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ORIGINAL ARTICLE
Full Kinetic Chain Manual and Manipulative Therapy Plus
Exercise Compared With Targeted Manual and Manipulative
Therapy Plus Exercise for Symptomatic Osteoarthritis of the
Hip: A Randomized Controlled Trial
James W. Brantingham, DC, PhD, Gregory Parkin-Smith, MTech(Chiro), MBBS, MSc, DHSc,
Tammy Kay Cassa, DC, Gary A. Globe, DC, MBA, PhD, Denise Globe, DC, MHSA, PhD,
Henry Pollard, DC, PhD, Katie deLuca, BAppSci (Ex & Sp Sci), MChiro, Muffit Jensen, DC,
Stephan Mayer, DC, Charmaine Korporaal, MTech(Chiro)
ABSTRACT. Brantingham JW, Parkin-Smith G, Cassa TK,
Globe GA, Globe D, Pollard H, deLuca K, Jensen M, Mayer S,
Korporaal C. Full kinetic chain manual and manipulative therapy
plus exercise compared with targeted manual and manipulative
therapy plus exercise for symptomatic osteoarthritis of the hip: a
randomized controlled trial. Arch Phys Med Rehabil 2012;93:
259-67.
Objective: To determine the short-term effectiveness of full
kinematic chain manual and manipulative therapy (MMT) plus
exercise compared with targeted hip MMT plus exercise for
symptomatic mild to moderate hip osteoarthritis (OA).
Design: Parallel-group randomized trial with 3-month
follow-up.
Setting: Two chiropractic outpatient teaching clinics.
Participants: Convenience sample of eligible participants
(N⫽111) with symptomatic hip OA were consented and ran-
domly allocated to receive either the experimental or compar-
ison treatment, respectively.
Interventions: Participants in the experimental group re-
ceived full kinematic chain MMT plus exercise while those in
the comparison group received targeted hip MMT plus exer-
cise. Participants in both groups received 9 treatments over a
5-week period.
Main Outcome Measures: Western Ontario and McMasters
Osteoarthritis Index (WOMAC), Harris hip score (HHS), and
Overall Therapy Effectiveness, alongside estimation of clini-
cally meaningful outcomes.
Results: Total dropout was 9% (n⫽10) with 7% of total data
missing, replaced using a multiple imputation method. No statis-
tically significant differences were found between the 2 groups for
any of the outcome measures (analysis of covariance, P⫽.45 and
P⫽.79 for the WOMAC and HHS, respectively).
Conclusions: There were no statistically significant differ-
ences in the primary or secondary outcome scores when com-
paring full kinematic chain MMT plus exercise with targeted
hip MMT plus exercise for mild to moderate symptomatic hip
OA. Consequently, the nonsignificant findings suggest that
there would also be no clinically meaningful difference be-
tween the 2 groups. The results of this study provides guidance
to musculoskeletal practitioners who regularly use MMT that
the full kinematic chain approach does not appear to have any
benefit over targeted treatment.
Key Words: Exercise; Hip; Musculoskeletal manipulations;
Osteoarthritis; Rehabilitation.
©2012 by the American Congress of Rehabilitation
Medicine
IN THE UNITED STATES, mild to moderate symptomatic
osteoarthritis (OA) of the hip has a prevalence of 3% to 4%
of the population, affecting 12 to 30 million people.
1-5
There-
fore, hip OA is a leading cause of disability and morbidity,
while significantly increasing the risk of falls.
1,2,6-9
The cost of
managing hip OA made up a significant portion of the $128
billion spent on arthritic conditions in the USA in 2003.
10-12
Hence, early and effective management would reduce morbid-
ity and the costs associated with symptomatic hip OA.
Various drugs are effective in treating symptomatic hip OA, but
they have little effect on the progression of hip OA,
1
and a
considerable number of patients may not tolerate the side effects
of these drugs, such as gastrointestinal upset and renal dysfunc-
tion, particularly with chronic use.
13-15
Moreover, the risk of drug
interactions in patients with comorbidities is an additional con-
cern.
16,17
An alternative is surgical intervention, such as joint
replacement, but this is regarded as premature for mild to mod-
erate hip OA. Therefore, manual, manipulative, and exercise ther-
From the Department of Research, Cleveland Chiropractic College, Los Angeles,
CA (Brantingham, Parkin-Smith, Cassa, Globe G, Globe D, Jensen, Mayer); School
of Chiropractic & Sports Science, Murdoch University, Perth, WA, (Parkin-Smith,
Brantingham); Faculty of Science, Department of Chiropractic, Macquarie Univer-
sity, Sydney, NSW, (Pollard, deLuca) Australia; Department of Chiropractic and
Somatology, Durban University of Technology, Durban, South Africa (Korporaal,
Brantingham).
Supported by a grant from UniHealth Foundation, a nonprofit philanthropic orga-
nization whose mission is to support and facilitate activities that significantly improve
the health and well being of individuals and communities within its service area (grant
no. 1447), and intramurally funded by Cleveland Chiropractic College, Los Angeles.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit on the authors or on any organi-
zation with which the authors are associated.
Clinical Trial Registration No.: NCT00523172.
Reprint requests to Gregory Parkin-Smith, MTech(Chiro), MBBS, MSc, DHSc,
School of Chiropractic & Sports Science, Murdoch University, South St, Murdoch,
WA 6150, Australia, e-mail: g.parkin-smith@murdoch.edu.au.
0003-9993/12/9302-00211$36.00/0
doi:10.1016/j.apmr.2011.08.036
List of Abbreviations
ANCOVA analysis of covariance
CI confidence interval
HHS Harris hip score
MCID minimally clinically important difference
MMT manual and manipulative therapy
OA osteoarthritis
OTE Overall Therapy Effectiveness
WOMAC Western Ontario and McMasters
Osteoarthritis Index
259
Arch Phys Med Rehabil Vol 93, February 2012
Author's personal copy
apies are emerging as viable treatment options for symptomatic
hip OA where drug or surgical intervention is limited.
Manual and manipulative therapy (MMT), exercise therapy, or
combinations of both, are commonly used by musculoskeletal
practitioners to treat symptomatic hip OA, particularly among
those practitioners with further training in MMT.
18-20
However,
many of these therapies have not been tested in clinical trials.
For example, the effectiveness of exercise therapy for symp-
tomatic hip OA appears to be equivocal, and only 1 trial has
compared exercise therapy with manual therapy, reporting that
manual therapy was superior.
3,19
Yet, exercise therapy is used
routinely as a first-line treatment for symptomatic hip OA by
musculoskeletal practitioners, with or without additional drug
therapy.
1,19,21-23
The addition of MMT to exercise therapy is emerging as a
promising approach to reduce the symptoms of mild to mod-
erate hip and knee OA.
19,24-26
For example, Hoeksma et al
19
applied MMT to the hip joint with pre- and postpassive and
active assisted stretching, which was shown to be superior to
exercise therapy alone. Thus, a logical next step would be to
expand the work of Hoeskma and compare MMT plus exercise
with MMT plus exercise and treatment of other joints in the
same kinematic chain.
Deyle et al,
27
in patients with knee OA, applied MMT by
targeting both the knee joint and other joints within the local
kinematic chain, like the hip, low back, and associated soft
tissues, demonstrating improvement in symptoms. This kine-
matic chain approach, referred to by Brantingham et al
28
as the
“full kinematic chain” approach, where joints and soft tissues
within the kinematic chain of the affected joint are also treated,
is often used by musculoskeletal practitioners who offer MMT
in clinical practice.
27-30
Even though the full kinematic chain
approach reflects a natural extension of hip MTT in clinical
practice, the speculated benefit over targeted hip MMT has not
yet been demonstrated.
Thus, the purpose of this study was to determine the short-
term effectiveness of full kinematic chain MMT plus exercise
compared with targeted hip MMT plus exercise for symptom-
atic mild to moderate hip OA.
22,31-33
The objective was to compare the experimental treatment (full
kinematic chain MMT plus exercise) with the comparison treat-
ment (targeted hip MMT plus exercise) in terms of hip-related
symptoms in the short term, with 3-month follow-up. The research
hypothesis was that the experimental treatment (full kinematic
chain MMT plus exercise) would result in greater change in
outcome measure scores over the comparison group (targeted hip
MMT plus exercise) in terms of hip-related symptoms.
METHODS
Setting, Practitioners, and Participants
This study was implemented across 2 chiropractic outpatient
teaching clinics. Thirteen senior chiropractic interns, under the
supervision of 3 experienced chiropractors with a special in-
terest in extremity joint disorders, participated as treating prac-
titioners in this trial. The 13 practitioners provided treatment to
participants in both treatment groups, respectively, and were
not blind to the treatments provided in either intervention
group. However, the practitioners did not collect data or have
access to the collected data, in order to reduce the risk of bias.
Participants were recruited through convenience sampling over
a 2-year period where candidates presenting with hip pain were
screened by phone or in person for eligibility. Eligible patients
were then invited to participate in the study, but were allowed a
cooling-off period of at least 5 days to consider volunteering for
the study without feeling pressured to do so. One hundred and
eleven eligible patients volunteered for the study, were consented,
and then randomly allocated to a treatment group.
Selection Criteria
Inclusion criteria. All eligible participants had a diagnosis
of symptomatic mild to moderate hip OA based on the diag-
nostic criteria of the American College of Rheumatology and
the Kellgren-Lawrence grade for hip OA; suitable grades for
this study were grades 0 to 3.
34,35
This diagnosis was reached
after thorough assessment of each eligible participant at their
first encounter by a registered chiropractor.
The inclusion criteria were: (1) hip pain with less than 15° of
internal rotation and less than 115° flexion or hip pain with
greater than 15° internal rotation with morning stiffness of less
than 60 minutes; (2) a Kellgren-Lawrence grade of 0 to 3 on
plain-film radiograph; (3) age of 40 years and older and 85
years or younger;
19,36-38
(4) ability to stand and walk without
assistance for most (ⱖthree-quarters) of the day, as keeping
active and performing exercises would otherwise be difficult;
and (5) a fall risk assessment: one leg standing test of more
than 5 seconds to qualify for the Berg Balance Scale, and a
Berg Balance Scale score of more than 45.
Exclusion criteria. Exclusion criteria included: (1) Kell-
gren-Lawrence grade 4 hip degenerative changes on plain-film
radiograph, indicating severe hip OA and being more amenable
to surgical intervention; (2) possibility of serious pathologic or
psychiatric disorders; (3) possibility of a disorder that would
prevent the participant performing exercises or receiving
MMT; (4) history of lumbar herniated disk or low back injury,
as the clinical outcome would be very different in such pa-
tients; (5) very poor scores for the Berg Balance Scale (ie, ⬍5s
and score of ⬍45); and (6) bilateral symptomatic hip OA.
This project received approval from the Institutional Review
Board of Cleveland College of Chiropractic, USA, and the
Research Ethics Committee of Macquarie University,
Australia.
Interventions
Comparison group: targeted hip MMT plus exercise. The
treatment comprised of targeted hip MMT (using high-veloc-
ity, low-amplitude thrust-type manipulation) with pre- and
posttreatment stretch of the same hip, provided at each treat-
Fig 1. Demonstration of manipulation of the hip joint, in a position
of axial elongation and internal rotation while tolerated by the
patient.
260 MANUAL THERAPY FOR HIP OSTEOARTHRITIS, Brantingham
Arch Phys Med Rehabil Vol 93, February 2012
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ment session (appendix 1, see fig 1).
19,29,32,33
General advice
for safely increasing exercise (eg, walking, progressing toward
aerobic exercise daily) was only formally provided after week
5 (ninth visit)—participants were advised to keep active and
slowly increase their exercise routine, as able. No treatment
was provided between the ninth visit (final session in week 5)
and 3-month follow-up.
Experimental group: full kinematic chain MMT plus ex-
ercise. In addition to targeted hip MMT, joint mobilization
and joint manipulation were applied to joints and soft tissues in
the kinematic chain on the side of the affected
hip.
18,26,28,29,32,39
Treatment was applied to areas, such as the
low back, knee, and ankle, at the discretion of the treating
practitioner (see appendix 1, see fig 1).
19,27,28,39
General advice
was provided in the same fashion as for the comparison group,
with no additional treatment provided between the ninth visit
(week 5) and 3-month follow-up.
Treatment Period
Participants in both the experimental group and the standard
group received 9 treatments over a 5-week period, with fol-
low-up at 3 months.
Outcome Measures
The primary outcome measure was the Western Ontario and
McMasters Osteoarthritis Index (WOMAC), a 24-question sur-
vey used to assess and monitor hip OA, including the param-
eters of pain, joint stiffness, and function.
40-42
Each parameter
(question) was scored out of 100, with a maximum total score
of 2400 (mm); for example pain was scored on a visual analog
scale out of 100mm.
The secondary outcome measures were (1) the Harris hip
score (HHS), a 10-item scale used to score hip OA, including
pain and hip function,
19,26,40,43-45
where a score of 90 to 100 is
excellent, 80 to 90 is good, 70 to 79 is fair, 60 to 69 is poor, and
below 60 is a failed result; and 2 the Overall Therapy Effec-
tiveness (OTE) tool, which measures patient-perceived satis-
faction and improvement with care,
19,46-48
with the 2 sections
of the OTE on a 15-point and 7-point scale, respectively.
The WOMAC index is a valid and reliable measure of
changes in pain and function, used in various hip OA trials,
where a 20% overall change in score (ie, 480/2400) is reported
as being clinically meaningful. For the HHS, a clinically mean-
ingful posttreatment score appears to be an increase in score of
more than 4 points (40%).
40-42,45,49,50
The OTE data were amenable to being dichotomized into 2
categories, being improved and not improved, with a 30% or
greater change in mean scores from baseline to the final treat-
ment considered clinically meaningful and, therefore, im-
proved.
4,50
Various authors report that a 30% of more change
in scores from baseline to the final treatment for patient satis-
Fig 2. Patient flow (Consolidated Standards of Reporting Trials diagram).
261MANUAL THERAPY FOR HIP OSTEOARTHRITIS, Brantingham
Arch Phys Med Rehabil Vol 93, February 2012
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faction and overall perception of improvement is clinically
meaningful.
46-48,50,51
Randomization and Data Management
Randomization was conducted using a random numbers
process where a sequence of random numbers with sequence
boundaries was generated using computer software, using an
atmospheric noise approach (www.random.org). This random-
ization process was conducted by 1 of the authors who did not
participate as a clinician in the trial or collect data. Each
random treatment assignment was placed in a sealed opaque
envelope, producing a series of sequentially numbered sealed
envelopes, thus conferring allocation concealment. As each
volunteer consented to participate, the treating intern then
opened an envelope and identified the treatment group to which
the participant was assigned. The data were collected and kept
separate from the clinical records to reduce the chance of
treatment contamination.
52
Sample Size Calculation
The sample size was estimated using data from published
trials investigating treatment for hip OA using the WOMAC
index as the primary outcome measure.
18,27,53-55
A 30% (or
720/2400) difference in the WOMAC index was considered
meaningful in this trial for estimating sample sizes, being a
more conservative figure than some published estimates of
around 20% (or 480/2400).
19,48-51
The projected sample size to yield 80% power of detecting
a difference at a 5% level of significance (2-tailed test;
G*Power 3.0 software
a
) using a 3-point difference in outcome
measures (effect size index⫽.29) was 50 participants per
group. Allowing for a 15% dropout rate,
56,57
60 participants per
group were intended to be recruited (N⬇120).
56-59
Data Analysis
Intention-to-treat analysis was performed by replacing miss-
ing data using a multiple imputations method (WinMICE pro-
totype version 0.1
b
), and statistically comparing the original
datasets with the datasets with missing data inserted. The
calculations were performed using a multilevel regression
model that created 5 multilevel imputations by the soft-
ware.
60,61
The missing data were replaced with the mean value
of the 5 multilevel imputations.
60,61
Datasets were amenable to the F test (analysis of covariance,
[ANCOVA]) and ttest.
56,62
Primary analysis was between-
group analysis of WOMAC data, while secondary analysis was
between-group analysis of the HHS and OTE data. In both
primary and secondary analyses, weighted ANCOVA was used
because ANCOVA accounts for the possibility of undetected
differences between sample means at baseline and accommo-
dated for possible data variance caused by the selected cova-
riates of patient age and duration of symptoms. If a significant
difference(s) was detected between datasets using ANCOVA,
Tukey honestly significant difference analysis was conducted
automatically to establish where the difference(s) lay.
Within-group OTE data were amenable to dichotomization,
producing 2 categories—improved and not improved—where a
30% change in score (720/2400) for WOMAC was the thresh-
old for dichotomization. The frequency of within-group dichot-
omized data was then represented as a ratio (in %) of cases that
either improved or did not improve.
All statistical analyses were conducted, including confidence
intervals (CIs), at a 95% confidence level (
␣
⫽.05), using
2-tailed tests
56,57
(SPSS version 12
c
) and G*Power soft-
ware.
58,59
The estimated differences in between-group means were
explored to identify any clinically meaningful change as a
result of the interventions. A difference in between-group
means of 20% or more in the primary outcome measure,
49,63
representing a minimally clinically important difference
(MCID) of 20%, alongside a between-group effect size index
of .20 or more in the primary outcome measure, was considered
clinically meaningful in this trial. Differences in between-
group mean scores of less than 20% or an effect size of less
than .20 were considered too small to infer a clinical benefit of
1 treatment over the other.
56
RESULTS
Patient Characteristics and Baseline Data
The flow of participants is represented in figure 2 (Consol-
idated Standards of Reporting Trials). Of the 398 subjects
screened, 237 were assessed, with 111 eligible participants
volunteering for the study. Eligible volunteers provided written
Table 1: Sample Characteristics–Descriptive Statistics and Group
Comparison
Variable
Comparison Group
(targeted MMT plus
exercise) n⫽58
Experimental Group
(full kinetic chain MMT
plus exercise) n⫽53
Age (y) 62.8⫾10.3 63.3⫾10.7
Ageⱖ50y, number of
cases (% of cases)
51 (88) 49 (92)
Sex (% of cases)
Men 45 44
Women 55 56
BMI 23.9⫾3.6 24.2⫾3.8
Duration of symptoms (d) 67⫾86 50⫾66
45–90 32–68
Duration of symptoms
Number of cases (% of
cases)
ⱕ42d 32⫾55 34⫾64
43–168d 23⫾40 2⫾4
⬎168d 3⫾517⫾32
Radiographic findings (KL
grades)*
(% of cases)
02630
13021
21925
32524
ACR criteria (% of cases)
†
Criteria A 34 42
Criteria B 66 58
Baseline scores
WOMAC (mm)
‡
1163⫾415 1148⫾456
1052–1271 1024–1276
HHS
§
62⫾962⫾12
59–64 58–65
NOTE. Values are mean ⫾SD, 95% CI, or as otherwise indicated.
Abbreviations: ACR, American College of Rheumatology; BMI, body
mass index; KL, Kellgren-Lawrence.
*KL grades: grade 0, none; grade 1, doubtful; grade 2, minimal; and
grade 3, moderate.
†
ACR criteria: criteria A, hip pain and ⬍15° internal rotation and
⬍115° flexion; criteria B, hip pain with ⬎15° internal rotation causing
hip pain and morning stiffness ⬍60min.
‡
WOMAC scores in millimeters out of a total possible score of 2400.
§
HHS scores out of a total possible score of 100.
262 MANUAL THERAPY FOR HIP OSTEOARTHRITIS, Brantingham
Arch Phys Med Rehabil Vol 93, February 2012
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informed consent prior to random allocation. Fifty-eight par-
ticipants were randomized to the comparison group (targeted
hip MMT plus exercise) and 53 to the experimental group (full
kinematic chain MMT plus exercise). Blind assessment and
data collection was carried out at both clinical sites according
to a previously used format.
28
Ten participants either dropped
out of the study or had missing data (3 in the comparison group
and 7 in the experimental group), with the data from 101
participants available for initial analysis.
Each appointment was 30 minutes in duration, meaning that
the overall treatment dose per treatment session was 30 min-
utes, with each participant in both groups receiving a total of
4.5 hours of treatment over the respective treatment periods.
Examination of the descriptive and patient characteristics sug-
gests that the 2 groups were similar at baseline (table 1). Baseline
scores for the primary outcome measure indicated that the major-
ity of participants in both groups had unilateral moderate symp-
tomatic hip OA (see table 1), where the WOMAC scores at
baseline for the comparison group was 1163 (48.5%) and 1148
(47.8%) for the experimental group. The HSS scores were 62
(62%, implying 38% disability) for both groups.
Intention-to-Treat Analysis
Examination of all the datasets in this trial revealed that 7%
of the data were missing, which were accounted for by imput-
ing missing values,
64
with the datasets with missing data re-
placed being used for all statistical analyses.
Data Analysis
Between-group statistical analysis of the primary outcome
(WOMAC) and the secondary outcomes (HHS and OTE) did
not reveal any significant differences (weighted ANCOVA;
P⫽.45, P⫽.79, P⫽.88, respectively) between the 2 interven-
tion groups on primary and secondary analysis, implying sim-
ilar scores in both groups (tables 2 and 3).
There was minimal difference (range, 1%–5%; ⬍MCID
value of 20%) between groups when comparing estimated
means at the 5-week and 3-month follow-up points.
Figure 3 shows the trend in outcomes for the 2 groups over
the treatment period (baseline, week 5, and 3-month follow-
up), providing insight into potential within-group outcomes,
although no presumptions concerning effectiveness of the in-
dividual treatment groups can be inferred, because no control
or placebo group is included in this trial. The change in
WOMAC scores (out of 2400) from baseline to the ninth
consultation (week 5), baseline to the 3-month follow-up, and
ninth consultation (week 5) to the 3-month follow-up for the
comparison group (MMT plus exercise) for the WOMAC was
545⫾442 (95% CI, 431– 659), 501⫾474 (95% CI, 379 – 623),
and ⫺44⫾252 (95% CI, ⫺109 to 21), respectively. The scores
for the experimental group (full kinematic chain MMT plus
exercise) at the same timepoints were 408⫾432 (95% CI,
242–574), 383⫾467 (95% CI, 255–511), and ⫺24⫾259 (95%
CI, ⫺94 to 46), respectively.
The mean residual scores after the treatment period (week 5)
are offered in table 2.
DISCUSSION
To our knowledge, this is the first randomized controlled
trial comparing full kinematic chain MMT plus exercise with
Table 2: Comparison of Scores of the Comparison Group
(targeted hip MMT plus exercise) With the Experimental Group
(full kinematic chain MMT plus exercise) for the WOMAC and HHS
at Week 5 and 3-Month Follow-Up
Week 5
3-mo
Follow-Up
Analysis
POutcome Measure
Mean ⫾
SD or
95% CI
Mean ⫾
SD or
95% CI
WOMAC (mm)*
Total Score
Comparison group 618⫾405 662⫾464 .45 (ANCOVA)
(targeted MMT
plus exercise)
507–720 535–779
Experimental group 740⫾561 764⫾567
(full kinematic
chain MMT
plus exercise)
590–899 613–925
Subscales Scores
Pain
Comparison group 117⫾80 136⫾100 .58 (ttest)
90–144 112–160
Experimental group 126⫾88 122⫾73 .10 (ttest)
76–136 69–135
Stiffness
Comparison group 62⫾42 65⫾44 .98 (ttest)
48–76 50–80
Experimental group 62⫾48 68⫾38 .37 (ttest)
46–78 55–81
HHS
†
Comparison group 71⫾13 71⫾13 .79 (ANCOVA)
(targeted MMT plus
exercise)
68–75 67–74
Experimental group 72⫾17 69⫾18
(full kinematic
chain MMT
plus exercise)
66–76 64–74
*WOMAC scores in millimeters out of a total possible score of 2400.
†
HHS scores out of a total possible score of 100.
Table 3: Group Comparison–OTE Scores, Based on Dichotomised Data Where the Decision-Making Threshold Value is a 30% Change in
Score for Dichotomization
Group
Week 5
(% of cases)
3-mo Follow-Up
(% of cases)
Analysis of Data
From Week 5 (P)
Analysis of Data From
3-mo Follow-Up (P)
Comparison group (targeted MMT plus exercise)
Improved 89 72
Not improved 11 28 .88 .86
Experimental group (full kinematic chain MMT
plus exercise)
Improved 79 66
Not improved 21 34
263MANUAL THERAPY FOR HIP OSTEOARTHRITIS, Brantingham
Arch Phys Med Rehabil Vol 93, February 2012
23 % overall
Change
(Pain 20%
= MCID)
at 3 mo ↓22%
Change
40% overall
at 3 mo
43%
1163 base
1148 base
(comparison = local, Exp= FKC)
(Comparison=local , Exp=FKC for WOMAC
Overall)
↓
Local 62
23% overall
Change
23% overall
Change
26% overall
19% overall
=MCID
WOMAC DISABILITY NOT DONE.
DATA not individually Calculated.
HHS comparable
47%
42%
36%
34%
Both Groups
did > 9-10
points at 5
weeks and at
3 mos all > MCID
= ↑ 4 points.
(Stiff 22%= MCID)
OTE is far above the MCID of 30
Global Rating of Change/patient satisfaction
Author's personal copy
targeted hip MMT plus exercise for symptomatic mild to
moderate hip OA, with a 3-month follow-up.
The outcomes of this trial demonstrate that there were nei-
ther statistically significant nor clinically meaningful differ-
ences when comparing the experimental group (full kinematic
chain MMT plus exercise) with the comparison group (targeted
hip MMT plus exercise). The distinctive contribution of this
trial is that, particularly for those musculoskeletal practitioners
who regularly use manual and manipulative therapies (in the
form of joint and/or soft tissue manipulation), it provides
guidance regarding the choice of MMT approach; in this case,
full kinematic chain MMT does not appear have any benefit
over targeted hip MMT.
The within-group changes observed in trial are consistent
with the positive outcomes reported with the use of MMT for
hip OA in published trials.
18,19,26,65
In addition, this study
shows that the outcomes in both groups appear to be retained
up to the 3-month follow-up without further treatment, which is
unique to this study. However, these results only provide
insight into the potential benefit of MMT and are not evidence
of effectiveness.
Study Limitations
The limitation of this trial is that there is no control group
featuring no treatment or a placebo treatment. Therefore, the
natural history of symptomatic hip OA, which is often charac-
terized by fluctuating signs and symptoms, alongside the po-
tential effect of the Hawthorne phenomenon, may account for
some of the improvement seen in each treatment group.
Also, as a pragmatic trial, this study also does not permit
conclusions to be drawn about the effect of individual treat-
ments used as part of the treatment package in each group.
This study excluded patients that had severe hip OA
(Kellgren-Lawrence grade 4), because such cases are more
amenable to surgical intervention rather than conservative
treatment. However, Hoeksma et al
19
reported meaningful
improvements in participants with grade 4 hip OA, implying
that this grade of hip OA should be considered for inclusion
in future studies.
CONCLUSIONS
There were no statistically significant or clinically meaning-
ful differences in the primary or secondary outcome measure
scores when comparing full kinematic chain MMT plus exer-
cise with targeted hip MMT plus exercise for mild to moderate
symptomatic hip OA. The results of this study provides guid-
ance to musculoskeletal practitioners who regularly use MMT
that full kinematic chain approach does not appear to have any
benefit over targeted treatment.
Acknowledgment: We thank Cheryl Hawk, DC, PhD, for her
help, insights, and suggestions.
APPENDIX 1: GLOSSARY
MMT: Manual and manipulative therapy
Active-assisted stretch: a stretch or stretching technique that is accomplished by the operator with conscious assistance by the
participant (patient).
End feel (or end play): discrete, short-range movements of a joint independent of muscular action, determined by springing the
joint at the limit of its passive range of motion.
Mobilization: a form of manipulation applied within the physiologic passive range of motion, without thrust.
Manipulation: a form of manipulation that involves a directed thrust applied to a joint through the physiologic passive range
of motion, without exceeding the anatomic limit.
Mortise separation and plantar snap: specific manipulative techniques that include a thrust to the mortise joint and tarsal
joints, respectively.
Hip OA Treatments
Comment: All MMT and exercise procedures should take into account patient age, stiffness, abilities, tolerance, and contrain-
dications before executing the hip axial elongation with high-velocity, low-amplitude, thrust-type manipulation (a distractive
impulse pull) or passive and active-assistive stretch.
Control Treatment: Targeted Hip MMT Plus Exercise
1. The procedure begins with premanipulative stretches of muscles around the affected hip joint, which may include psoas,
quadriceps, hamstrings, tensor fasciae latae, gracilis, long adductors, and sartorius.
Fig 3. Trends in outcomes within each treatment group (WOMAC
and HHS). The lines are the plotted baseline, week 5, and 3-month
follow-up mean scores. The graphs, therefore, provide insight as to
the trend in outcomes.
264 MANUAL THERAPY FOR HIP OSTEOARTHRITIS, Brantingham
Arch Phys Med Rehabil Vol 93, February 2012
Author's personal copy
APPENDIX 1: GLOSSARY (Cont’d)
2. Premanipulative stretching is followed by axial elongation of the affected limb in slight hip abduction and hip flexion of
about 30°, immediately followed by the application of a high-velocity low-amplitude, thrust-type manipulation (traction
pull/thrust) in this position.
3. This is then followed by active assisted stretch of tight muscles around the hip.
4. Thereafter, hip flexion and hip end feel spring of the affected limb is assessed, and if not improved (ie, approximating or similar
flexion and end-feel as the unaffected hip), the procedure is repeated. With the addition of some internal rotation, where:
5. Axial elongation of the affected limb in slight hip abduction and hip flexion of about 30° and with some internal rotation
of the hip joint, immediately followed by the application of a high-velocity low-amplitude, thrust-type manipulation (traction
pull/thrust) in this position. The addition of some internal rotation acts to “tighten up” the hip joint thereby approximating
the close packed position of the joint.
6. This is then followed by active-assisted stretch of tight muscles around the hip.
7. Thereafter, hip flexion and hip end feel spring of the affected limb is assessed and if not improved (ie, approximating or
similar flexion and end-feel of the unaffected hip), then repeat procedure (5) as required.
8. The procedure may be performed up to 5 times, checking hip flexion and end feel spring in flexion after each procedure. Stop
applying the procedure when hip flexion and end feel spring in flexion of the affected limb is similar or the same as that of
the unaffected hip joint, or after 5 procedures, whichever comes first; and
9. The treatment included pain-free exercise, gradually increasing the exercises within tolerance. Participants were advised to
keep active and slowly increase their exercise routine, as able.
Experimental Treatment: Full Kinematic Chain MMT
Targeted MMT is applied to the affected hip joint in the manner described previously for the control group. MMT to other
joints in the kinematic chain are only provided if the patient is able to tolerate the procedure and does not demonstrate
contraindications to MMT.
Additional MMT is applied, as indicated, where:
1. Joint mobilization and/or manipulation is applied to the lumbosacral and/or sacroiliac joints using joint mobilization
techniques and high- or low-velocity, low-amplitude, thrust-type manipulation(s)appropriate.
2. Mobilize and/or manipulate the ipsilateral knee by applying flexion and extension mobilization, gentle axial elongation, and
patellar mobilization, after which and add controlled end-range of motion thrusts (high-velocity, low-amplitude, thrust-type
manipulation) if tolerated by the patient (including, for example, forced knee flexion to increase A-P or P-A proximal fibular joint
glide).
3. Mobilize and/or manipulate the ipsilateral ankle by applying mortise separation (axial elongation of the ankle joint with and
without an A-P scoop to increase talar A-P glide; or using a supine, dorsiflexed ankle with A-P mobilization of the distal
tibia to increase ankle dorsiflexion and talar A-P glide), and A-P distal fibula mobilization and manipulation.
4. Additional foot mobilization and/or manipulation may be applied, as indicated, such as STJ eversion, inversion, or axial
elongation, D-P small tarsal(s) mobilization or manipulation (D-P thrust on small tarsals applied like a mortise separation),
forefoot figure of 8 mobilization, intermetatarsal glide mobilization, axial elongation of the metatarsophalangeal joints; and
5. The treatment included pain-free exercise, gradually increasing the exercises within tolerance. Participants were advised to
keep active and slowly increase their exercise routine, as able.
The core set of full kinematic chain MMT procedures is summarized in the list below:
1. Hip axial elongation manipulation
2. Spinal or SI manipulation
3. Knee flexion and extension mobilization
4. Knee axial elongation manipulation (mobilization or manipulation)
5. Patellar mobilization
6. Mortise separation (mobilization or manipulation of cuboid, etc)
7. A-P distal fibula
8. STJ eversion, inversion
9. D-P small tarsals (like mortice separation)
10. Forefoot figure of 8 mobilizations
11. Intermetatarsal glide (no forced end ROM thrust with knee OA)
12. Axial elongation of the toes or MTPJs
13. Plantar snap move (plantar to dorsal)
14. If indicated proximal fibular mobilization or HVLA adjustment
Other MMT/adjustments as carefully indicated and inversion and axial elongation
Abbreviations: A-P, anterior to posterior; HVLA, manipulation; MTPJ, metatarsophalangeal joint; P-A, posterior to anterior; SI,
sacroiliac; STJ, subtalar joint.
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