 10.1016/j.joca.2012.12.014
Source: PubMed

ABSTRACT OBJECTIVE: To evaluate the clinical effectiveness of manual physiotherapy and/or exercise physiotherapy in addition to usual care for patients with osteoarthritis of the hip or knee. DESIGN: In this 2 x 2 factorial randomized controlled trial, 206 adults (mean age 66 years) who met the American College of Rheumatology criteria for hip or knee osteoarthritis were randomly allocated to receive manual physiotherapy (n=54), multi-modal exercise physiotherapy (n=51), combined exercise and manual physiotherapy (n=50), or no trial physiotherapy (n=51). The primary outcome was change in the Western Ontario and McMaster osteoarthritis index (WOMAC) after one 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 0 to 240. Intention to treat analysis showed adjusted reductions in WOMAC scores at one year compared with the usual care group of 28.5 (95% confidence interval 9.2 to 47.8) 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=0.027). Physical performance test outcomes favoured the exercise therapy group. CONCLUSIONS: Manual physiotherapy provided benefits over usual care, that were sustained to one year. Exercise physiotherapy also provided physical performance benefits over usual care. There was no added benefit from a combination of the two therapies.

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Available from: J. Haxby Abbott, Aug 30, 2015
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    • "Between group N ¼ 29 Within group N ¼ 28 Between group N ¼ 28 Within group N ¼ 28 Abbott et al., 2013 Aglamis et al., 2008 ✓ ✓ ✓ ✓ Avelar et al., 2011 ✓ # Baker et al., 2001 ✓ ✓ ⃡ ✓ Bautch et al., 1997 ✓ Bennell et al., 2005 ⃡ ✓ ⃡ ✓ Bennell et al. 2010 ✓ ✓ Brismee et al., 2007 ✓ ✓ ✓ ✓ Dias et al., 2003 ✓ ✓ Durmus et al., 2012 ✓ ✓ Ettinger et al., 1997+ ✓ ✓ Farr et al., 2010 ✓ Fitzgerald et al., 2011 ⃡ ✓ Foroughi et al., 2011 ✓ ✓ Foy et al., 2011 ✓ ✓ Hasegawa 2010 ✓ ✓ ✓ ✓ Jenkinson et al., 2009 ✓ ⃡ ✓ ✓ Kawasaki et al., 2008 ✓ ✓ Kawasaki et al. 2009 ⃡ ⃡ Keefe et al., 2004 ⃡ Kirkley et al., 2008 Lim et al., 2008 ✓ ⃡ McCarthy et al., 2004 McKnight et al., 2010 ✓ ✓ Messier et al., 2000 # ✓ Messier et al. 2007 ⃡ # Mikesky et al., 2006 ⃡ Miller et al., 2006 ✓ ✓ Ni et al., 2010 ✓ ✓ Olejerova et al., 2008 O'Reilly et al., 1999 ✓ ✓ ✓ ✓ Osteras et al., 2012 ⃡ Peloquin et al., 1999 ✓ ✓ # # Pisters et al., 2010 ✓ ✓ Rejeski et al., 2002+ # ✓ # # Rogind et al., 1998 ⃡ # ⃡ # Salancinski et al., 2012 ✓ ✓ ⃡ ⃡ Sayers et al., 2012 ⃡ ⃡ ⃡ ⃡ Schlenk et al., 2011 ⃡ ✓ Silva et al., 2008 ✓ ✓ Simao et al., 2012 # ⃡ Somers et al., 2012 ✓ # ✓ # Song et al., 2003 ✓ ✓ Talbot et al., 2003 ⃡ ⃡ ✓ Thomas et al., 2002 ✓ ✓ Topp et al., 2002 ⃡ ✓ ⃡ # Wang et al., 2009 ✓ ✓ ✓ ✓ Wang et al. 2011 ✓ Key: + ¼ findings from primary paper and follow up papers, ✓ ¼ significantly lower pain in physical activity group over time or compared to non-physical activity group/ significantly better physical function in physical activity group over time or compared to non-physical activity group. 4 ¼ no significant difference over time or between groups. "
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    ABSTRACT: To determine whether long-term physical activity is safe for older adults with knee pain. A comprehensive systematic review and narrative synthesis of existing literature was conducted using multiple electronic databases from inception until May 2013. Two reviewers independently screened, checked data extraction and carried out quality assessment. Inclusion criteria for study designs were randomised controlled trials (RCTs), prospective cohort studies or case control studies, which included adults of mean age over 45 years old with knee pain or osteoarthritis (OA), undertaking physical activity over at least three months and which measured a safety related outcome (adverse events, pain, physical functioning, structural OA imaging progression or progression to total knee replacement (TKR)). Of the 8614 unique references identified, 49 studies were included in the review, comprising 48 RCTs and one case control study. RCTs varied in quality and included an array of low impact therapeutic exercise interventions of varying cardiovascular intensity. There was no evidence of serious adverse events, increases in pain, decreases in physical function, progression of structural OA on imaging or increased TKR at group level. The case control study concluded that increasing levels of regular physical activity was associated with lower risk of progression to TKR. Long-term therapeutic exercise lasting three to thirty months is safe for most older adults with knee pain. This evidence supports current clinical guideline recommendations. However, most studies investigated selected, consenting older adults carrying out low impact therapeutic exercise which may affect result generalizability. PROSPERO 2014:CRD42014006913. Copyright © 2015. Published by Elsevier Ltd.
    Osteoarthritis and Cartilage 05/2015; 60. DOI:10.1016/j.joca.2015.05.002 · 4.66 Impact Factor
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    ABSTRACT: Study design Methodological study nested within a multicentre randomised controlled trial (RCT) of yoga plus usual general practitioner (GP) care vs usual GP care for chronic low back pain. Objective To explore the treatment effects of non-compliance using three approaches in an RCT evaluating yoga for low back pain. Summary of background data A large multicentre RCT using intention-to-treat (ITT) analysis found that participants with chronic low back pain who were offered a 12-week progressive programme of yoga plus usual GP care had better back function than those offered usual GP care alone. However, ITT analysis can underestimate the effect of treatment in those who comply with treatment. As such, the data were analysed using other approaches to assess the problem of non-compliance. The main outcome measure was the self-reported Roland Morris Disability Questionnaire (RMDQ). Methods Complier average causal effect (CACE) analysis, per-protocol analysis and on-treatment analysis were conducted on the data of participants who were fully compliant, predefined as attendance of at least three of the first six sessions and at least three other sessions. The analysis was repeated for participants who had attended at least one yoga session (i.e. any compliance), which included participants who were fully compliant. Each approach was described, including strengths and weaknesses, and the results of the different approaches were compared with those of the ITT analysis. Results For the participants who were fully compliant (n = 93, 60%), a larger beneficial treatment effect was seen using CACE analysis compared with per-protocol, on-treatment and ITT analyses at 3 and 12 months. The difference in mean change in RMDQ score between randomised groups was -3.30 [95% confidence interval (CI) -4.90 to -1.70, P < 0.001] at 3 months and -2.23 (95% CI -3.93 to -0.53, P = 0.010) at 12 months for CACE analysis, -3.12 (95% CI -4.26 to -1.98, P < 0.001) at 3 months and -2.11.86 (95% CI -3.33 to -0.89, P = 0.001) at 12 months for per-protocol analysis, and -2.91 (95% CI -4.06 to -1.76, P < 0.001) at 3 months and -2.10 (95% CI -3.31 to -0.89, P = 0.001) at 12 months for on-treatment analysis. For the participants who demonstrated any compliance (n = 133, 85%), the results were generally consistent with the fully compliant group at 3 months, but the treatment effect was smaller. The difference in mean change in RMDQ score between randomised groups was -2.45 (95% CI -3.67 to -1.24) for CACE analysis, -2.30 (95% CI -3.43 to 1.17) for per-protocol analysis and -2.15 (95% CI -3.25 to -1.06) for on-treatment analysis, which was slightly less than that for ITT analysis. In contrast, at 12 months, per-protocol and on-treatment analyses showed a larger treatment effect compared with CACE and ITT analyses: per protocol -1.86 (95% CI -3.02 to -0.71), on-treatment -1.99 (95% CI -3.13 to -0.86) and CACE -1.67 (95% CI -2.95 to -0.40). Conclusion ITT analysis estimated a slightly smaller treatment effect in participants who complied with treatment. When examining compliance, CACE analysis is more rigorous than per-protocol and on-treatment analyses. Using CACE analysis, the treatment effect was larger in participants who complied with treatment compared with participants who were allocated to treatment, and the difference between ITT and CACE analyses for the fully compliant group at 3 months was small but clinically important. Per-protocol and on-treatment analyses may produce unreliable estimates when the effect of treatment is small. International Standard Randomised Trial Number Register ISRCTN 81079604.
    Physiotherapy 01/2013; 100(3). DOI:10.1016/ · 2.11 Impact Factor
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    ABSTRACT: To investigate the effectiveness of a patient education (PE) program with or without the added effect of manual therapy (MT) compared to a minimal control intervention (MCI). In a single-centre university hospital setting, a total of 118 patients with clinical and radiographic unilateral hip OA from primary care were randomized into one of three groups: PE, PE plus MT or MCI. The PE was taught by a physiotherapist involving five sessions. The MT was delivered by a chiropractor involving 12 sessions and the MCI included a home stretching program. Primary outcome was self-reported pain severity on an 11-box numeric rating scale (NRS) immediately following a 6-week intervention period. Patients were followed for one year. Primary analysis included 111 patients (94%). In the combined group (PE+MT), a clinically relevant reduction in pain severity compared to the MCI of 1.90 points (95% CI (0.9 - 2.9) was achieved. Effect size (Cohen's d) for the PE+MT minus the MCI was 0.92 (95% CI 0.41 - 1.42). Number needed to treat for PE+MT was 3 (95% CI 2 - 7). No difference was found between the PE and MCI groups, with mean difference 0.0 (95% CI -1.0 - 1.0). At 12 months, not including patients receiving hip surgery the statistically significant difference favoring PE+MT was maintained. For primary care patients with osteoarthritis of the hip, a combined intervention of manual therapy and patient education was more effective than a minimal control intervention. Patient education alone was not superior to the minimal control intervention. Trial registration:clinicaltrials.govNCT01039337.
    Osteoarthritis and Cartilage 06/2013; 16(10). DOI:10.1016/j.joca.2013.06.009 · 4.66 Impact Factor
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