Effects of Manual Therapy in Addition to Exercise Therapy for Knee Osteoarthritis

Evidence-Based Practice – Issue 1-2016

The incremental effects of manual therapy or booster session in addition to exercise therapy for knee osteoarthritis: a randomized clinical trial

Article.  Abbott JH, et al., “The Incremental Effects of Manual Therapy or Booster Session in Addition to Exercise Therapy for Knee Osteoarthritis: A Randomized Clinical Trial,” Journal of Orthopaedic and Sports Physical Therapy 2015; 45(12):  975-983.

Purpose.  To investigate the addition of manual therapy to exercise therapy for the reduction of pain and increase of physical function in people with knee osteoarthritis, and whether “booster” sessions compared to consecutive sessions may improve outcomes.   

Study Design.  A factorial randomized controlled trial.

Methods

Subjects

• 75 Total participants randomized into one of 4 groups

  • Exercise Therapy (19)

  • Exercise Therapy with Booster Sessions (19)

  • Exercise Therapy and Manual Therapy (18)

  • Exercise Therapy with Booster Session and Manual Therapy (19)

  • 9 subjects were lost to follow-up

• Inclusion criteria
  • > 40 years of age
  • Crepitus with motion
  • < 30 minutes of morning stiffness
  • Bony tenderness
  • Bony enlargement
  • No palpable warmth of synovium
• Exclusion Criteria
  • Rheumatoid Arthritis
  • Previous total joint replacement
  • Previous surgery to lower limbs in past 6 months
  • Injection to the knee in past 30 days
  • Physical health concerns that may preclude from exercise
• Protocols
  • Exercise Therapy (12 consecutive 45 min sessions)
    • 10 min aerobic exercise (walk or cycle)
    • 3×10 of resisted knee extension, hip extension, knee flexion
    • 60 second passive stretch of knee flexors, knee extensors, and plantar flexors
    • Strengthening of plantar flexors, hip abductors, hip lateral rotators, trunk muscles, and stretching of hip flexor and knee extensors as needed.
  • Exercise + Manual Therapy (12 consecutive 45 min sessions)
    • All exercises as noted above
    • Non-thrust passive knee flexion and extension
    • A-P tibiofemoral
    • P-A tibiofemoral
    • Patellar glides
    • Manual stretching and Soft-tissue manipulation of quads, hamstrings, calf, hip adductors, and peri-patellar structures
  • Exercise + Booster Sessions (8 consecutive 45 min sessions; followed by 2 sessions at 5 months, 1 session at 8 months, and 1 session at 11 months)
    • All exercises as noted above
  • Exercise + Manual Therapy + Booster Sessions (8 consecutive 45 min sessions; followed by 2 sessions at 5 months, 1 session at 8 months, and 1 session at 11 months)
    • All exercises as noted above
    • Non-thrust passive knee flexion and extension
    • A-P tibiofemoral
    • P-A tibiofemoral
    • Patellar glides
    • Manual stretching and Soft-tissue manipulation of quads, hamstrings, calf, hip adductors, and peri-patellar structures
• Outcome Measures
  • Self-reported disability scale (WOMAC)
  • Numeric Pain Rating Scale
  • Timed up-and-go
  • 30 second sit-to-stand
  • 40 meter fast-paced walk test
• Results
  • Results from booster sessions + manual therapy or exercise + manual was significantly greater than exercise alone
  • Exercise + Booster yielded the greatest improvement
  • The combination of exercise + manual therapy + booster was not superior to exercise alone.
• Clinical significance
  • Manual therapy improved the effectiveness of exercise in 12 consecutive therapy sessions.
  • Distributing therapy session over a year in the form of booster sessions was more effective than consecutive sessions.