Elsevier

Manual Therapy

Volume 16, Issue 2, April 2011, Pages 109-117
Manual Therapy

Systematic review
Manual therapy for osteoarthritis of the hip or knee – A systematic review

https://doi.org/10.1016/j.math.2010.10.011Get rights and content

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.

Introduction

Osteoarthritis is the most common form of arthritis and one of the leading causes of pain and disability worldwide (NICE, 2008, Reginster, 2002). It is characterised by a progressive loss of articular cartilage, joint space narrowing, sclerosis of subchondral bone and osteophyte formation. Soft tissues such as the capsule can undergo soft tissue contracture and fibrosis (Cameron and Macnab, 1975, Jacobs, 1960). These changes can result in pain, impaired mobility, reduced muscle strength, limitation in activities of daily living (Steultjens et al., 2000, Steultjens et al., 2001) and reduced quality of life (Salaffi et al., 2005), with the knee and hip joints most commonly affected. Management aims to control pain and reduce disability (Hinton et al., 2002, Sarzi-Puttini et al., 2005). Non-pharmacologic measures such as education, weight loss, physical therapies, and exercise should be tried first, with adjunctive pharmacologic intervention (Brandt, 2000). Manual therapy is a physical treatment used by physiotherapists, chiropractors, osteopaths and other practitioners to treat musculoskeletal pain and disability, and includes massage therapy, joint mobilisation and manipulation. Recently published clinical guidelines on the management of OA recommended manual therapy as an adjunctive therapy to exercise for OA (NICE, 2008, RACGP, 2009). Of note is that in one of the guidelines, this recommendation was based on just one study (Hoeksma et al., 2004) which compared manual therapy head-to-head with exercise rather than as a supplementary intervention. Some of its proposed mechanisms include mechanical alteration of tissues, neurophysiological effects and a psychological influence (Hoving et al., 2004).

No known systematic reviews have evaluated the effect of manual therapy in the management of hip or knee OA. The aim of this review was to determine if manual therapy is beneficial for people with hip or knee OA in reducing pain or improving physical function.

Section snippets

Methods

An extensive computerised literature search of MEDLINE (Ebsco, PubMed, OVID) (January 1966 – October 2009) and the following databases from inception date to October 2009: CINAHL (Ebsco), EMBASE, PEDro, Cochrane Library, ISI Web of Science and PsychINFO was undertaken by all four authors.

Subject headings and keywords based around population, interventions and study design were used to identify potential citations (Appendix A). The references of all included publications and systematic reviews

Trials

The search yielded 1209 potentially eligible studies. Following the exclusion process (Fig. 1), eight articles which had manual therapy as a treatment component remained. Four articles which examined manual therapy in combination with exercise were excluded (Bennell et al., 2005, Deyle et al., 2005, Deyle et al., 2000, Stoneman, 2001). The four remaining studies included manual therapy as a sole intervention and met the inclusion criteria.

Characteristics of the included studies

All four studies were single-centre trials conducted in

Discussion

This is the first known systematic review to evaluate the effect of manual therapy in hip or knee OA. The small number of included studies indicates the limited research to date. Although patients were randomly allocated to groups in all trials, the method of randomisation in three of the trials which used variations of pre-prepared sealed envelopes can be subject to bias compared with computer-generated numbers (Pocock, 1983, Schulz, 1995). Blinding of treatment providers and study

Conclusion

From the available data, there is silver level evidence that manual therapy has a beneficial effect compared with exercise therapy in those with hip OA, both in the short and long-term for pain reduction and increased physical function. These results are based on one study with a low risk of bias and a small sample. There is less convincing evidence from three studies with a high risk of bias that manual therapy is no better than placebo or Meloxicam medication, but manual therapy, in the form

Author contributions

Study conception and design: French, Brennan, White, Cusack.

Acquisition of data: French, Brennan, White, Cusack.

Analysis and interpretation of data: French, Brennan, Cusack.

Manuscript preparation: French, Brennan, Cusack.

All authors were involved in critically appraising the manuscript for intellectual content and approved the final version prior to submission for publication. Ms French had full access to all of the data in the study and takes responsibility for the integrity of the data and

Acknowledgements

We are extremely grateful to Professor Adam Perlman and Dr James Brantingham for providing specific data from their trials. We thank Professor Ronan Conroy, Royal College of Surgeon in Ireland (RCSI) for his statistical advice. Sincere thanks also to Ms Grainne McCabe, Librarian, RCSI, Anne Murphy, Librarian AMNCH, Kathryn Smith, Deputy Head of Library Academic Services Life Sciences, UCD and Ms Angela Rice, Librarian, MMUH for their assistance with literature searching.

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