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QUESTION: In patients with osteoarthritis of the knee, how effective is manual physical therapy and exercise in decreasing pain and stiffness and increasing function and walking distance?
Outpatient clinic of a US army medical centre in Fort Sam Houston, Texas.
83 patients (mean age 61 y, 59% women) who had osteoarthritis of the knee, no surgical procedure on either lower limb in the previous 6 months, and no physical impairment that would preclude study participation. 69 patients (83%) completed the treatment.
Patients were allocated to manual physical therapy and exercise (n=42) or placebo (ultrasonography at a subtherapeutic intensity) (n=41) given twice weekly for 4 weeks. Physical therapy consisted of passive joint movements; muscle stretching; and soft tissue mobilisation applied to the knee and to the lumbar spine, hip, or ankle if necessary. The exercise programme involved stretching routines for the lower limbs; range of motion exercises for the knee, including stationary cycling; and muscle strengthening exercises for the hip and knee. Intervention group patients also did the exercises at home, 30 minutes/day.
Main outcome measures
Change in stiffness, pain, and function subscores on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) (visual analogue scale version) and the distance covered during a 6 minute walk test.
At 8 weeks, mean WOMAC scores decreased more in the intervention group than in the placebo group (p<0.05) (table).
Intervention group patients increased their 6 minute walking distance more than placebo group patients (p<0.05) (table). At 1 year, fewer intervention group patients had knee surgery than placebo group patients (p=0.039) (table).
In patients with osteoarthritis of the knee, manual physical therapy and exercise decreased pain and stiffness and increased function and the distance walked in 6 minutes.
Deyle et al conducted a well designed, assessor masked, randomised, clinical trial of the efficacy of manual therapy and exercise on US army personnel with osteoarthritis of the knee. Army personnel are probably representative of the general population and possibly more disciplined and compliant.
The trial is remarkable because favorable outcomes were achieved in 4 weeks and maintained at 8 weeks using non-invasive interventions. Furthermore, 50% of patients assessed at 1 year maintained their benefits, albeit at a slightly reduced rate.
In scrutinising the study methods, it is notable that neither the sample size nor the anticipated dropout rate was justified in the text. It was not clear which of the 2 main outcomes reported was considered primary in testing the study hypothesis. Because of the unbalanced dropout rate, the use of a multiple imputation analysis to account for missing data might have been helpful. Any loss of outcome data regardless of how it occurs clearly reduces the statistical precision of a trial and may also introduce bias if the losses vary by treatment group.1
This trial showed that control patients had statistically significant higher rates of surgeries and intra-articular steroid injections at 1 year. On the basis of this finding, physicians treating patients with osteoarthritis might improve pharmacological management by referring patients earlier rather than later to physical therapists. This small change could diminish the burden of disability and reduce the presumably higher cost of invasive surgery and rehabilitation after surgery.