No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Manual therapy for osteoarthritis of the hip or knee - A systematic review
Abstract
The aim of this systematic review was to determine if manual therapy improves pain and/or physical function in people with hip or knee OA. Eight databases were searched for randomised controlled trials (RCTs). Data were extracted and risk of bias assessed by independent reviewers. Four RCTs were eligible for inclusion (280 subjects), three of which studied people with knee OA and one studied those with hip OA. One study compared manual therapy to no treatment, one compared to placebo intervention, whilst two compared to alternative interventions. Meta-analysis was not possible due to clinical heterogeneity of the studies. One study had a low risk of bias and three had high risk of bias. All studies reported short-term effects, and long-term effects were measured in one study. There is silver level evidence that manual therapy is more effective than exercise for those with hip OA in the short and long-term. Due to the small number of RCTs and patients, this evidence could be considered to be inconclusive regarding the benefit of manual therapy on pain and function for knee or hip OA.
... Manual therapy refers to a collection of therapeutic interventions used by chiropractors and physiotherapists in the management of OA 19 , although manual therapy is also used by a variety of other healthcare practitioners. The current lack of high-quality evidence prevents manual therapy from being considered a core treatment 19 , which is reflected in the recent ACR and OARSI guidelines. ...
... Manual therapy refers to a collection of therapeutic interventions used by chiropractors and physiotherapists in the management of OA 19 , although manual therapy is also used by a variety of other healthcare practitioners. The current lack of high-quality evidence prevents manual therapy from being considered a core treatment 19 , which is reflected in the recent ACR and OARSI guidelines. However, the National Institute for Health and Care Excellence (NICE) guideline and the US Bone and Joint Initiative recognize the potential contributions that manual therapy can have on patient outcomes. ...
... 13,15 The NICE guidelines consider manual therapy an appropriate adjunct treatment for hip OA 15 , while the US Bone and Joint Initiative recommends consideration of manual therapy when in combination with exercise 13 . A recent review on manual therapy found improvements in pain and physical function in the short-and long-term (up to six months) for patients with OA. 19 This investigation included four randomized control trials (RCT) comparing manual therapy alone to other or no interventions and excluded trials that combined manual therapy with other treatment options. However, three of the included studies were rated as having a high risk of bias and only one study examined hip OA patients. ...
Knee and hip osteoarthritis (OA) place a significant burden on the Canadian health system and are a major public health challenge. This brief commentary discusses the recently published Osteoarthritis Research Society International guideline and the American College of Rheumatology guideline for the management of OA. Special attention has been given to the role of manual therapy, exercise, and patient education for the treatment of knee and hip OA. This article also reviews the Good Life with osteoArthritis in Denmark (GLA:D®) treatment program for knee and hip OA and the implementation of this program in Canada. Lastly, the authors discuss the opportunity for the Canadian chiropractic profession to embrace treatment programs like GLA:D® and take an active role in the strengthening of the Canadian health system from a musculoskeletal perspective.
... Although OA is a progressive and degenerative disease that can naturally worsen over time regardless of intervention, the best available evidence seems to favor exercise therapy for short-term pain relief, requiring more RCTs to confirm the duration of the effect. In addition, these exercise programs must be personalized and should be introduced gradually as the patient is able to tolerate it (34). ...
... Seven randomized clinical trials were identified that have measured the pain intensity of hip OA by subjecting subjects to a TM intervention compared to a control group of which 4 (34,36,37,(40)(41)(42)(43)(44)(45)(46)(47) (Table III) (Table III). ...
... Four randomized clinical trials were identified that have measured the pain intensity of hip OA when subjecting subjects to an intervention with MT + Ex in conjunction with exercises, within which 2 studies used the Visual Analog Scale (34,36,37,40,45,46) to measure the intensity of pain. The remaining 2 studies used the NPRS (37) and the WOMAC pain section (36) ( Table IV) ...
Introduction: Osteoarthritis (OA) is the most common joint disease, increases with age and it is estimated that in those over 60 years of age more than 80 % have OA in at least one joint. Currently, the evidence regarding MT in hip OA has had unclear results. Therefore, the main objective of this study is to determine the effectiveness and recommendation of MT in the hip OA. And secondary objectives, (I) review the existing literature on the intervention of MT in hip OA, (II) calculate the effectiveness of TM techniques in hip OA and (III) determine if there are benefi ts after the MT intervention in hip OA. Methods: A systematic search was carried out in electronic databases, in order to compile the available literature between the years 2000 and 2019, taking as reference the PRISMA statement for systematic reviews. Letters to the editor, bibliographic reviews and gray literature were excluded. Results: After reviewing 30 articles, we included 7 RS and 14 RCTs. 7 RCTs measured pain intensity of OA in response to MT vs. a control group. 4 RCTs measuring pain intensity in hip OA using MT + Ex. Seven RCTs measured function in subjects with hip OA in response to MT vs. CG. Two RCTs evaluated the effects of MT + Ex on function. Discussion: Although the results were in favor of manual therapy, compared to the control group, these were not statistically signifi cant, so we propose to car
... Although OA is a progressive and degenerative disease that can naturally worsen over time regardless of intervention, the best available evidence seems to favor exercise therapy for short-term pain relief, requiring more RCTs to confirm the duration of the effect. In addition, these exercise programs must be personalized and should be introduced gradually as the patient is able to tolerate it (34). ...
... Seven randomized clinical trials were identified that have measured the pain intensity of hip OA by subjecting subjects to a TM intervention compared to a control group of which 4 (34,36,37,(40)(41)(42)(43)(44)(45)(46)(47) (Table III) Table III). ...
... Four randomized clinical trials were identified that have measured the pain intensity of hip OA when subjecting subjects to an intervention with MT + Ex in conjunction with exercises, within which 2 studies used the Visual Analog Scale (34,36,37,40,45,46) to measure the intensity of pain. The remaining 2 studies used the NPRS (37) and the WOMAC pain section (36) ( Table IV) ...
... Aber woher kommt diese Entwicklung? Tatsächlich gilt es zu akzeptieren, dass als Schlussfolgerung vieler Reviews zur Effektivität von Manueller Therapie die traditionelle Manuelle Therapie (überwiegend passive Bewegungen wie Mobilisation und Manipulation am Individuum) weniger effektiv ist als in Kombination mit aktiven Therapien und alleinige passive Anwendungen nicht besser sind als ein Placebo [1][2] [3]. Damit öffnet die IFOMPT logischerweise auch die Türen für andere Denkmodelle, die psychosoziale Einflüsse und die externe Evidenz unseres professionellen Handelns hinterfragt. ...
... Ich bin teilweise seiner Meinung und möchte dies anhand von einigen Beispielen erläutern: ▪ Laut Dr. Harriette Wittink, Lektorin an der Hogeschool Utrecht (Niederlande), haben "Hands-on-Techniken" bei langwierigen Rückenbeschwerden im Vergleich zu normalem Bewegen nur ein minimales Outcome. Das übergeordnete Endziel "Lebensqualität" lässt sich besser durch regelmäßiges Bewegen als mit Manueller Therapie erreichen [3]. ▪ Dr. Lisa Roberts, Physiotherapeutin und Psychologin, hat durch wissenschaftliche Untersuchungen festgestellt, dass ein Therapeut, der während der Therapie systematisch "lacht", deutlich bessere Effekte erzielt als mit "Hands-on-Techniken" ohne systematisches Lachen. ...
... ▪ Dr. Lisa Roberts, Physiotherapeutin und Psychologin, hat durch wissenschaftliche Untersuchungen festgestellt, dass ein Therapeut, der während der Therapie systematisch "lacht", deutlich bessere Effekte erzielt als mit "Hands-on-Techniken" ohne systematisches Lachen. Daher erachtet sie die Rolle von "Hands-on-Techniken" für weniger wichtig [3]. ...
... However, there is inconclusive evidence on the overall effects of OMT treatment [19]. Previous studies have demonstrated promising effects of OMT in reducing pain and improving physical function in patients with knee OA [7,8,10,20,21], but isolated effectiveness of OMT has not been well-established [22,23]. In addition, only two systematic reviews and meta-analyses have been published indicating effectiveness of OMT and exercise for managing pain and functional limitations in individuals with knee OA [9,23]. ...
... Previous studies have demonstrated promising effects of OMT in reducing pain and improving physical function in patients with knee OA [7,8,10,20,21], but isolated effectiveness of OMT has not been well-established [22,23]. In addition, only two systematic reviews and meta-analyses have been published indicating effectiveness of OMT and exercise for managing pain and functional limitations in individuals with knee OA [9,23]. However, French et al. [23] study included only 4 trials out of which 3 had a high risk of bias, whereas, Jansen et al. [9] study did not assess risk of bias in their included trials. ...
... In addition, only two systematic reviews and meta-analyses have been published indicating effectiveness of OMT and exercise for managing pain and functional limitations in individuals with knee OA [9,23]. However, French et al. [23] study included only 4 trials out of which 3 had a high risk of bias, whereas, Jansen et al. [9] study did not assess risk of bias in their included trials. Therefore, this systematic review and meta-analysis aimed to evaluate the effects of OMT on pain, functional disability, ROM, and physical performance in patients with knee OA. ...
Objective:
This systematic review to aimed to evaluate the effects of orthopaedic manual therapy (OMT) on pain, improving function, and physical performance in patients with knee osteoarthritis (OA).
Data sources:
Four databases (PubMed, Web of Science, CENTRAL, and CINAHL) were searched.
Study selection:
Trials were required to compare OMT alone or OMT in combination with exercise therapy, with exercise therapy alone or control.
Data extraction:
Data extraction and risk assessment were done by two independent reviewers. Outcome measures were visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score, WOMAC function score, WOMAC global score, and stairs ascending-descending time.
Results:
Eleven randomized controlled trials were included (494 subjects), four of which had a PEDro score of 6 or higher, indicating adequate quality. The results of the meta-analysis indicated that reduction of VAS score in OMT compared with the control group was statistically insignificant (SDM: -0.59; 95% CI: -1.54 to -0.36; P=0.224). The reduction of VAS score in OMT compared with exercise therapy group was statistically significant (SDM: -0.78; 95% CI: -1.42 to -0.17; P=0.013). The reduction of WOMAC pain score in OMT compared with the exercise therapy group was statistically significant (SDM: -0.79; 95% CI: -1.14 to -0.43; P=0.001). Similarly, the reduction of WOMAC function score in OMT compared with the exercise therapy group was statistically significant (SDM: -0.85; 95% CI: -1.20 to -0.50; P=0.001). However, the reduction of WOMAC global score in OMT compared with the exercise therapy group was statistically insignificant (SDM: -0.23; 95% CI: -0.54 to -0.09; P=0.164). The reduction of stairs ascending-descending time in OMT compared with the exercise therapy group was statistically significant (SDM: -0.88; 95% CI: -1.48 to -0.29; P=0.004).
Conclusions:
This review indicated OMT compared with exercise therapy alone provides short-term benefits in reducing pain, improving function, and physical performance in patients with knee OA.
Review registration:
PROSPERO 2016:CRD42016032799.
... It is highly prevalent among the ageing population and is diagnosed in approximately 10% of men and 18% of women older than 60 years (5,29,57,58). OA occurs most frequently in the hip and the knee joint (27,31,57). In the knee joint, the medial tibiofemoral compartment is the most frequently affected (9). ...
... Based on radiography, OA is characterized by progressive degeneration of the articular cartilage (5,12,17,19,57). This cartilage degeneration includes osteophyte formation, subchondral cysts, joint space narrowing and sclerosis of the subchondral bone (12,17,27,29). The presence of symptoms only, can lead to the clinical diagnosis of OA (29). ...
Osteoarthritis of the knee causes chronic knee pain, loss of function and disability in the ageing population. When no treatment is applied, a guaranteed onset of symptoms and/or structural damage can be observed in the diseased knee. This work reviewed the different published guidelines, proposing combinations of weight reduction, physical therapy and rehabilitation, self-management education programs and pharmacological treatment. Randomized clinical trials, systematic reviews and guidelines were identified using the databases PubMed and Web of Science. Specific journals and reference lists were investigated. Sixty high quality articles were included concerning the conservative treatment of knee osteoarthritis. Weight loss when BMI > 28kg/m 2 ; aerobic, proprioception and strengthening training; NSAIDs (ibuprofen, diclofenac, aceclofenac), IA corticosteroid and IA hyaluronic acid has the highest evidence. To achieve the greatest positive clinical and structural outcome, a combined conservative therapy is recommended.
... Abbott et al. [37] also confirms this long-term results however, of all evaluated outcomes, significant statistical differences (P < 0.05) were only obtained in WOMAC comparing with the other groups (the differences between the authors may be explained by the protocols used and the physical therapists years of experience [36]). Other systematic reviews also confirm the positive effects of MM in these patients [36,110,111]. ...
... Menichini et al. evaluated the effects of vitamin D supplementation in women with PCOS. Considering the increasing evidence supporting the contribution of vitamin D deficiency in metabolic disturbances, they reported that high doses of vitamin D compared to low dose and placebo demonstrated beneficial effects on total testosterone, FAI and SHBG and suggested that vitamin D supplementation at high doses may be useful for insulin resistance, hyperlipidemia and hormonal functions [111]. ...
Surgical intervention plays a crucial role in the diagnosis, staging, and treatment of malignant pleural mesothelioma (MPM) and can apply with curative intent using extended pleurectomy/decortication or extrapleural pneumonectomy (EPP). EPP is defined as the en-bloc resection of the pleura, lung, diaphragm, and pericardium, excision of previous biopsy and chest tube sites, and radical mediastinal lymphadenectomy and other lymph nodes such as found in the mammary chain, along the intercostal structure and in the costodiaphragmatic region, as well as reconstruction of the diaphragm and pericardium with prosthetic patches to prevent herniation. It was shown that EPP could be performed with acceptable morbidity and mortality. One of the most complex decisions is the surgical indication. Laparoscopy or contralateral pleuroscopy should be performed in case of suspicion of intra-abdominal or contralateral disease in staging imaging. Mediastinal staging is performed via endobronchial ultrasound or mediastinoscopy to exclude N3 disease. The analysis of prognostic factors to identify patient groups benefitting from multimodality therapy led to the development of different prognostic scores, such as the Multimodality Prognostic Score Technical experience has led to decreased operative times and surgical adaptations that include the reconstruction of the diaphragm and pericardium with mesh in all patients regardless of side, buttressing of the bronchial stump with well-vascularized tissue, and advanced methods of haemostasis including argon beam coagulation and topical haemostatic agents for chest wall bleeding.
... The overall number of sessions across all the included studies ranged from 12 to 48, with a median of 18 [16][17][18][19][20][21][22][23][24] sessions per study. The duration of the exercise programs exhibited variability, spanning from 4 to 12 weeks, with a mean duration of 7.1 (2.6) weeks. ...
Background/Objective: Knee osteoarthritis (OA) is a common and debilitating condition affecting older adults, often progressing to advanced stages and requiring total joint replacement. Exercise therapy is widely recognized as the first-line approach for the prevention and initial management of OA. This systematic review assessed the effectiveness of home-based exercises (HBEs) compared to supervised exercises in alleviating pain and reducing disability among patients with knee OA. Methods: A systematic search of PubMed, Cochrane Library, and ScienceDirect identified randomized controlled trials (RCTs) published between January 2001 and October 2024. Methodological quality was evaluated using the Physiotherapy Evidence Database (PEDro) scale, and a meta-analysis was conducted to quantify the efficacy of these interventions. Results: Ten RCTs involving 917 patients were included, ranging in moderate to high methodological quality (PEDro score: 6.3 ± 1.2). Intervention durations ranged from 4 to 12 weeks. Both supervised and HBEs were found to be effective, but supervised exercises demonstrated statistically significant improvements in pain (SMD = −0.45 [95% CI −0.79; −0.11], p = 0.015) and disability (SMD = −0.28 [95% CI −0.42; −0.14], p < 0.001) compared to HBEs. Conclusions: Despite the superiority of supervised exercises over HBEs, considering the cost-effectiveness and ease of implementation of HBEs, we developed recommendations to create a hybrid rehabilitation program that combines both approaches to maximize clinical outcomes.
... The technique is based on the principles of assessing and treating movement restrictions and pain through graded oscillatory movements [11,12] Clinical studies have demonstrated the effectiveness of the Maitland technique in managing OA symptoms. Joint mobilizations can significantly reduce pain and improve function in OA patients, particularly when combined with exercise therapy [13]. The combination of manual therapy and exercise is believed to have synergistic effects, maximizing the benefits for patients with OA. ...
Background: Hip osteoarthritis (OA) is a prevalent and debilitating condition characterized by pain, stiffness, and reduced functional ability. This study aimed to compare the effectiveness of eccentric and concentric exercises, both alone and in combination with the Maitland technique, in managing Hip OA. Methods: A randomized controlled trial was conducted with 100 participants diagnosed with Hip OA. Participants were randomly assigned to one of four intervention groups: eccentric exercise, concentric exercise, eccentric exercise combined with the Maitland technique, and concentric exercise combined with the Maitland technique. The interventions were administered over a 12-week period, with follow-up assessments at 24 weeks. Key outcomes measured included pain intensity (VAS), functional ability (WOMAC), quality of life (SF-36), muscle strength (isokinetic dynamometry), and joint range of motion (goniometry). Results: The eccentric exercise combined with Maitland technique group demonstrated the most substantial improvements across all outcomes. This group exhibited the greatest reduction in VAS pain scores, the most pronounced improvements in WOMAC scores, and the highest gains in both physical and mental components of the SF-36. Conclusion: Combining eccentric exercises with the Maitland technique offers superior benefits in managing Hip OA compared to either intervention alone or concentric exercises
... They can be utilized either individually or in combination during a session [25]. The choice of technique(s) is influenced by the clinical (e.g., experience), patient (e.g., personal characteristics, clinical status, and preferences) and external factors (e.g., session time) [135]. By applying these techniques, it is expected to Ref. [136]: improve tissues mobility and function; restore movement, stretching, or ROM; improve muscle activation and timing; decrease pain; and improve circulation. ...
Objective: This umbrella review aimed to summarize (and update) the effectiveness of non-pharmacological andnon-surgical interventions for patients with knee osteoarthritis.Methods: The study followed the PRISMA guidelines. Manual and electronic databases were searched, to identifysystematic reviews, following the P (knee osteoarthritis) I (non-pharmacological and non-surgical treatments) C(pharmacological, surgical, placebo, no intervention, or other non-pharmacological/non-surgical conservativetreatments) O (pain, function, quality of life, and other knee-specific measures) model. The quality of evidencewas assessed using the R-AMSTAR checklist and GRADE principles.Results: The search yielded 4086 records, of which 61 met the eligibility criteria. After evaluation with R-AMSTAR, four systematic reviews were excluded, resulting in 57 included systematic reviews, with an overallscore of 29.6. The systematic reviews were published between 2018 and 2022 (29.8% in 2022), conducted in 19countries (52.6% in China), and explored 24 distinct interventions. The systematic reviews encompassed 714trials (mean of 13 � 7.7 studies per systematic review), and 59,343 participants (mean 1041 � 1002 per sys-tematic review, and 82 � 59.2 per study). The majority of participants were older obese women (61.6 � 4.2 years,30.2 � 3.6 kg/m2, 70%, respectively).Conclusions: Based on the systematic reviews findings, Diet Therapy, Patient Education, and Resistance Trainingare strongly supported as core interventions for managing patients with knee osteoarthritis. Aquatic Therapy,Balance Training, Balneology, Dietary Supplements, Extracorporeal Shockwave Therapy, and Tai Ji show mod-erate support. For other interventions, the evidence quality was low, results were mixed or inconclusive, or therewas not sufficient efficacy to support their use.
... As an intervention that physical therapists continue to utilize and that patients perceive as beneficial (21), manual therapy may have the ability to provide a window of opportunity to enable active intervention approaches, such as exercise (21,22). To better understand their applicability and generalizability in real-world clinical practice, it is important to understand where manual therapy trials fall along the explanatory-pragmatic spectrum (5,9,23,24). The Rating of Included Trials on the Efficacy-Effectiveness Spectrum (RITES) tool was developed to enable the assessment of published trials along this spectrum (19), but has not yet been used to assess knee OA trials. ...
Introduction: Manual therapy is an often-utilized intervention for the management of knee osteoarthritis (OA). The interpretation of results presented by these trials can be affected by how well the study designs align applicability to real-world clinical settings. Aim: To examine the existing body of clinical trials investigating manual therapy for knee OA to determine where they fall on the efficacy-effectiveness spectrum. Methods: This systematic review has been guided and informed by the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Randomized controlled trials that investigated manual therapy treatments for adults with knee OA were retrieved via searches of multiple databases to identify trials published prior to April 2023. The Rating of Included Trials on the Efficacy-Effectiveness Spectrum (RITES) tool was used to objectively rate the efficacy-effectiveness nature of each trial design. The Cochrane Risk of Bias 2.0 assessment tool (RoB-2) was used to assess the risk of bias across five domains. Results: Of the 36 trials, a higher percentage of trials had a greater emphasis on efficacy within all four domains: participant characteristics (75.0%), trial setting (77.8%), flexibility of intervention (58.3%), and clinical relevance of experimental and comparison intervention (47.2%). In addition, 13.9% of the trials had low risk of bias, 41.7% had high risk of bias, and 44.4% had some concerns regarding bias. Conclusions: While many trials support manual therapy as effective for the management of knee OA, a greater focus on study designs with an emphasis on effectiveness would improve the applicability and generalizability of future trials.
... Despite positive results in some painful joint conditions (shoulder, elbow, and ankle) and preliminary results from a case series of patients with knee OA (Abbott, 2001, Collins et al., 2004, Dimitrova, 2008, Anap, 2012, Djordjevic et al., 2012and Takasaki et al., 2013, the effects of MWM on the hip have not been investigated in isolation. Thus, there is a need for further research to confirm the effectiveness of manual therapy intervention in hip OA (French et al., 2011). Due to the conflicting evidence regarding the efficacy of manual therapy for hip OA (Abbott et al., 2013 andBennell et al., 2014), new studies are required to determine whether alternate forms of manual therapy (such as MWM), that have not been investigated in isolation may be effective in hip OA. ...
Study Objectives: To determine the immediate effects of a single session of MWM on hip pain in people with hip OA. The secondary objective was to evaluate the immediate effects of MWM on hip ROM and physical performance in these subjects. Design: A double blind randomized placebo controlled trial. Setting: Subjects were taken from Out patient Physiotherapy Dept. of Jaipur Physiotherapy College, Maharaj Vinayak Global University Jaipur and different hospitals in Jaipur. Methods: A total of 40 subjects were recruited for the study on the basis of inclusion and exclusion criteria after signing the informed consent form. The subjects were randomly allocated into two Groups (experimental (MWM group) and placebo (sham intervention group). Outcome Measure: Pain thresh hold was measured using NPRS (Numeric Pain Rating Scale), Hip flexion and internal rotation ROM, The Timed Up and Go (TUG) test, The 30s Chair Stand (CS) test, The 30s Chair Stand (CS) test. Result: We took the baseline and post-intervention data as well as within-group and between-groups differences for hip pain, hip ROM and functional tests. The intensity of pain (F = 29.06, P < 0.01). 16 patients receiving MWM, in contrast to 2 patients receiving sham mobilisation, experienced a decrease in hip pain more than the MDC of 0.83. A significant Group by Time interaction was detected for hip flexion (F = 74.13; P < 0.01) and hip internal rotation (F = 18.38; P < 0.01) ROM. An ANOVA also revealed a significant Group by Time interaction for all functional tests (TUG: F = 10.00, P < 0.01; CS: F = 29.46, P < 0.01; SPW: F = 23.80, P < 0.01). Conclusion: This study showed that pain immediately decreased, hip flexion and internal rotation ROM and physical function improved after a single session of hip MWM in elderly subjects suffering hip OA. Although the observed immediate changes are greater than the MDC and previous reports for MCID, more research is necessary to determine long-term efficacy.
... [16][17][18] Decreased level of estrogen for long period of time can result into decreased bone mineral density, reduction in muscle strength and flexibility, impairment of muscle performance and functional capacity. [23,24] It is strong evidence that exercises is becoming one of the most important alternative treatment procedures. [26,27] There are some researches that stated that resistance training may result in increased muscle strength, range of motion and functional ability with patients of knee osteoarthritis. ...
... Manual therapy was defined as the application of manual force to the cervical joint, muscles, or connective tissues using techniques such as massage therapy, joint mobilization, and/or manipulation. 23 The control intervention could be no intervention or a placebo intervention. Session duration, session frequency, and program duration were recorded to assess the similarity of the studies. ...
Aims:
To examine the effect of manual therapy applied to the cervical joint for reducing pain and improving mouth opening and jaw function in people with TMDs.
Methods:
A systematic review of randomized controlled trials was performed. Participants were adults diagnosed with TMDs. The experimental intervention was manual therapy applied to the cervical joint compared to no intervention/placebo. Outcome data relating to orofacial pain intensity, pressure pain threshold (PPT), maximum mouth opening, and jaw function were extracted and combined in meta-analyses.
Results:
The review included five trials involving 213 participants, of which 90% were women. Manual therapy applied to the cervical joint decreased orofacial pain (mean difference: -1.8 cm; 95% CI: -2.8 to -0.9) and improved PPT (mean difference: 0.64 kg/cm2; 95% CI: 0.02 to 1.26) and jaw function (standardized mean difference: 0.65; 95% CI: 0.3 to 1.0).
Conclusion:
Manual therapy applied to the cervical joint had short-term benefits for reducing pain intensity and improving jaw function in women with TMDs. Further studies are needed to improve the quality of the evidence and to investigate the maintenance of benefits beyond the intervention period.
... 31 The joint mobilization techniques were found to modulate pain and also improve extensibility of contractile tissues and movement of joints. 32 Its neurophysiological effects are mechanoreceptor mediated pain gate analgesia blocking nociception at spinal cord dorsal horn; periaqueductal grey matter and rostro-ventral medulla mediated descending pain inhibition mostly through activity of noradrenaline and to some extent opioids and serotonin causing reduction in maladaptive cognitive-affective mechanisms observed in pain neuromatrix. 33 A case series 34 and RCT 35 reported immediate improvements after Mulligan's mobilization alone, on passive knee flexion range of motion and knee pain scores in OA. ...
Objectives: The purpose of the study was to compare the effect of Mobilisation with Movement and conventional physiotherapy in patients with unilateral medial compartment tibiofemoral knee osteoarthritis. Methods: A total of 30 subjects with osteoarthritis knee diagnosed clinically were included in the study and randomised equally into two groups, 15 in each. Group A had Mobilisation with Movement and Group B underwent conventional physiotherapy.The outcome measures used were Visual Analogue Scale (VAS) and Oxford knee score (OKS). The measurement were taken at baseline and after 2 weeks of intervention. Results: The paired and unpaired t tests were used to compare within and between the groups respectively. Both the groups improved in pain and Oxford knee score, but Group A improved significantly more in Visual analogue scale (VAS) (P<0.0001) and Oxford knee score (OKS) (P <0.0405) than Group B. Conclusion: The study concluded that Mobilisation with Movement (MWM) provides superior benefits over conventional physiotherapy in improving the pain and functions. Keywords: Knee Osteoarthritis, Mobilisation with Movement, Shortwave diathermy, VAS, OKS
... . 특히 국내 해양자원을 연계한 해 양치유센터의 개발 사업이 현재 진행되고 있으며, 지역주 민뿐만 아니라 국내 및 해외 만성 질환자의 건강증진 및 삶의 질 향상 등 웰니스 증진의 일환으로 연계할 수 있다 (이성재, & 이한석, 2019 (이현옥, 2012;인창식, 2013;French et al., 2011;Miller et al., 2010). ...
... In our study, just a few randomized control trials (RCTs) was in line with the results presented by Whittaker et al [71]. Besides, some other RCTs reported that the therapeutic efficiency of manual therapy, myofascial release technique, and Swedish massage could not be confirmed easily and needs further investigation [17,72]. ...
Background: One of the most destructive forms of arthritis is knee osteoarthritis (KOA) that leads to disability because of pain in elderly individuals and also increases utilization of health care among them. Through improving local circulation and joint flexibility, and relaxation of muscles, massage therapy is capable of relieving painful musculoskeletal conditions. Therefore, it may be beneficial for treatment of KOA. Moreover, the successfulness of exercise therapy in treatment of KOA broadly is proved and required to be reviewed more. Through a comprehensive review, the present study is aimed to investigate the role of massage therapy on knee osteoarthritis. Method: A literature search was carried out using the five most well-known databases of Europe PubMed, PubMed, EMBASE, MEDLINE, and Google Scholar from 2010 to 2020. All the articles were searched in English with the main subject of massage therapy on knee osteoarthritis. During the search from all 284 searched, articles 189 deleted due to the subject similarity and finally, 82 article were chosen to be included in the research inclusion criteria. Results: Manual therapy is an effective treatment option in the management of KOA patients. It could be used alone or in combination with other available types of therapies. Conclusion: The present study provides a general set of information about manual therapy and its effectiveness in the management of KOA patients.
... This can be attributed to the different findings of the relevant research studies, which lack consensus regarding main outcomes and conclusions. Although according to several studies which investigated the effectiveness of MT in knee OA, the use of MT techniques in OA patients has been advocated, important variables such as the actual short-and long-term effects of the intervention, the dosage of the OA medication used and the effects of the combined application with other techniques (therapeutic exercise) remain unclear [13][14][15][16]. Considering the above-mentioned scientific deficit, in this systematic review, we evaluated previous studies to assess the effect of MT on knee OA symptoms. ...
Background and objectives: Osteoarthritis (OA) is among the most common degenerative diseases that induce pain, stiffness and reduced functionality. Various physiotherapy techniques and methods have been used for the treatment of OA, including soft tissue techniques, therapeutic exercises, and manual techniques. The primary aim of this systemic review was to evaluate the short-and long-term efficacy of manual therapy (MT) in patients with knee OA in terms of decreasing pain and improving knee range of motion (ROM) and functionality. Materials and Methods: A computerised search on the PubMed, PEDro and CENTRAL databases was performed to identify controlled randomised clinical trials (RCTs) that focused on MT applications in patients with knee OA. The keywords used were ‘knee OA’, ‘knee arthritis’, ‘MT’, ‘mobilisation’, ‘ROM’ and ‘WOMAC’. Results: Six RCTs and randomised crossover studies met the inclusion criteria and were included in the final analysis. The available studies indicated that MT can induce a short-term reduction in pain and an increase in knee ROM and functionality in patients with knee OA. Conclusions: MT techniques can contribute positively to the treatment of patients with knee OA by reducing pain and increasing functionality. Further research is needed to strengthen these findings by comparing the efficacy of MT with those of other therapeutic techniques and methods, both in the short and long terms.
... Lower limb joint mobilizations and manipulation have been explored in some musculoskeletal conditions of the lower limb, such as patellofemoral pain syndrome, hip and knee osteoarthritis, but studies in tendinopathies are scarce [78][79][80][81][82]. Only two case reports have been conducted aiming to evaluate the efficacy of joint mobilization and manipulation in Achilles tendinopathy (Table 3) [34,83]. ...
Objective: To summarize the available literature with regards to the potential analgesic effect and mechanism of joint mobilization and manipulation in tendinopathy. Results: The effect of these techniques in rotator cuff tendinopathy and lateral elbow tendinopathy, applied alone, compared to a placebo intervention or along with other interventions has been reported in some randomized controlled trials which have been scrutinized in systematic reviews. Due to the small randomized controlled trials and other methodological limitations of the evidence base, including short-term follow-ups, small sample size and lack of homogenous samples further studies are needed. Literature in other tendinopathies such as medial elbow tendinopathy, de Quervain's disease and Achilles tendinopathy is limited since the analgesic effect of these techniques has been identified in few case series and reports. Therefore, the low methodological quality renders caution in the generalization of findings in clinical practice. Studies on the analgesic mechanism of these techniques highlight the activation of the descending inhibitory pain mechanism and sympathoexcitation although this area needs further investigation. Conclusion: Study suggests that joint mobilization and manipulation may be a potential contributor in the management of tendinopathy as a pre-conditioning process prior to formal exercise loading rehabilitation or other proven effective treatment approaches.
... Copyright © 2020. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted non-commercial use, distribution, and reproduction in any medium provided article is properly cited the physiotherapist can use manual therapy as a solid treatment base (13)(14)(15) . One of these manual therapy techniques includes Mobilization with Movement (MWM), a type of joint mobilization developed by Brian Mulligan (16,17) . ...
Introduction: The Mulligan concept is a manual therapy technique that addresses the restoration of arthrocinematic processes and inadequate osteocinematic movements, resulting in reduced muscle tension, postural failure and pain relief. Objectives: To analyze the effectiveness of the Mulligan concept in reducing lower limb pain processes in classical dancers. Methods: Longitudinal study, approved by the Ethics and Research Committee of the Universidade Estadual do Piauí, according to the decision of No. 2064503, composed by 4 classical dancers. An evaluation of the pain level was performed using a digital algometer (Wagner Instruments) with a ten-kilogram-force (Kgf) capacity in dancers who presented painful symptoms in the knee. The level pain before and after the intervention with the Mulligan concept was verified in the following points: patellar ligament (PL), medial collateral ligament (MCL) and lateral collateral ligament (LCL). The Mulligan concept was performed actively, painlessly, with adjustments by the therapist and was maintained at the end of the knee amplitude for 10 seconds. This protocol was repeated 3 times in the first attendance, in the second 10 times, in the third there were 2 repetitions of 10 slides and in the subsequent attendances there were 3 repetitions of 10 slides. Results: An increase in the average of the pain threshold in patellar, medial collateral and lateral collateral ligaments was observed in all participants of the study, when comparing the initial values of the 1st care and the final values of the 12th Mulligan session. The lateral collateral ligament presented the most significant result, with p = 0.02. Statistical analysis was performed through the BioEstat 5.0 program. The Shapiro-Wilk tests were applied to assess the normality of variables, and the t-student test was considered statistically significant p<0.05. Conclusion: statistically the lateral collateral ligament showed an immediate and lasting significant improvement in the pain threshold of the dancers with the therapeutic intervention of the Mulligan concept.
... The results of the 2013 systematic review (85) show that manual therapy can improve joint pain and function in patients with knee OA, and has good short-term and longterm effects. The results of the 2011 systematic review (86) show that manual therapy is effective in improving shortterm and long-term pain and physical function in patients with hip OA compared with exercise therapy. In summary, OA patients can use manipulation therapy, massage and other methods to relieve pain and improve physical function. ...
Osteoarthritis (OA) is a degenerative disease of middle-aged and elderly people, contributed a higher burden of disease in China and the world. In 2017, under the support of the Rheumatology and Immunology Expert Committee of the Cross-Strait Medical and Health Exchange Association. The objective was to develop an evidence-based diagnosis and treatment guideline for OA in China based on emerging new evidence. The guideline was registered at International Practice Guidelines Registry Platform (IPGRP-2018CN028). The grading of recommendations assessment, development and evaluation (GRADE) approach was used to rate the quality of evidence and the strength of recommendations, and the RIGHT (Reporting Items for Practice Guidelines in Healthcare) checklist was followed to report the guideline. The guideline provides recommendations for the OA diagnosis, disease risks monitoring and evaluate, treatment purpose and physical, medical and surgical interventions. This guideline is intended to serve as a tool for Chinese clinicians for the best decisions-making on diagnosis and treatment of OA.
... Manual therapy (MT) is a physical treatment used by a variety of therapists to treat mainly musculoskeletal pain and disability [10]. It includes massage, joint mobilization/manipulation, myofascial release, nerve manipulation, strain/counterstrain, and acupressure [11]. ...
Objectives
The aim of this study was to quantify and analyze the presence and type of self-acknowledged limitations (SALs) in a sample of manual therapy (MT) randomized controlled trials.
Study Design and Setting
We randomly selected 120 MT trials. We extracted data related to SALs from the original reports and classified them into 12 categories. After data extraction, specific limitations within each category were identified. A descriptive analysis was performed using frequencies and percentages for qualitative variables.
Results
The number of SALs per trial article ranged from 0 to 8, and more than two-thirds of trials acknowledged at least two different limitations. Despite its small proportion, 9% of trials did not report SALs. The most common limitation declared, in almost half of our sample, related to sample size (47.5%) followed by limitations related to study length and follow-up (33.3%) and inadequate controls (32.5%).
Conclusion
Our results indicate that at least two different limitations are consistently acknowledged in MT trial reports, the most common being those related to sample size, study length, follow-up, and inadequate controls. Analysis of the reasons behind the SALs gives some insights about the main difficulties in conducting research in this field and may help develop strategies to improve future research.
... 7 Manual therapy is a technique used to treat musculoskeletal dysfunctions and pain and usually includes manual therapies, such as massages, joint mobilization, and manipulations. 8 In the literature, manual therapy protocols show positive results in improving the symptoms caused by KOA, such as pain, stiffness, and functional aspects. 9 Studies have shown that joint mobilization therapies have proved to be a benefit in the management of pain (hypoalgesia) 10,11 as well in the predominance of mechanical alterations in the affected joint, such as significant gains in the range of motion (ROM) 12 and proprioception. ...
Objective
To evaluate the short-term effects of Mulligan's mobilization with movement (MWM) on pain, physical function, emotional aspects, and proprioceptive acuity after a 2-week treatment period and throughout a 3-week follow-up period.
Methods
A single group of 30 participants (60.96 ± 5.16 years) with symptomatic knee osteoarthritis (KOA) was evaluated. The protocol involved 5 evaluations moments, before (baseline) and after 2 weeks of intervention (24 hours after the last session), and at 3-week follow-up. The intervention included 3 Mulligan's MWM techniques. The variables evaluated were pain (pressure pain threshold and Visual Numeric Scale), physical function (range of motion, proprioceptive acuity, and the Western Ontario and McMaster Universities Osteoarthritis Index) and emotional aspects (Beck Depression Inventory). Analysis of variance for repeated measures was used considering a significance level of 5%.
Results
At the second evaluation (after intervention), the pressure pain threshold presented higher values for rectus femoris, tibialis anterior, and patellar tendon sites and reduced values for the Visual Numeric Scale, Beck Depression Inventory, and Western Ontario and McMaster Universities Osteoarthritis Index compared with baseline. Also, during the follow-up period, all variables returned close to baseline levels. Proprioceptive acuity and range of motion did not present significant changes.
Conclusion
Scores for pain relief, physical function, and emotional aspects improved after a course of MWM in this single group of individuals with KOA. Mobilization with movement had limited outcome during follow-up. It suggests that future clinical trials on the use of MWM for KOA should be considered.
... Manual therapy refers to a group of methods used by physiotherapists, osteopaths, and chiropractors, with special training [12], to improve the range of motion [13] and function [14,15] and decrease pain [16] at the knee joint. From the point of view of terminology, the term manual therapy includes a lot of different techniques. ...
Objectives:
The purpose of this study was to evaluate the impact of manual therapy on the management of rheumatoid arthritis (RA) patients with knee pain.
Materials and methods:
This was a small, randomized clinical pilot study. Subjects were 46 patients with diagnosed RA, randomly assigned to the manual therapy group (postisometric relaxation and joint mobilization) or control group (standard exercise). Subjects in each group had 10 sessions of interventions, once a day with one day break after the sixth day. Outcomes included the pain intensity of knee, Knee Society Score, Oxford Knee Score, and Health Assessment Questionnaire.
Results:
There were no statistically significant differences between groups, except for the pain intensity of the knee.
Conclusions:
This study suggests that manual therapy (postisometric relaxation and joint mobilization) may have clinical benefits for treating knee pain and function in rheumatoid patients. Further extended studies are expected to determine the effectiveness of manual therapy in RA patients with knee pain.
... [9][10] Several studies have revealed the positive effects of joint mobilization with exercise in the management of KOA. [11][12] The American College of Rheumatology (ACR) also recommends that patients with knee OA receive manual physical therapy in combination with knee strengthening exercises under the supervision of a quali ed physiotherapist. 13 In 1980, Brian Mulligan proposed a joint mobilization technique for the management of various musculoskeletal conditions to increase movement and reduce joint pain. ...
Background
Knee Osteoarthritis (KOA) has a huge negative impact on gait parameters and on many components of biomechanics, including impairment of dynamic lower limb alignment and control of lumbopelvic movement. Specifically addressing these problems in treatment regimens is therefore critical but they must first be studied in detail before they can be used clinically to treat patients with KOA. This study protocol focuses on whether Mulligan joint mobilization with movement demonstrably decreases pain and restores healthy joint biomechanics and whether trunk stabilization exercises improve stability of the trunk, thereby distributing the weight of the body evenly on both feet. Because the treatment effects of neither treatment are conclusive, this study aims to determine their efficacy versus isometric knee strengthening.Method:The study protocol is a three-arm randomized controlled trial. After initial screening by a referring consultant, subjects who fulfil the study criteria will be randomly assigned to one of three groups. They will then be given an explanation of study objective and asked for their informed consent to participate in the study. Group 1 will receive Mulligan mobilization with kinesiotaping and knee strengthening. Group 2 will receive trunk stabilization exercises, knee strengthening, and kinesiotaping. Group 3 will receive knee strengthening along with kinesiotaping. All participants will be evaluated using a visual analogue scale, Knee injury and Osteoarthritis Outcome Score, stair climb test and 6-minute walk test at the baseline, 3rd and end of 6th week.DiscussionThe results of this study will answer focused questions concerning the relative efficacy of each treatment in KOA patients. The findings of this study will inform clinical decision-making by healthcare professionals and researchers.Trial registration: NCT04099017
... Several studies have revealed the positive effects of joint mobilization with exercise in the management of KOA. [11][12] The American College of Rheumatology (ACR) also recommends for patients with knee OA to receive manual physical therapy in combination with knee strengthening exercises under the supervision of a qualified physiotherapist. 13 In 1980, Brian Mulligan proposed a joint mobilization technique for the management of various musculoskeletal conditions to reduce movement restriction and joint pain. ...
Knee Osteoarthritis (KOA) patients have a huge negative impact on gait parameters and altered biomechanics in many components, including impairments of dynamic lower limb alignment and lumbopelvic movement control. The understanding of these components seems to be very crucial and there is need to add these unfocused components in treatment regimens in the research setting to see its effects; before using as a routine treatment regime in Clinical practice for patients with KOA. This study protocol focuses on whether Mulligan joint mobilization with movement provides evident effects on decreasing pain and restoring the joint biomechanics. Trunk stabilization exercises improve the stability of the trunk which distributes the weight of the body evenly on both feet biomechanically. The treatment effects of both treatments are inconclusive. Accordingly, the study aims to determine the efficacy of Mulligan joint mobilizations and trunk stabilization exercises versus isometric knee strengthening for KOA. It is a study protocol of a three-arm randomized control trial. Initial screening of the subjects will be carried out by a referring consultant. Subjects who fulfill the study criteria will be randomly allocated into three groups After an explanation of study objective and obtaining informed consent. Group 1 will receive mulligan mobilization with kinesiotaping and knee strengthening. Group 2 will receive trunk stabilization exercise, knee strengthening, and Kinesiotaping. Group 3 will receive knee strengthening along with kinesiotaping. All participants will be evaluated using visual analogue scale, Knee injury and Osteoarthritis Outcome Score, stair climb test and 6-minute walk test at 1st, 3rd and 6th week. The results of this study will answer a clearly focused question investigated in KOA patients. Finding of this study will serve as a guide to inform clinical decision making for healthcare professionals, researcher, and patients.
Trial registration
NCT04099017
... The most common form of arthritis is OA, which is one of the main causes of pain and disability in individuals around the world. (French et al., 2011). Osteoarthritis is a major reason of functional disability. ...
This chapter introduces kinesiology of hip. It starts by anatomy (bones, static and dynamic stabilizers, veins and nerves) of hip. The chapter continues with biomechanics and osteokinematics of the hip. The relation between femur and pelvis is explained as kinesiology. Movements of the hip during walking and running are explained. At the end of the chapter, changes in the hips in neurological and orthopedic illness situations will be explained.
... Manual therapy (MT) is a physical treatment used by a variety of therapists to treat, mainly musculoskeletal pain and disability. It includes massage and soft tissue techniques, joint mobilization, and manipulation [1]. Since its origin, methods and approaches have evolved greatly [2]. ...
Objective:
The aim of this review was to evaluate a selection of major reporting aspects in manual therapy (MT) trials, before and after the publication of the CONSORT extension for non-pharmacological trials (CONSORTnpt) STUDY DESIGN AND SETTING: We randomly selected 100 MT trials published between 2000 and 2015 and divided them into a pre-CONSORTnpt (n=50) and a post-CONSORTnpt (n=50) group. We extracted data about relevant issues of internal validity, reliability and description of interventions. Two authors extracted data independently. Percentages were used for descriptive analyses and Fisher's exact test and the chi-square test were used for group comparisons.
Results:
Six different types of MT interventions with up to 20 controls were analyzed. The most common populations/conditions studied were healthy subjects and subjects with lower back or neck pain. Over 70% of studies included multi-session interventions and 42% of studies reported long-term follow-up. The only significant differences between groups were the inclusion of a flowchart diagram, the estimated effect size, precision descriptions and the description of intervention procedures.
Conclusion:
Our findings suggest that trials in MT show poor reporting even after availability of standardized guidelines.
... Manual therapy is not considered a core treatment for knee OA due to the lack of high quality evidence that currently exists. 9 However, almost 50% of individuals with knee OA use some form of complementary and alternative medicine, which includes manual therapy. 10 The existing evidence base supporting the use of manual therapy for knee OA is comprised of only a small number of trials and review papers. ...
Introduction:
The purpose of this study is to review the pain and functional outcomes of a multimodal intervention in three patients with knee osteoarthritis (OA). This study explores how manual therapy can be delivered within an evidence-based framework for the management of knee OA.
Methods:
Medical records were reviewed for three patients with knee OA who underwent a standardized multimodal intervention including education, exercise, and manual therapy. Changes in pain intensity and function from baseline to post-intervention were calculated and compared to thresholds for minimal clinically important differences.
Results:
One participant met the threshold for clinically significant improvement in pain and two participants for function. No adverse events were reported.
Conclusion:
Combined education, exercise, and manual therapy delivered over a 6-week period improved function in two of the three patients reviewed. Higher quality research is required to explore whether this multimodal intervention may improve outcomes in individuals with knee OA.
... Abbott et al. 40 also confirms this long-term results however, of all evaluated outcomes, significant statistical differences (P<0.05) were only obtained in WOMAC comparing with the other groups (the differences between the authors may be explained by the protocols used and the physical therapists years of experience 36 ). Other systematic reviews confirm the positive effects of MM in knee OA patients and propose that the neurophysiological effects through activating type II mechanoreceptors (inhibiting of type IV nociceptors, resulting in pain reduction) and the enhance of the Golgi tendon organ activity (causing muscle relaxation via reflex inhibition) are the main responsible mechanisms for reaching positive results 36, 113,114 . ...
OBJECTIVE
The aim of the present systematic review and meta-analysis is to know, based on the available randomized controlled trials, if the non-surgical and non-pharmacological interventions commonly used for knee osteoarthritis (OA) patients are effective and which are the most effective ones.
MATERIAL AND METHODS
RCTs were identified through electronic databases respecting the following terms to guide the search strategy: PICO (Patients - Humans with knee OA; Intervention - Non-surgical and non-pharmacological interventions; Comparison - Pharmacological, surgical, placebo, no intervention, or other non-pharmacological/non-surgical interventions; Outcomes - Pain, physical function and patient global assessment). The methodological quality of the selected publications was evaluated using the PEDro and GRADE scales. Additionally, a meta-analysis was performed using the RevMan. Only studies with similar control group, population characteristics, outcomes, instruments and follow-up, were compared in each analysis.
RESULTS
Initially, 52 RCTs emerge however, after methodological analysis, only 39 had sufficient quality to be included. From those, only 5 studies meet the meta-analysis criteria. Exercise (especially resistance training) had the best positive effects on knee OA patients. Pulsed Electromagnetic Fields and Moxibustion showed to be the most promising interventions from the others. Balance Training, Diet, Diathermy, Hydrotherapy, High Level Laser Therapy, Interferential Current, Mudpack, Neuromuscular Electrical Stimulation, Musculoskeletal Manipulations, Shock Wave Therapy, Focal Muscle Vibration, stood out, however more studies are needed to fully recommend their use. Other interventions did not show to be effective or the results obtained were heterogeneous.
CONCLUSIONS
Exercise is the best intervention for knee OA patients. Pulsed Electromagnetic Fields and Moxibustion showed to be the most promising interventions from the others options available.
... for poor posture and hyperkyphosis, and it has shown promising results as a conservative treatment [1,4]. Manual Therapy (MT) is a technique used to treat various musculoskeletal conditions including but not limited to adhesive capsulitis [6], subacromial impingement syndrome [7], and osteoarthritis [8]. Treatment using manual therapy techniques has not been studied as extensively as the other therapeutic modalities, and therefore a literature review on the topic was conducted to determine if it is a viable treatment for kyphotic posture. ...
Objective: To review the literature regarding the use of manual therapy techniques and their effectiveness on improving posture in adults. Background: Hyperkyphosis of the upper spine is a condition that increases with age and leads to decreased pulmonary function, balance, and muscle strength. Numerous reviews have looked at the effect of therapeutic exercise, but few have examined the effects of manual therapy techniques on hyperkyphotic posture.
... 21 However, there are conflicting results regarding the efficacy of rehabilitation programs. 22,23 A further understanding of GMed and GMin activity during functional tasks in people with hip OA could direct better rehabilitation strategies. ...
The gluteal muscles act as stabilisers of the hip joint and are important for the maintenance of hip function. Atrophy and weakness of the gluteal muscles has been identified in people with hip OA, but it is not known whether these muscles also exhibit altered activity patterns. The aim of this study was to compare gluteal muscle activity in people with hip OA and healthy older adults.
Fine wire intramuscular electrodes were inserted into the three segments of gluteus medius (GMed) and two segments of gluteus minimus (GMin) in 20 participants with unilateral hip OA and 20 age‐ and gender‐matched controls. Electromyographic activity of these muscle segments was examined during walking along a 10m walkway.
Peak amplitude, average amplitude and time to peak were compared between groups during the stance phase of the gait cycle.
During early stance, the OA group demonstrated a higher burst of activity in posterior GMin (p=0.02) and trends towards a higher peak in anterior GMin. Both groups displayed peak activity in anterior GMin in the early stance phase in contrast to previous reports in young adults. This early burst of muscle activity was more pronounced with increasing severity of OA. No differences were identified in GMed activity.
While altered GMin activity is associated with ageing, these changes were more pronounced in participants with hip OA. To reduce disability associated with hip OA, future rehabilitation programs should consider targeted gait strategies and exercises for GMin.
This article is protected by copyright. All rights reserved.
... Overall, the 35 included systematic reviews [47][48][49][50][51][52][53]55,56,[58][59][60][61][62][63][64][65][67][68][69][70][72][73][74][75][76][77][78][79][80][82][83][84][85][86] were published from 2007 48 to 2017 59,62,80 and were conducted in America (Canada 64 ), Asia (Chi- na 49,53,56,[60][61][62][63]72,77,79,80,[84][85][86] , Japan 73 48 and Switzerland 68,69 ) and Oceania (Australia 51,59,82 ). ...
Objective: Update the last known umbrella review and summarize the available high-quality evidence from systematic reviews on the effectiveness of non-pharmacological
and non-surgical interventions for patients with knee osteoarthritis (OA).
Methods: The systematic reviews were identified throught electronic databases, such as: MEDLINE, Embase, Physiotherapy Evidence Database (PEDro), The Cochrane Library, SciELo, Science Direct, Google Scholar, Research Gate and B-ON. The studies’ selection
respected the following terms to guide the search strategy using the P (humans with knee osteoarthritis) I (non-pharmacological and non-surgical treatments) C (pharmacological, surgical, placebo, no intervention, or other non-pharmacological/ non-surgical conservative treatments) O (pain, functional status, stiffness, inflammation, quality of life and patient global assessment) model.
Results: Following the PRISMA statement, 41 systematic reviews were found on the electronic databases that could be included in the umbrella review. After methodical
analysis (R-AMSTAR), only 35 had sufficient quality to be included. There is gold evidence that Standard Exercise programs can reduce pain and improve physical function in patients with knee OA. Additionally, there is silver evidence for Acupuncture, Aquatic
Exercise, Electroacupuncture, Interferential Current, Kinesio Taping, Manual Therapy, Moxibustion, Pulsed Electromagnetic Fields, Tai Chi, Ultrasound, Yoga, and Whole-Body Vibration. For other interventions, the quality of evidence is low or did not show sufficient efficacy from the systematic reviews to support their use.
Conclusion: Comparing to the last known umbrella review, similar results were achieved on Acupuncture and Exercise interventions to improve the patients’ pain, stiffness, function and quality of life, but different results were found regarding the utilization of Transcutaneous Electrical Nerve Stimulation and Low-Level Laser Therapy as they do not improved the patients’ pain and physical function.
... In the musculoskeletal treatment of the joint dysfunctions, the physiotherapist can use manual therapy (musculoskeletal manipulation) as a solid basis of treatment. [8][9][10] One of these manual therapy techniques, includes mobilization with movement (MWM), a type of joint mobilization developed by Brian Mulligan. 11, 12 Mulligan's original theory for the efficacy of a MWM is based on the concept of a positional joint failure, which occurs due to the injury and it can lead to a change in the joint alignment and consequently in its biomechanics, resulting in symptoms such as pain, joint stiffness or weakness. ...
... Although the prevalence of knee OA increases through middle age, there is conflicting evidence as to whether this increase continues throughout the elderly years (Forman et al. 1983). Several studies to address this question found that the prevalence of knee OA did not increase with age among elderly subjects (Forman et al. 1983;French et al. 2011). Based on the results of the current study, in the future we will extend the proposed method to the elderly groups such as the age above 60 to detect the presence of knee OA and its progression. ...
Gait measures have received increasing attention in the evaluation of patients with knee osteoarthritis (OA). Comprehending gait parameters is an essential requirement for studying the causes of knee disorders. The aim of this work is to develop a new method to distinguish between asymptomatic (AS) and osteoarthritic knee gait patterns using gait analysis via deterministic learning. Spatiotemporal parameters and three-dimensional knee joint rotations and translations are measured and compared in 19 patients with knee OA and 28 AS control subjects during level walking. The classification approach consists of two stages: a training stage and a classification stage. In the training stage, gait features representing gait dynamics, including knee rotations and translations, are derived from the kinematic data of the knees in six-degree-of-freedom. Gait dynamics underlying gait patterns of AS control subjects and patients with knee OA are locally accurately approximated by radial basis function (RBF) neural networks. The obtained knowledge of approximated gait dynamics is stored in constant RBF networks. Gait patterns of AS control subjects and patients with knee OA constitute a training set. In the classification stage, a bank of dynamical estimators is constructed for all the training gait patterns. Prior knowledge of gait dynamics represented by the constant RBF networks is embedded in the estimators. By comparing the set of estimators with a test knee OA gait pattern to be classified, a set of classification errors are generated. The average norms of the errors are taken as the classification measure between the dynamics of the training gait patterns and the dynamics of the test knee OA gait pattern according to the smallest error principle. Finally, experiments are carried out to demonstrate that the proposed method can effectively separate the gait patterns between the groups of AS control subjects and patients with knee OA. By using the two-fold cross-validation and leave-one-out cross-validation styles, the correct classification rates for knee OA gait patterns are reported to be 95.7 and 97.9%, respectively.
... Physiotherapy includes a range of interventions such as exercises, electrotherapy and manual therapy. Manual therapy comprises soft tissue techniques, joints mobilisations or manipulations [8]. A technique, Mobilisation with Movement (MWM), has been proposed in 1993 by Brian Mulligan to treat peripheral joints [9]. ...
Objective - To review the available evidence on the effectiveness of Mobilisation with Movement (MWM) as a treatment modality for shoulder pain and dysfunction in specific and non-specific pain syndromes.
Design - Critical review.
Participants - People with shoulder pain and dysfunction regardless of diagnoses.
Data sources - AMED, CINAHL, Cochrane Reviews Library and Central Register of Controlled Trials, Medline, PEDro, Web of Science and the reference lists of retrieved studies.
Study selection - Randomised controlled trials of good methodological quality according to the PEDro scale guidelines with MWM as primary independent variable were included. Included studies had at least one measure of pain and/or dysfunction of the shoulder as outcome measure.
Results - Databases and reference lists searches yielded a total of 149 citations. Five studies met the inclusion criteria, involving 169 participants in total. MWM were found to be efficient in reducing pain, increasing self-reported function and range of motion. Results regarding the superiority of MWM to other interventions were mixed. MWM were not found to be effective on isometric strength and pain pressure threshold. The duration of effects was poorly researched, as only one trial conducted follow-up measurements.
Conclusion - Despite the paucity of research, a limited number of methodologically robust trials suggest that MWM may be an effective intervention to reduce shoulder pain, improve range of motion and improve shoulder function. Nevertheless, MWM was not found to be conclusively superior to a sham technique.
Physical rehabilitation is a vital component for the recovery of patients with knee injuries or after a surgical procedure. Part of the rehabilitation treatment includes manual therapy and the use of assistive devices, all these elements play a crucial role in the functional prognosis of the patient. In the context of knee rehabilitation, physical therapists need to find more effective methods and treatments to optimize the final result in terms of function and quality of life in patients with an injury. Hence, in addition to conventional therapies techniques, the introduction of other devices has become an effective strategy to enhance therapeutic outcomes.In this regard, knee mobilizers are devices specifically designed to facilitate and control joint movement during the rehabilitation process. These devices play an important role in providing support and stability, thus contributing to a more effective recovery.There are an important variety of mobilizers with different characteristics each. However, this kind of assistive machines are too expensive for patients and rehabilitation clinics, with poor availability for some parts of the Metropolitan Area of Guadalajara and, sometimes, it’s difficult to adapt their features for patients with different anthropometric characteristics and treatment goals. This lack of adaptability and availability represent an opportunity to develop an assistive device that covers the needs mentioned above. Hence, this project aims to design a passive knee mobilizer to enhance the results of rehabilitation in patients with lower limb disabilities and post-operative procedures. The initiative addresses a fundamental challenge, which is the lack of independence and mobility among this population. The design criteria for this device included anthropometric measurements, interviews with physiotherapists and patients and a systematic literature review. During the design process it was important to select the proper materials, some of the characteristics taken into consideration were these: durability, maintenance, comfort, and cost.Some of the design implementations of this product included an adjustable limb holder to adapt the arm height for pediatric and adult users, a special seat that allows patients to shift their position to ensure the rehabilitation of both knees. Finally, the adaptation of a linear actuator for passive therapy. This machine is remotely controlled so that the physiotherapist can adjust it according to the patient's needs. Finally, it’s important to mention that the design of this product was based on local regulations and international standards. For example, ISO 13485, which outlines Quality Management Systems for Medical Devices and Mexican Official Normatives.
Objective/aims:
The aims of this study are to collect the most common non-pharmacological and non-surgical interventions used by the Portuguese physical therapists in their knee osteoarthritis patients, and to deeper understand the factors associated to their intervention choices.
Methods:
This study incorporated a mixed-methods design. For the quantitative data it was choose an e-survey (with 25 close-end questions, plus general information of the study and a clinical vignette), retrieving sociodemographic and self-reported practice on knee osteoarthritis information. It was analysed response frequencies and associations between variables with logistic regression analyses. For the qualitative data, it was chosen to perform semi-structured interviews in purposefully selected physical therapists to include different sociodemographic factors and survey responses regarding the physical therapists' interventions chosen. After the interviews, the audios were collected, anonymised, transcribed verbatim, and the texts explored by the thematic approach.
Results:
From the 277 PTs that shown interest in participating in the study, 120 fully completed the questionnaire and, from those, 10 participated in the interviews. The most chosen interventions included Resistance Exercise, Manual Therapy, Nutrition/Weight Loss, Self-care/Education, Stretching and Aquatic Exercise. Furthermore, it seems that PTs' individual characteristics (age, experience, and clinical reasoning), patient's characteristics (clinical findings and preferences), and work-related factors (facility type, work environment and available resources) are the main actors responsible for an intervention chosen.
Conclusions:
In the Portuguese PTs context the most important interventions are Exercise, Manual Therapy, Nutrition/Weight Loss, and Self-care/Education; these interventions chosen may be influenced by PT, patient and work-related factors.
Osteoarthritis of the knee generally affects individuals from the fifth decade, the typical age of middle-age athletes. In the early stages, management is conservative and multidisciplinary. It is advisable to avoid sports with high risk of trauma, but it is important that patients continue to be physically active. Conservative management offers several options; however, it is unclear which ones are really useful. This narrative review briefly reports the conservative options for which there is no evidence of effectiveness, or there is only evidence of short-term effectiveness.
Objective We investigated the effects of Kinesio Taping with Laser Therapy (KTLT) on the Pain threshold, Blood flow, and Balance ability of patients with Knee Osteoarthritis.
Methods A total of 32 patients were randomly divided into KTLT and Control (CON) group. KTLT group was performed 30 min three times a week for four weeks in low-level laser therapy (LLLT) treatment process with Taping. CON group performed 30 min three times a week for four weeks in sham LLLT treatment process with sham taping. To measure the oppressive pain threshold, Commander Algometer and for the measurement of the blood flow rate of the skin surface, a noninvasive approach, Laser Doppler imaging equipment was used and the standing balance ability test was performed by Center of Pressure (COP), Limited of Stability (LOS).
Results There was a significant difference (P<0.05) between before and after training in both groups, and KTLT group showed significant improvement in both groups.
Conclusions In this study, we confirmed KTLT on the Pain threshold, Blood flow, and Balance ability of Patient with Knee Osteoarthritis.
Background:
The number of randomized clinical trials (RCTs) for manual therapy (MT) has increased exponentially in recent years but the quality of reporting is heterogeneous.
Objective:
To assess the quality of the reporting of results in RCTs manual therapy, both in the text and in the graphs.
Study design:
Methodological review.
Methods:
We reviewed a random sample of 120 RCTs in MT published between 2000 and 2020 in indexed journals. We identified the primary outcome for each trial, and evaluated the completeness and correctness of reporting of results in the text and in the graphs.
Results:
Forty per cent of the RCTs explicitly identified the primary outcome and 47.5% reported a sample size calculation. In 46.7% of the trials, the reporting of between groups comparisons was complete (including effect size and precision). Only 29.2% used the confidence interval as a measure of precision. Fifty-eight per cent of the trials reported significant differences in the results, and 30.8% reported a value of clinical relevance for at least one variable of the study. Forty-seven per cent reported the primary outcome graphically but only 19.6% of the graphs were self explanatory and 66.1% had problems of visual clarity.
Conclusions:
Despite some improvements in the most recent literature, our findings suggest that the reporting of the results in MT trials is generally incomplete and graphics are often poor. These shortcomings could affect the interpretation of the results and their application in clinical practice. Improvements are needed in the reporting of results in order to advance clinical practice and research in manual therapy.
Synopsis:
The use of manual therapy as an intervention has garnered intense debate - often mired in a straw man argument that manual therapy is a purely passive intervention. When passive interventions are equated with low-value care, it is easy to deride manual therapy as "low-value" care. However, manual therapy describes a wide variety of different treatments. Manual therapy can have passive components and even be primarily passive in some scenarios. But manual therapy can also form an integral part of highly active treatment strategies. We implore investigators to describe manual therapy interventions used in trials in sufficient detail that can be reproduced, to help end-users of research (including clinicians) make better decisions when assessing the value of treatments. This viewpoint challenges the assumption that manual therapy is always a passive treatment of low value. J Orthop Sports Phys Ther, Epub 1 Jul 2021. doi:10.2519/jospt.2021.10330.
Various treatment devices or tables have been developed for generating axial rotation of the lumbar spine during spinal mobilization. However, the effects of the design of such treatment devices on the axial rotation of the lumbar spine have not been thoroughly investigated. In this study, the influences of the location of the treatment table rotational axis on the biomechanical behaviors of the lumbar spine were investigated for spinal mobilization using finite element analysis. The axial rotation of spinal mobilization with a supine posture on a treatment table was simulated. The sacrum was rotated by 10° along the axial rotation axis. The initial axis location was around the posterior edge of the nucleus pulposus of the L5–S intervertebral disc. The axis location was varied in the posterior direction from 0 to 200 mm in increments of 50 mm. Changes in the spine biomechanics, such as the intersegmental rotation, intradiscal pressure, and stresses on the ligaments and fibers of the annulus fibrosus, were investigated. Upon movement of the rotation axis towards the posterior direction, (1) the rotation angle along the lateral bending direction increased, (2) the intradiscal pressure increased, (3) the stresses on fibers of the annulus fibrosus and ligaments increased, and (4) the facet joint forces increased. Based on these findings, we conclude that careful consideration of the rotation axis location is important and necessary in the development of treatment beds for spinal manipulation.
Die Arthrose als weltweit häufigste Gelenkerkrankung des erwachsenen Menschen beschreibt die fortlaufende Zerstörung eines Gelenks entweder als primäre Erkrankung bei altersbedingter Degeneration oder auf der Grundlage sekundärer Ursachen. Die Erkrankung nimmt ihren Ausgang in der Regel vom Gelenkknorpel und erfasst im Verlauf alle artikulären und periartikulären Strukturen der gelenkigen Funktionseinheit. Für den betroffenen Patienten resultiert regelhaft ein zunehmender schmerzhafter Funktionsverlust mit einer wesentlichen Reduktion der Lebensqualität. Vielfach kann eine Behandlung über viele Jahre erfolgreich mit konservativen Maßnahmen gestaltet werden. Sollte hiermit keine ausreichende Kontrolle des Leidensdrucks mehr erreichbar sein, muss die Option einer operativen Intervention diskutiert werden. Die aktuellen Bemühungen der Grundlagenforschung fokussieren derzeit auf das Ziel einer möglichst frühzeitigen Unterbrechung und bestenfalls vollständigen Vorbeugung des Degenerationsprozesses.
Background and Purpose
Mulligan's mobilization with movement was shown to be effective when implemented in multimodal therapy for knee osteoarthritis. However, no study has evaluated the Mulligan's technique in isolation and compared the relative effectiveness with sham‐controlled interventions. Hence, the present study examined the immediate effects of Mulligan's techniques with sham mobilization on the numerical pain rating scale (NPRS) and timed up and go (TUG) test in individuals with knee osteoarthritis.
Methods
Thirty participants (mean age: 55.3 ± 8.3 years) with symptoms at the knee and radiographic diagnosis of knee osteoarthritis were randomized into sham ( n = 15) and intervention ( n = 15) groups. The intervention (I) group received Mulligan's mobilization glides that resulted in relative pain relief for three sets of 10 repetitions. For the sham (S) group, the therapist's hand was placed over the joint surfaces mimicking the pain‐relieving glides, without providing the gliding force. The outcome measures NPRS and TUG were recorded by a blinded assessor pre‐ and post‐intervention.
Results
Statistically significant differences were identified between the groups in post‐intervention median (interquartile range) NPRS (I group: 4.00 [2.00–5.00]; S group: 6.00 [4.00–7.00]) and TUG scores (I group: 10.9 [9.43–10.45]; S group: 13.18 [10.38–16.00]) with the intervention group demonstrating better outcomes ( p < .05). Within‐group, the post‐intervention scores of NPRS and TUG were significantly lower ( p < .05) compared to the pre‐intervention scores in the intervention group. In the sham group, a statistically significant pre–post change was noticed only in the NPRS scores but not in the TUG scores.
Conclusion
Mulligan's techniques were effective in improving pain and functional mobility in individuals with knee osteoarthritis. The underlying mechanisms for observed effects must be examined further, as participants reported pain relief following sham mobilization.
Study Design: Case report.
Background: The purpose of this case report is to describe the use of tibiofemoral joint mobilizations to improve knee flexion in a patient with arthrofibrosis following total knee arthroplasty (TKA) and failed manipulation under anesthesia (MUA).
Case Description: A 62-year-old female presented to physical therapy 15 days after TKA with full knee extension, 45 deg of active knee flexion, 48 deg of passive knee flexion, pain, and a Lower Extremity Functional Scale (LEFS) score of 28.
Interventions/Outcomes: A multimodal intervention strategy was used initially with minimal improvement in knee flexion. The patient was diagnosed with fibrosis and MUA was performed. Passive knee flexion was 80 deg before MUA and 75 deg after MUA. Focused grade III and IV tibiofemoral joint mobilizations were used after MUA. At discharge, the patient had 90 deg of active and 116 deg of passive knee flexion, no pain, and an LEFS score of 80.
Discussion: A conventional multimodal intervention approach was ineffective for a patient who developed arthrofibrosis following TKA. A focused intervention approach of grade III and IV tibiofemoral joint mobilizations improved knee flexion, pain, and function following TKA and failed MUA.
Objective:
To assess the effect of a one to one intervention by a nurse on the outcomes of patients undergoing Total Knee Replacement (TNR) surgery.
Methods:
A quasi-experimental design was used with 60 participants, half of which received a one to one intervention including education and exercise training by a nurse prior to surgery. Follow up was at two and four weeks post-surgery to assess pain, knee function using the Hospital for Special Surgery (HSS) Knee Rating Sheet and activities of daily living measured on the Lower Extremity Functional Scale (LEFS). ANOVA tests were used to compare significant differences between groups.
Results:
The intervention group had less pain at two and four weeks, p = 0.00, and better knee function at four weeks, p = 0.026. Activities of daily living were better for the intervention group at both two and four weeks, p = 0.002 and 0.048.
Conclusion:
The one to one intervention provided by a nurse before TKR surgery was instrumental in decreasing pain, improving knee function and enhancing activities of daily living.
Background:
The prevalence and cost of hip osteoarthritis (OA) is rising. Mechanical diagnosis and therapy (MDT) is an orthopedic classification and treatment system based on mechanical and symptomatic response to repeated and sustained end-range movements. There has been no investigation of the association between MDT and patients diagnosed with hip OA.
Case description:
This case report presents a 71-year-old female diagnosed with hip OA and matching the currently accepted clinical prediction rule (CPR) for symptomatic hip OA. The patient was classified and treated by a Diplomat of MDT and co-examiner using MDT.
Outcomes:
Short- and long-term (13 months) outcomes were excellent, demonstrating rapid abolishment of symptoms and improvement in function in 5 visits over 21 days. The patient demonstrated the ability to prevent and manage reoccurrence of symptoms independently; nevertheless, she received a total hip replacement which was not in accordance with current guidelines and recommendations.
Conclusion:
This case report raises questions about whether or not pathologies traditionally associated with the etiology of hip OA are actually at fault. Moreover, it raises questions about the utility of special tests and CPRs typically utilized to identify those structures. The case report provides preliminary evidence from one patient that MDT may be capable of providing effective short- and long-term outcomes in the management of hip OA.
Clinical criteria for the classification of patients with hip pain associated with osteoarthritis (OA) were developed through a multicenter study. Data from 201 patients who had experienced hip pain for most days of the prior month were analyzed. The comparison group of patients had other causes of hip pain, such as rheumatoid arthritis or spondylarthropathy. Variables from the medical history, physical examination, laboratory tests, and radiographs were used to develop different sets of criteria to serve different investigative purposes. Multivariate methods included the traditional “number of criteria present” format and “classification tree” techniques.
Clinical criteria: A classification tree was developed, without radiographs, for clinical and laboratory criteria or for clinical criteria alone. A patient was classified as having hip OA if pain was present in combination with either 1) hip internal rotation ≥15º, pain present on internal rotation of the hip, morning stiffness of the hip for ≤60 minutes, and age >50 years, or 2) hip internal rotation <15º and an erythrocyte sedimentation rate (ESR) ≤45 mm/hour; if no ESR was obtained, hip flexion ≤115º was substituted (sensitivity 86%; specificity 75%).
Clinical plus radiographic criteria: The traditional format combined pain with at least 2 of the following 3 criteria: osteophytes (femoral or acetabular), joint space narrowing (superior, axial, and/or medial), and ESR <20 mm/hour (sensitivity 89%; specificity 91%). The radiographic presence of osteophytes best separated OA patients and controls by the classification tree method (sensitivity 89%; specificity 91%).
The “number of criteria present” format yielded criteria and levels of sensitivity and specificity similar to those of the classification tree for the combined clinical and radiographic criteria set. For the clinical criteria set, the classification tree provided much greater specificity. The value of the radiographic presence of an ostophyte in separating patients with OA of the hip from those with hip pain of other causes is emphasized.
Manual therapy is often used with exercise to treat neck pain. This cervical overview group systematic review update assesses if manual therapy, including manipulation or mobilisation, combined with exercise improves pain, function/disability, quality of life, global perceived effect, and patient satisfaction for adults with neck pain with or without cervicogenic headache or radiculopathy. Computerized searches were performed to July 2009. Two or more authors independently selected studies, abstracted data, and assessed methodological quality. Pooled relative risk (pRR) and standardized mean differences (pSMD) were calculated. Of 17 randomized controlled trials included, 29% had a low risk of bias. Low quality evidence suggests clinically important long-term improvements in pain (pSMD-0.87(95% CI:-1.69,-0.06)), function/disability, and global perceived effect when manual therapy and exercise are compared to no treatment. High quality evidence suggests greater short-term pain relief [pSMD-0.50(95% CI:-0.76,-0.24)] than exercise alone, but no long-term differences across multiple outcomes for (sub)acute/chronic neck pain with or without cervicogenic headache. Moderate quality evidence supports this treatment combination for pain reduction and improved quality of life over manual therapy alone for chronic neck pain; and suggests greater short-term pain reduction when compared to traditional care for acute whiplash. Evidence regarding radiculopathy was sparse. Specific research recommendations are made.
A systematic review of randomised controlled trials (RCTs) was conducted to determine the effectiveness of manual therapy (MT) techniques for the management of musculoskeletal disorders of the shoulder. Seven electronic databases were searched up to January 2007, and reference lists of retrieved articles and relevant MT journals were screened. Fourteen RCTs met the inclusion criteria and their methodological qualities were assessed using the PEDro scale. Results were analyzed within diagnostic subgroups (adhesive capsulitis (AC), shoulder impingement syndrome [SIS], non-specific shoulder pain/dysfunction) and a qualitative analysis using levels of evidence to define treatment effectiveness was applied. For SIS, there was no clear evidence to suggest additional benefits of MT to other interventions. MT was not shown to be more effective than other conservative interventions for AC, however, massage and Mobilizations-with-Movement may be useful in comparison to no treatment for short-term outcomes for shoulder dysfunction.
Knee osteoarthritis is a highly prevalent condition with a significant socioeconomic burden to society. It is known to effect sufferers through pain, loss of function and changes in health related quality of life. Management typically involves pharmacologic and/or exercise based therapy approaches to reduce pain. Previous studies have shown multimodal treatment approaches incorporating manual therapy to be efficacious. The aim of this study is to determine if a manual therapy technique knee protocol can alter the self reported pain experienced by a group of chronic knee osteoarthritis sufferers in a randomised controlled trial.
43 participants with a chronic, non-progressive history of osteoarthritic knee pain, aged between 47 and 70 years were randomly allocated following a screening procedure to an intervention group (n=26; 18 men and 8 women, mean age 56.5 years) or a control group (n=17; 11 men and 6 women, mean age 54.6 years). Participants were matched for present knee pain intensity measured on a visual analogue scale. The intervention consisted of the Macquarie Injury Management Group Knee Protocol whilst the control involved a non-forceful manual contact to the knee followed by interferential therapy set at zero. Participants received three treatments per week for two consecutive weeks with a follow up immediately after the final treatment. Post-treatment Participants completed 11 questions including present knee pain intensity and feedback regarding their response to treatment utilizing a visual analogue scale. Results were analysed using descriptive statistics.
Prior to the intervention, there was no significant differences in age or present knee pain intensity. Following treatment, the intervention group reported a significant decrease in the present pain severity (mean 1.9) when compared to the control group (mean 3.1). Response to treatment questions indicated that compared to the control group, the intervention group felt the intervention had helped them (intervention mean 7.0; control mean 3.4), felt it decreased their knee symptoms such as crepitus (intervention mean 6.0; control mean 3.4) and improved their knee mobility (intervention mean 6.4; control mean 3.4) and their ability to perform general activities (intervention mean 6.5; control mean 3.8). Importantly the MIMG Knee Protocol intervention group reported no adverse reactions during treatment.
A short-term manual therapy knee protocol significantly reduced pain suffered by participants with osteoarthritic knee pain and resulted in improvements in self-reported knee function immediately after the end of the 2 week treatment period.
To determine whether treatment with spinal manipulative therapy (SMT) administered in addition to standard care is associated with clinically relevant early reductions in pain and analgesic consumption.
104 patients with acute low back pain were randomly assigned to SMT in addition to standard care (n = 52) or standard care alone (n = 52). Standard care consisted of general advice and paracetamol, diclofenac or dihydrocodeine as required. Other analgesic drugs or non-pharmacological treatments were not allowed. Primary outcomes were pain intensity assessed on the 11-point box scale (BS-11) and analgesic use based on diclofenac equivalence doses during days 1-14. An extended follow-up was performed at 6 months.
Pain reductions were similar in experimental and control groups, with the lower limit of the 95% CI excluding a relevant benefit of SMT (difference 0.5 on the BS-11, 95% CI -0.2 to 1.2, p = 0.13). Analgesic consumptions were also similar (difference -18 mg diclofenac equivalents, 95% CI -43 mg to 7 mg, p = 0.17), with small initial differences diminishing over time. There were no differences between groups in any of the secondary outcomes and stratified analyses provided no evidence for potential benefits of SMT in specific patient groups. The extended follow-up showed similar patterns.
SMT is unlikely to result in relevant early pain reduction in patients with acute low back pain.
Joint traction and other mobilization techniques are commonly used in physical therapy for patients with osteoarthrosis. The aim of this study has been to: (a) measure the separation of the joint surfaces in the normal hip joint during application of different forces; (b) investigate whether or not the degree of separation was influenced by the position of the joint; (c) compare hip joint laxity in men and women; (d) find the traction force needed to cause the appearance of vacuum phenomena. To achieve a separation in the hip joint, a traction force of at least 400 N must be applied. The distraction was greater in the loose packed position than in the close packed position at equal force and in both males and females. Vacuum phenomena appeared at between 400 and 600 N of traction, varying with joint position.
Significant progress has been made in outcome measurement procedures for osteoarthritis (OA) clinical trials, and guidelines have been established by the US Food and Drug Administration, European League Against Rheumatism, the World Health Organization/International League of Associations for Rheumatology, and the Group for the Respect of Ethics and Excellence in Science. However, there remains a need for further international harmonization of measurement procedures used to establish beneficial effects in Phase III clinical trials. A key objective of the OMERACT III conference was to establish a core set of outcome measures for future phase III clinical trials. During the conference, using a combination of discussion and polling procedures, a consensus was reached by at least 90% of participants that the following 4 domains should be evaluated in future phase III trials of knee, hip, and hand OA: pain, physical function, patient global assessment, and, for studies of one year or longer, joint imaging (using standardized methods for taking and rating radiographs, or any demonstrably superior imaging technique). These evidence based preferences, achieved with a high degree of consensus, establish an international standard for future phase III trials and will also facilitate metaanalysis and Cochrane Collaborative Project goals.
To establish the relationships between the range of joint motion (ROM) and disability in patients with osteoarthritis (OA) of the knee or hip. Two related issues were addressed: (1) the inter-relationships between ROMs of joint actions, and (2) the relationship between ROM and disability.
Data on 198 patients with OA of the knee or hip were used. The ROM was assessed bilaterally for the hip and knee, using a goniometer. Disability was assessed using a self-reporting method (questionnaire) and an observational method. Correlation and factor analysis were used to establish the inter-relationships between the ROMs of joint actions. Correlation and multiple regression analyses were carried out to establish the relationships between ROM and disability.
Close inter-relationships were found between the ROMs of the same joint action of the lateral and contralateral joints; inter-relationships between ROMs of different joint actions were substantially weaker. Low ROMs were associated with high levels of disability, both self-reported and observed. Some 25% of the variation in disability levels could be accounted for by differences in ROM. In both knee and hip OA patients, flexion of the knee and extension and external rotation of the hip were found to be most closely associated with disability.
Restricted joint mobility, especially in flexion of the knee and extension and external rotation of the hip, appears to be an important determinant of disability in patients with OA.
Objective: Reduced muscle strength is regarded as a risk factor for pain and disability in osteoarthritis (OA). Currently, various indices for muscle strength are used when assessing determinants of pain and disability. The goal of the present study was to evaluate these indices of muscle strength.
Design: Isometric muscle strength was measured for 16 muscle actions around the knees and hips in 52 patients with OA of the hip and 70 patients with OA of the knee. Various indices of muscle strength were derived from these measurements, applying five alternative approaches. These approaches ranged from a single overall index to a set of 16 separate indices. The internal consistency of these indices was determined (Cronbach's α), and it was determined to what extent they could reveal the association between reduced muscle strength on the one hand and pain and disability on the other hand.
Results: Internal consistency was satisfactory for all indices (Cronbach's α >0.74). As expected, reduced muscle strength was associated with increased disability, but no clear relationship could be established between muscle weakness and pain. The strength of these associations did not depend on the approach used to derive the indices for muscle strength.
Conclusions: The indices did not show major differences with regard to internal consistency or the extent to which the association with pain and disability could be revealed. For reasons of parsimony, approaches resulting in few indices appear to be most useful. However, muscle strength was found to be significantly reduced around affected joints, compared with muscle strength around unaffected joints. Therefore, the most suitable approach for reducing muscle strength data into indices is one that results in as few indices as possible, but with separate indices for muscle strength around affected and unaffected joints.
The prevalence of arthritis is high, with osteoarthritis (OA) being one of the most frequent disorders in the population. In England and Wales, between 1.3 and 1.75 million people have OA and a further 0.25-0.5 million have rheumatoid arthritis (RA), while in France some 6 million new diagnoses of OA are made each year. In 1997, approximately 16% of the US population had some form of arthritis. This prevalence is expected to increase in the coming years, as arthritis more often affects the elderly, a proportion of the population that is increasing. The economic burden of such musculoskeletal diseases is also high, accounting for up to 1-2.5% of the gross national product of western nations. This burden comprises both the direct costs of medical interventions and indirect costs, such as premature mortality and chronic and short-term disability. The impact of arthritis on quality of life is of particular importance. Musculoskeletal disorders are associated with some of the poorest quality-of-life issues, particularly in terms of bodily pain (mean score from the MOS 36-item Short Form Health Survey of 52.1) and physical functioning (49.9), where quality of life is lower than that for gastrointestinal conditions (bodily pain 52.9, physical functioning 55.4), chronic respiratory diseases (72.7, 65.4) and cardiovascular conditions (64.7, 59.3).
Descriptive method guidelines.
To help reviewers design, conduct, and report reviews of trials in the field of back and neck pain.
In 1997, the Cochrane Collaboration Back Review Group published method guidelines for systematic reviews. Since its publication, new methodologic evidence emerged and more experience was acquired in conducting reviews.
All reviews and protocols of the Back Review Group were assessed for compliance with the 1997 method guidelines. Also, the most recent version of the Cochrane Handbook (4.1) was checked for new recommendations. In addition, some important topics that were not addressed in the 1997 method guidelines were included (e.g., methods for qualitative analysis, reporting of conclusions, and discussion of clinical relevance of the results). In May 2002, preliminary results were presented and discussed in a workshop. In two rounds, a list of all possible recommendations and the final draft were circulated for comments among the editors of the Back Review Group.
The recommendations are divided in five categories: literature search, inclusion criteria, methodologic quality assessment, data extraction, and data analysis. Each recommendation is classified in minimum criteria and further guidance. Additional recommendations are included regarding assessment of clinical relevance, and reporting of results and conclusions.
Systematic reviews need to be conducted as carefully as the trials they report and, to achieve full impact, systematic reviews need to meet high methodologic standards.
Randomized controlled trials have been developed essentially in the context of pharmacological treatments (ie, oral drugs; intra-articular injection; and topical, intramuscular, and intravenous treatments), but assessment of the effectiveness of nonpharmacological treatments (ie, surgery, arthroscopy, joint lavage, rehabilitation, acupuncture, and education) presents specific issues.
To compare the quality of articles of nonpharmacological and pharmacological treatments of hip and knee osteoarthritis and to identify specific methodological issues related to assessment of nonpharmacological treatments.
We searched MEDLINE and the Cochrane Central Register of Controlled Trials for articles of randomized controlled trials published between January 1, 1992, and February 28, 2002, in 28 general medical and specialty journals with high impact factors and assessing nonpharmacological and pharmacological treatments in patients with hip or knee osteoarthritis.
The quality of the methods reported in the selected articles was assessed by 2 independent reviewers using the Jadad scale, the Delphi list, and guidelines found in the Users' Guides to the Medical Literature. Investigators also used a checklist of items developed by the authors to analyze study characteristics.
A total of 110 articles were included in the analysis; 50 (45.5%) assessed nonpharmacological treatments and 60 (54.5%) assessed pharmacological treatments. Reports of nonpharmacological treatments had a lower global quality score than did reports of pharmacological treatments as measured by the Jadad scale (mean [SD] score, 1.4 [1.3] vs 3.0 [1.3]) and the Delphi list (mean [SD] score, 5.2 [1.5] vs 7.5 [1.1]). Lack of reporting adequate random sequence generation and intention-to-treat analyses were found in both nonpharmacological and pharmacological articles. Nonpharmacological treatments were less often compared with a placebo than were pharmacological treatments (28.0% of articles vs 71.7%). Compared with pharmacological articles, nonpharmacological articles less often described blinding of patients (26.0% vs 96.7%), care providers (6.0% vs 81.7%), and outcome assessors (68.0% vs 98.3%). Care providers' skill levels could influence treatment effect in 84.0% of nonpharmacological articles vs 23.3% of pharmacological articles.
In this analysis of reports of hip and knee osteoarthritis therapy, nonpharmacological articles scored lower than pharmacological articles in terms of quality. Assessments of nonpharmacological treatments must take into consideration additional methodological issues.
Compiled by Cochrane collaborators and members of OMERACT (Outcome Measures in Rheumatology), Evidence-based Rheumatology is an essential resource for evidence-based medicine as applied to the musculoskeletal disorders. The introductory section covers the principles of evidence-based medicine in rheumatology, followed by clinical chapters covering all the major disorders. Each chapter includes non-drug therapy, drug therapy, and consumer evidence-based summaries. Evidence-Based Series: Evidence-based Rheumatology, part of the acclaimed series BMJ Evidence-based medicine textbooks that have revolutionised clinical medicine literature, comes with a fully searchable CD-ROM of the whole text. The text is kept up to date online at www.evidbasedrheum.com. Note: CD-ROM/DVD and other supplementary materials are not included as part of eBook file.
OMERACT is the acronym for an international, informally organized network aimed at improving outcome measurement in rheumatology. Chaired by an executive committee it organizes consensus conferences in a 2-yearly cycle that circles the globe since 2002. Data driven recommendations are prepared and updated by expert working groups. Recommendations include core sets of measures for most of the major rheumatologic conditions. Since 2002 patients have been actively engaged in the process. OMERACT 8 will take place in Malta, May 2006 (www.omeract.org).
Recent empirical evidence supports the importance of adequate randomization in controlled trials. Trials with inadequate allocation concealment have been associated with larger treatment effects compared with trials in which authors reported adequate allocation concealment. While that provides empirical evidence of bias being interjected into trials, trial investigators rarely document the sensitive details of subverting the intended purpose of randomization. This article relates anonymous accounts of deciphering assignment sequences before allocation based on experiences acquired from epidemiologic workshops for physicians. These accounts run the gamut from simple to intricate operations, from transillumination of envelopes to searching for code in the office files of the principal investigator. They indicate that deciphering is something more frequent than a rare occurrence. These accounts prompt some methodological recommendations to help prevent deciphering. Randomized controlled trials appear to annoy human nature-if properly conducted, indeed they should.
Background: Few investigations include both subjective and objective measurements of the effectiveness of treatments for osteoarthritis of the knee. Beneficial interventions may decrease the disability associated with osteoarthritis and the need for more invasive treatments. Objective: To evaluate the effectiveness of physical therapy for osteoarthritis of the knee, applied by experienced physical therapists with formal training in manual therapy. Design: Randomized, controlled clinical trial. Setting: Outpatient physical therapy department of a large military medical center. Patients: 83 patients with osteoarthritis of the knee who were randomly assigned to receive treatment (n = 42; 15 men and 27 women [mean age, 60 ± 11 years]) or placebo (n = 41; 19 men and 22 women [mean age, 62 ± 10 years]). Intervention: The treatment group received manual therapy, applied to the knee as well as to the lumbar spine, hip, and ankle as required, and performed a standardized knee exercise program in the clinic and at home. The placebo group had subtherapeutic ultrasound to the knee at an intensity of 0.1 W/cm 2 with a 10% pulsed mode. Both groups were treated at the clinic twice weekly for 4 weeks. Measurements: Distance walked in 6 minutes and sum of the function, pain, and stiffness subscores of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). A tester who was blinded to group assignment made group comparisons at the initial visit (before initiation of treatment), 4 weeks, 8 weeks, and 1 year. Results: Clinically and statistically significant improvements in 6-minute walk distance and WOMAC score at 4 weeks and 8 weeks were seen in the treatment group but not the placebo group. By 8 weeks, average 6-minute walk distances had improved by 13.1 % and WOMAC scores had improved by 55.8% over baseline values in the treatment group (P < 0.05). After controlling for potential confounding variables, the average distance walked in 6 minutes at 8 weeks among patients in the treatment group was 170 m (95% Cl, 71 to 270 m) more than that in the placebo group and the average WOMAC scores were 599 mm higher (95% Cl, 197 to 1002 mm). At 1 year, patients in the treatment group had clinically and statistically significant gains over baseline WOMAC scores and walking distance; 20% of patients in the placebo group and 5% of patients in the treatment group had undergone knee arthroplasty. Conclusions: A combination of manual physical therapy and supervised exercise yields functional benefits for patients with osteoarthritis of the knee and may delay or prevent the need for surgical intervention.
Massage therapy is frequently employed for low back pain (LBP). The aim of this systematic review was to find the evidence for or against its efficacy in this indication. Four randomized clinical trials were located in which massage was tested as a monotherapy for LBP. All were burdened with major methodological flaws. One of these studies suggests that massage is superior to no treatment. Two trials imply that it is equally effective as spinal manipulation or transcutaneous electrical stimulation (TES). One study suggests that it is less effective than spinal manipulation. It is concluded that too few trials of massage therapy exist for a reliable evaluation of its efficacy. Massage seems to have some potential as a therapy for LBP. More investigations of this subject are urgently needed.
Objective
To discuss the concepts of the minimal clinically important difference (MCID) and the smallest detectable difference (SDD) and to examine their relation to required sample sizes for future studies using concrete data of the condition-specific Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the generic Medical Outcomes Study 36-Item Short Form (SF-36) in patients with osteoarthritis of the lower extremities undergoing a comprehensive inpatient rehabilitation intervention.MethodsSDD and MCID were determined in a prospective study of 122 patients before a comprehensive inpatient rehabilitation intervention and at the 3-month followup. MCID was assessed by the transition method. Required SDD and sample sizes were determined by applying normal approximation and taking into account the calculation of power.ResultsIn the WOMAC sections the SDD and MCID ranged from 0.51 to 1.33 points (scale 0 to 10), and in the SF-36 sections the SDD and MCID ranged from 2.0 to 7.8 points (scale 0 to 100). Both questionnaires showed 2 moderately responsive sections that led to required sample sizes of 40 to 325 per treatment arm for a clinical study with unpaired data or total for paired followup data.Conclusion
In rehabilitation intervention, effects larger than 12% of baseline score (6% of maximal score) can be attained and detected as MCID by the transition method in both the WOMAC and the SF-36. Effects of this size lead to reasonable sample sizes for future studies lying below n = 300. The same holds true for moderately responsive questionnaire sections with effect sizes higher than 0.25. When designing studies, assumed effects below the MCID may be detectable but are clinically meaningless.
For the purposes of classification, it should be specified whether osteoarthritis (OA) of the knee is of unknown origin (idiopathic, primary) or is related to a known medical condition or event (secondary). Clinical criteria for the classification of idiopathic OA of the knee were developed through a multicenter study group. Comparison diagnoses included rheumatoid arthritis and other painful conditions of the knee, exclusive of referred or paraarticular pain. Variables from the medical history, physical examination, laboratory tests, and radiographs were used to develop sets of criteria that serve different investigative purposes. In contrast to prior criteria, these proposed criteria utilize classification trees, or algorithms.
A randomized controlled trial comparing manipulation with mobilization for recent onset neck pain.
To determine whether neck manipulation is more effective for neck pain than mobilization.
Randomized controlled trial with blind assessment of outcome.
Primary care physiotherapy, chiropractic, and osteopathy clinics in Sydney, Australia.
Patients (N=182) with nonspecific neck pain less than 3 months in duration and deemed suitable for treatment with manipulation by the treating practitioner.
Participants were randomly assigned to receive treatment with neck manipulation (n=91) or mobilization (n=91). Patients in both groups received 4 treatments over 2 weeks.
The number of days taken to recover from the episode of neck pain.
The median number of days to recovery of pain was 47 in the manipulation group and 43 in the mobilization group. Participants treated with neck manipulation did not experience more rapid recovery than those treated with neck mobilization (hazard ratio=.98; 95% confidence interval, .66-1.46).
Neck manipulation is not appreciably more effective than mobilization. The use of neck manipulation therefore cannot be justified on the basis of superior effectiveness.
Multiple disease-specific systematic reviews on the effectiveness of physical therapy intervention for shoulder dysfunction have been inconclusive. To date, there have been two systematic reviews that examined manual therapy specifically but both considered effects within diagnoses. The purpose of this systematic review was to identify the effectiveness of manual therapy to the glenohumeral joint across all painful shoulder conditions. A search of MEDLINE, CINAHL, Web of Science, and Cochrane Central Register of Randomized Controlled Trials for articles dated 1996 to June 2009 was performed. Inclusion for review were manual therapy performed to the glenohumeral joint only; non-surgical painful shoulder disorders; subjects 18-80 years; and outcomes of range of motion, pain, function, and/or quality of life. Quality assessment was performed using the PEDro scale with subsequent data extraction. Seventeen related articles were found with seven fitting the inclusion criteria. The average PEDro score was 7.86, meeting the cutoff score for high quality. Significant heterogeneity in outcome measures prohibited meta-analysis. Five studies demonstrated benefits utilizing manual therapy for mobility, and four demonstrated a trend towards decreasing pain values. Functional outcomes and quality-of-life measures varied greatly among all studies. Manual therapy appears to increase either active or passive mobility of the shoulder. A trend was found favoring manual therapy for decreasing pain, but the effect on function and quality of life remains inconclusive. Future research utilizing consistent outcome measurements is necessary.
Thesis (Ph. D.)--Brigham Young University, 2001. Includes abstract. Vita. Includes bibliographical references (p. 62-70). Photocopy.
A correlation of the X-ray changes with the pathological changes seen in arthritic hips obtained at surgery or from cadavers, reveals 6 different patterns of osteoarthritis of the hip. The study suggests that the pathogenesis of the degenerative changes is different in each type and as such, would influence the results obtained by surgical intervention.
Clinical criteria for the classification of patients with hip pain associated with osteoarthritis (OA) were developed through a multicenter study. Data from 201 patients who had experienced hip pain for most days of the prior month were analyzed. The comparison group of patients had other causes of hip pain, such as rheumatoid arthritis or spondylarthropathy. Variables from the medical history, physical examination, laboratory tests, and radiographs were used to develop different sets of criteria to serve different investigative purposes. Multivariate methods included the traditional "number of criteria present" format and "classification tree" techniques. Clinical criteria: A classification tree was developed, without radiographs, for clinical and laboratory criteria or for clinical criteria alone. A patient was classified as having hip OA if pain was present in combination with either 1) hip internal rotation greater than or equal to 15 degrees, pain present on internal rotation of the hip, morning stiffness of the hip for less than or equal to 60 minutes, and age greater than 50 years, or 2) hip internal rotation less than 15 degrees and an erythrocyte sedimentation rate (ESR) less than or equal to 45 mm/hour; if no ESR was obtained, hip flexion less than or equal to 115 degrees was substituted (sensitivity 86%; specificity 75%). Clinical plus radiographic criteria: The traditional format combined pain with at least 2 of the following 3 criteria: osteophytes (femoral or acetabular), joint space narrowing (superior, axial, and/or medial), and ESR less than 20 mm/hour (sensitivity 89%; specificity 91%). The radiographic presence of osteophytes best separated OA patients and controls by the classification tree method (sensitivity 89%; specificity 91%). The "number of criteria present" format yielded criteria and levels of sensitivity and specificity similar to those of the classification tree for the combined clinical and radiographic criteria set. For the clinical criteria set, the classification tree provided much greater specificity. The value of the radiographic presence of an osteophyte in separating patients with OA of the hip from those with hip pain of other causes is emphasized.
Clinical criteria for the classification of symptomatic idiopathic (primary) osteoarthritis (OA) of the hands were developed from data collected in a multicenter study. Patients with OA were compared with a group of patients who had hand symptoms from other causes, such as rheumatoid arthritis and the spondylarthropathies. Variables from the medical history, physical examination, laboratory tests, and radiographs were analyzed. All patients had pain, aching, or stiffness in the hands. Patients were classified as having clinical OA if on examination there was hard tissue enlargement involving at least 2 of 10 selected joints, swelling of fewer than 3 metacarpophalangeal joints, and hard tissue enlargement of at least 2 distal interphalangeal (DIP) joints. If the patient had fewer than 2 enlarged DIP joints, then deformity of at least 1 of the 10 selected joints was necessary in order to classify the symptoms as being due to OA. The 10 selected joints were the second and third DIP, the second and third proximal interphalangeal, and the trapeziometacarpal (base of the thumb) joints of both hands. Criteria derived using the "classification tree" method were 92% sensitive and 98% specific. The "traditional format" classification method required that at least 3 of these 4 criteria be present to classify a patient as having OA of the hand. The latter sensitivity was 94% and the specificity was 87%. Radiography was of less value than clinical examination in the classification of symptomatic OA of the hands.
This review has focused on the prevalence and risk factors associated with knee and hip osteoarthritis. Risk factors for knee osteoarthritis are obesity and major injury, and knee osteoarthritis probably fits into the generalized osteoarthritis diathesis. Repetitive use, such as in jobs requiring heavy labor and knee bending, probably increases the risk of knee osteoarthritis. Hip osteoarthritis is probably frequently secondary to developmental defects. As Rothman (182) has pointed out in discussing causation, this does not necessarily mean that the same factors do not also contribute to causing hip osteoarthritis. Yet, it appears that, in many cases, developmental defects are severe enough to be sufficient causes of hip osteoarthritis. To delineate other causes, it may be necessary to examine risk factors separately in those with and in those without developmental disease. Although large epidemiologic studies are best able to identify the relative contributions of specific risk factors while controlling for other risk factors, new studies need to focus on important unresolved questions. First, longitudinal studies with comprehensive follow-up using repeated radiographic assessments are needed to identify factors that cause development of disease or the onset of symptoms. Second, cohorts with early and possibly asymptomatic disease need to be followed to determine the causes of progression or regression of disease and the natural history of disease. Such cohorts may include those at high risk of injury such as sports enthusiasts or manual laborers.
For the purposes of classification, it should be specified whether osteoarthritis (OA) of the knee is of unknown origin (idiopathic, primary) or is related to a known medical condition or event (secondary). Clinical criteria for the classification of idiopathic OA of the knee were developed through a multicenter study group. Comparison diagnoses included rheumatoid arthritis and other painful conditions of the knee, exclusive of referred or para-articular pain. Variables from the medical history, physical examination, laboratory tests, and radiographs were used to develop sets of criteria that serve different investigative purposes. In contrast to prior criteria, these proposed criteria utilize classification trees, or algorithms.
We evaluated the signs and symptoms suggestive of osteoarthritis (OA) of the knee in 682 elderly people. The results suggest that both the frequency of signs and symptoms and the degree of severity remain constant in the 7th, 8th and 9th decades. Differences between men and women and between blacks and whites were also noted--women and blacks tending to have more frequent and more severe evidence of OA of the knee. These data suggest that OA of the knee is a specific disease that affects only a portion of the population and is not inevitably progressive.
Recent empirical evidence supports the importance of adequate randomization in controlled trials. Trials with inadequate allocation concealment have been associated with larger treatment effects compared with trials in which authors reported adequate allocation concealment. While that provides empirical evidence of bias being interjected into trials, trial investigators rarely document the sensitive details of subverting the intended purpose of randomization. This article relates anonymous accounts run the gamut from simple to intricate operations, from transillumination of envelopes to searching for code in the office files of the principal investigator. They indicate that deciphering is something more frequent than a rate occurrence. These accounts prompt some methodological recommendations to help prevent deciphering. Randomized controlled trials appear to annoy human nature--if properly conducted, indeed they should.
Distraction is the most popular technique used in hip arthroscopy. It has been postulated that, if adequate distraction cannot initially be achieved with traction, it will be overcome by distension. The purpose of this study is to quantitate the additive effects of traction and distension in achieving distraction of the hip joint for arthroscopy. Eleven consecutive patients undergoing hip arthroscopy in the supine position on a fracture table were studied. Radiographs of the hip were obtained before and immediately after applying 50 pounds of traction. The hip was then immediately distended with 40 mL saline, and a third radiograph was obtained. After correcting for magnification, distraction was measured for traction alone (DT) and traction plus distension (DTD). A paired t-test was used to compare DT and DTD. Additionally, the ratio of distraction attributed to distension was compared with distraction attributed to traction ([DTD--DT]/DT) and was defined as the delta percent (delta %). Adequate distraction for arthroscopy was able to be achieved in all cases. Distraction due to traction alone (DT) ranged from 2.8 mm to 10.3 mm, with an average of 6.2 mm. Distraction due to traction plus distension (DTD) ranged from 4.8 m to 10.3 mm, with an average of 7.2 mm. The difference between DT and DTD was statistically significant (P < .05). The change in distraction due to distension (delta %) ranged from 0% to 81% with an average of 22%. This study shows that distension may facilitate distraction but the degree is variable.
Few meta-analyses of randomised trials assess the quality of the studies included. Yet there is increasing evidence that trial quality can affect estimates of intervention efficacy. We investigated whether different methods of quality assessment provide different estimates of intervention efficacy evaluated in randomised controlled trials (RCTs).
We randomly selected 11 meta-analyses that involved 127 RCTs on the efficacy of interventions used for circulatory and digestive diseases, mental health, and pregnancy and childbirth. We replicated all the meta-analyses using published data from the primary studies. The quality of reporting of all 127 clinical trials was assessed by means of component and scale approaches. To explore the effects of quality on the quantitative results, we examined the effects of different methods of incorporating quality scores (sensitivity analysis and quality weights) on the results of the meta-analyses.
The quality of trials was low. Masked assessments provided significantly higher scores than unmasked assessments (mean 2.74 [SD 1.10] vs 2.55 [1.20]). Low-quality trials (score < or = 2), compared with high-quality trials (score > 2), were associated with an increased estimate of benefit of 34% (ratio of odds ratios [ROR] 0.66 [95% CI 0.52-0.83]). Trials that used inadequate allocation concealment, compared with those that used adequate methods, were also associated with an increased estimate of benefit (37%; ROR=0.63 [0.45-0.88]). The average treatment benefit was 39% (odds ratio [OR] 0.61 [0.57-0.65]) for all trials, 52% (OR 0.48 [0.43-0.54]) for low-quality trials, and 29% (OR 0.71 [0.65-0.77]) for high-quality trials. Use of all the trial scores as quality weights reduced the effects to 35% (OR 0.65 [0.59-0.71]) and resulted in the least statistical heterogeneity.
Studies of low methodological quality in which the estimate of quality is incorporated into the meta-analyses can alter the interpretation of the benefit of intervention, whether a scale or component approach is used in the assessment of trial quality.
Massage therapy is frequently employed for low back pain (LBP). The aim of this systematic review was to find the evidence for or against its efficacy in this indication. Four randomized clinical trials were located in which massage was tested as a monotherapy for LBP. All were burdened with major methodological flaws. One of these studies suggests that massage is superior to no treatment. Two trials imply that it is equally effective as spinal manipulation or transcutaneous electrical stimulation (TES). One study suggests that it is less effective than spinal manipulation. It is concluded that too few trials of massage therapy exist for a reliable evaluation of its efficacy. Massage seems to have some potential as a therapy for LBP. More investigations of this subject are urgently needed.
Few investigations include both subjective and objective measurements of the effectiveness of treatments for osteoarthritis of the knee. Beneficial interventions may decrease the disability associated with osteoarthritis and the need for more invasive treatments.
To evaluate the effectiveness of physical therapy for osteoarthritis of the knee, applied by experienced physical therapists with formal training in manual therapy.
Randomized, controlled clinical trial.
Outpatient physical therapy department of a large military medical center.
83 patients with osteoarthritis of the knee who were randomly assigned to receive treatment (n = 42; 15 men and 27 women [mean age, 60 +/- 11 years]) or placebo (n = 41; 19 men and 22 women [mean age, 62 +/- 10 years]).
The treatment group received manual therapy, applied to the knee as well as to the lumbar spine, hip, and ankle as required, and performed a standardized knee exercise program in the clinic and at home. The placebo group had subtherapeutic ultrasound to the knee at an intensity of 0.1 W/cm2 with a 10% pulsed mode. Both groups were treated at the clinic twice weekly for 4 weeks.
Distance walked in 6 minutes and sum of the function, pain, and stiffness subscores of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). A tester who was blinded to group assignment made group comparisons at the initial visit (before initiation of treatment), 4 weeks, 8 weeks, and 1 year.
Clinically and statistically significant improvements in 6-minute walk distance and WOMAC score at 4 weeks and 8 weeks were seen in the treatment group but not the placebo group. By 8 weeks, average 6-minute walk distances had improved by 13.1% and WOMAC scores had improved by 55.8% over baseline values in the treatment group (P < 0.05). After controlling for potential confounding variables, the average distance walked in 6 minutes at 8 weeks among patients in the treatment group was 170 m (95% CI, 71 to 270 m) more than that in the placebo group and the average WOMAC scores were 599 mm higher (95% CI, 197 to 1002 mm). At 1 year, patients in the treatment group had clinically and statistically significant gains over baseline WOMAC scores and walking distance; 20% of patients in the placebo group and 5% of patients in the treatment group had undergone knee arthroplasty.
A combination of manual physical therapy and supervised exercise yields functional benefits for patients with osteoarthritis of the knee and may delay or prevent the need for surgical intervention.
Most patients with osteoarthritis seek medical attention because of pain. The safest initial approach is to use a simple oral analgesic such as acetaminophen (perhaps in conjunction with topical therapy). If pain relief is inadequate, oral nonsteroidal anti-inflammatory drugs or intra-articular injections of hyaluronic acid-like products should be considered. Intra-articular corticosteroid injections may provide short-term pain relief in disease flares. Alleviation of pain does not alter the underlying disease. Attention must also be given to nonpharmacologic measures such as patient education, weight loss and exercise. Relief of pain and restoration of function can be achieved in some patients with early osteoarthritis, particularly if an integrated approach is used. Patients with advanced disease may eventually require surgery, which generally provides excellent results.
To determine the minimal perceptible clinical improvement (MPCI) in patients with osteoarthritis (OA) with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire, and patient and investigator global assessment of disease status in randomized clinical trials for treatment of OA.
Subjects with OA of the knee or hip were randomized to receive either rofecoxib 12.5 or 25 mg once daily, ibuprofen 800 mg 3 times daily, or placebo for 6 weeks. The WOMAC and global assessments were completed at baseline and Weeks 2, 4, and 6. A patient global assessment of response to therapy (0 to 4 scale) was used to "anchor" the WOMAC scores. MPCI was defined as the difference in mean change from baseline in WOMAC (100 mm normalized visual analog scale, VAS) between patients with 0 = "None" global response to therapy and patients with 1 = "Poor" global response to therapy.
MPCI was determined to be 9.7, 9.3, and 10.0 mm for the WOMAC pain, physical function and stiffness subscales, respectively, and 11.1 mm for WOMAC question 1: Pain walking on a flat surface. The MPCI for the investigator was 0.4 with investigator assessment of disease status reported on a 0 to 4 Likert scale. Of note, the estimated MPCI for the WOMAC and investigator globals were similar irrespective of treatment, sex, age, or geographic region.
In this analysis, mean changes of roughly 9 to 12 mm (100 mm normalized VAS) on WOMAC scales were perceptible changes to patients with hip and knee OA. A mean decrease of 0.4 in global disease status (0 to 4 Likert scale) as assessed by the investigator corresponded to the patients' MPCI. Understanding the minimal perceptible differences may permit a better assessment of the clinical relevance of therapeutic interventions in OA.
Osteoarthritis (OA), previously called degenerative joint disease, is a common condition. Figures from the United States indicate that as many as 80% of the population has radiographic evidence of this disease by the age of 65 years, and difficulty with ambulation, mostly attributable to OA, accounts for as many as 30% of all visits to a doctor. There is no known cure for OA and hence treatments are used to reduce pain and other symptoms, maintain and/or improve joint mobility, and limit functional disability, with the overall management goal of improving the patients' quality of life. To this point, one of the key objectives of treatment is to manage knee pain. In the past, treatment was most often initiated with the prescription of nonsteroidal anti-inflammatory drugs (NSAIDs). However, evidence that (1) NSAIDs offer no additional symptomatic benefit over simple analgesics, such as paracetamol (acetaminophen), for many patients with OA, (2) NSAID-related adverse gastrointestinal (GI) effects are a significant cause or morbidity and mortality, and (3) NSAIDs could have a possible deleterious effect on articular cartilage metabolism, has led to a change in management strategy. Contemporary thinking is that nonpharmacologic measures should be tried first, with pharmacologic intervention used as an adjunct. Nonpharmacologic therapy includes such things as patient education, weight loss, physical therapy, occupational therapy, and exercise. Paracetamol, in doses of as high as 4000 mg/day, is the first-line drug of choice for the management of the pain of OA. If the patient does not respond to paracetamol, NSAIDs may be an appropriate alternative, provided they are not medically contraindicated. Because of their GI toxicity, it is suggested that NSAIDs be used in the lowest possible dose for the shortest possible time. In OA, the intensity of pain varies both during the day and night, enabling the use of NSAIDs with a short half-life on an as-needed basis. Strategies to reduce the risk of NSAID-related GI complications include prophylaxis with misoprostol. Current developments in the field of OA management are also discussed, including the emergence of drugs that specifically inhibit cyclooxygenase 2 (COX-2) and disease-modifying treatments.
Osteoarthritis is a common rheumatologic disorder. It is estimated that 40 million Americans and 70 to 90 percent of persons older than 75 years are affected by osteoarthritis. Although symptoms of osteoarthritis occur earlier in women, the prevalence among men and women is equal. In addition to age, risk factors include joint injury, obesity, and mechanical stress. The diagnosis is largely clinical because radiographic findings do not always correlate with symptoms. Knowledge of the etiology and pathogenesis of the disease process aids in prevention and management. Acetaminophen and nonsteroidal anti-inflammatory medications remain first-line drugs. Agents such as cyclooxygenase-2 inhibitors and sodium hyaluronate joint injections offer new treatment alternatives. Complementary medication use has also increased. Therapeutic goals include minimizing symptoms and improving function.
