Effects of orthopaedic manual therapy in knee osteoarthritis: a systematic review and meta-analysis

The Efficacy of Manual Therapy on Musculoskeletal Pain in Menopause: A Systematic Review

(1) Background: The aim of this review was to evaluate the effects of manual therapy for musculoskeletal pain in menopausal women. (2) Methods: A comprehensive search of manuscripts published from inception until 29 February 2024 was conducted on PubMed, EBSCO Information Services (EBSCOhost), Physiotherapy Evidence Database (Pedro), Web of Science, Scientific Electronic Library Online (SciELO), Cochrane Central Register of Controlled Clinical Trials, and Scopus using Medical Subject Headings (MeSH) and free terms. Randomized controlled trials (RCT) investigating the effects of manual therapy for musculoskeletal pain in postmenopausal women were included. Articles published in non-English or non-Portuguese languages, case reports, expert opinions, dissertations, conference papers, and gray literature were excluded. Studies were screened for population, musculoskeletal pain, intervention, and pain outcome by two independent reviewers using an ad hoc data extraction form. (3) Results: A total of 5 RCTs (4 with high risk of bias and 1 with low risk of bias) were included (total sample = 245), addressing thumb carpometacarpal osteoarthritis, thoracic kyphosis, chronic neck and backache, knee osteoarthritis, and sternocostal joint pain. The combined results of these studies showed improved musculoskeletal pain in menopausal women; duration of the follow-up was between 4 weeks to 6 months. Conclusions: The majority of studies included in this systematic review were effective in reducing musculoskeletal pain in menopausal women. These results come mainly from studies with a high risk of bias with small sample sizes, and the most representative follow-up period was short-term. Therefore, the results of this systematic review should be interpreted with caution.

Non-pharmacological and non-surgical interventions to manage patients with knee osteoarthritis: An umbrella review 5-year update

Objective

This umbrella review aimed to summarize (and update) the effectiveness of non-pharmacological and non-surgical interventions for patients with knee osteoarthritis.

Methods

The study followed the PRISMA guidelines. Manual and electronic databases were searched, to identify systematic 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 conservative treatments) O (pain, function, quality of life, and other knee-specific measures) model. The quality of evidence was 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 overall score of 29.6. The systematic reviews were published between 2018 and 2022 (29.8% in 2022), conducted in 19 countries (52.6% in China), and explored 24 distinct interventions. The systematic reviews encompassed 714 trials (mean of 13 ​± ​7.7 studies per systematic review), and 59,343 participants (mean 1041 ​± ​1002 per systematic 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 Training are 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 moderate support. For other interventions, the evidence quality was low, results were mixed or inconclusive, or there was not sufficient efficacy to support their use.

The Effectiveness of Exercise-Based Rehabilitation in People With Hand Osteoarthritis: A Systematic Review With Meta-analysis

OBJECTIVE: To investigate the effectiveness of exercise-based rehabilitation programs compared with nonexercise intervention or no intervention for people with hand osteoarthritis (OA). DESIGN: Intervention systematic review with meta-analysis. LITERATURE SEARCH: We searched 5 databases on July 23, 2023. STUDY SELECTION CRITERIA: We included randomized controlled trials that compared the effectiveness of rehabilitation programs that included an exercise component, with nonexercise intervention or no intervention for people with hand OA. DATA SYNTHESIS: Standardized mean differences (SMDs) were pooled using a random-effects model. The risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool. The certainty of the evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. RESULTS: Fourteen trials were included in the meta-analysis (n = 1341 participants). In the immediate term (<24 weeks), there was low-certainty evidence of an effect of exercise-based rehabilitation on improving pain (13 trials; SMD = -0.65; 95% CI: -1.06, -0.25), function (11 trials; SMD = -0.35; 95% CI: -0.54, -0.15), and grip strength (14 trials; SMD = 0.21; 95% CI: 0.03, 0.38). There was moderate-certainty evidence of an effect on reducing stiffness (7 trials; SMD = -0.33; 95% CI: -0.51, -0.16). There was low-certainty evidence of no effect on improving pinch strength and quality of life. For the long term (≥24 weeks), there was low-certainty evidence that exercise-based rehabilitation had no additional effect on improving pain, function, and stiffness. CONCLUSION: Exercise-based rehabilitation improved pain, function, stiffness, and grip strength in people with hand OA in the immediate term; the benefits were not maintained in the long term. J Orthop Sports Phys Ther 2024;54(7):1-11. Epub 20 March 2024. doi:10.2519/jospt.2024.12241.

The Management of Knee Osteoarthritis in the Real World: An Italian National Survey

Background: Knee osteoarthritis is a degenerative and inflammatory disease causing pain and worsening patients' quality of life. Various conservative treatment options exist, but a gap between scientific evidence and clinical practice is still present. The aim of this prospective multicenter observational study is to describe the real outpatient territorial management of patients with knee osteoarthritis and to analyze the correlation between the anthropometric and clinical characteristics of the population of patients suffering from symptomatic knee osteoarthritis who were screened in the national survey. Methods: The educational national project was divided into three modules: the first and the last through webinars; and the second held in daily practice. The participants had to register structured observations, which were then stored in a national database and analyzed in order to identify correlations. The subgroups were stratified by body composition, radiological severity of knee osteoarthritis, pain, and functional ability. Results: The project has been joined by 155 physicians, and 2.656 observations about real-world outpatients being treated for knee osteoarthritis in Italy were collected. Data relating to real-world pharmacological and rehabilitation therapies in correlation with body composition, the radiological severity of knee osteoarthritis, pain, and functional ability were reported. Conclusions: Currently, there are no standardized protocols using effective combinations of therapeutic exercises, physical agents, and medications to control the progression of knee osteoarthritis. This real-word national survey proved to be useful for describing the current state of the art of therapeutic management of knee osteoarthritis and for emphasizing the need to fill the gap between scientific evidence and clinical practice.

Pragmatism in manual therapy trials for knee osteoarthritis: a systematic review

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.

Effect of an Integrated Physiotherapy Protocol on Knee Osteoarthritis Patients: A Preliminary Study

BACKGROUND

Exercise therapy can potentially relieve symptoms and improve functional status of the knee osteoarthritis population. Despite the proved practical benefits, there is no standard, comprehensive physiotherapeutic protocol available targeting the physical and physiological impairment cluster associated with disease. Osteoarthritis is a whole joint disease, affecting joint cartilage, ligaments, menisci and joint associated muscles, from variable pathophysiological processes. Hence, there is a need to develop a physiotherapy protocol to address the multi-structural physical, physiological and functional impairments associated with the disease.

OBJECTIVE

The objective of the present study is to evaluate the efficacy of designed, therapist supervised, patient education, progressive resistance exercises, passive stretching exercises, soft tissue manipulation, muscle energy technique, Maitland mobilization, aerobic exercise, and neuromuscular training physiotherapy protocol on pain, disability, balance, and physical functional performance in knee osteoarthritis patients.

METHODOLOGY

The preliminary study was conducted on a (n = 60) sample of convenience. The samples were randomly allocated into two study groups, intervention, and control group. The control group was advised on a basic home program. On the other hand, the treatment of the intervention group was designed with a therapist supervised Physiotherapy Protocol. The outcome variables studied were the Visual Analogue Scale, Modified WOMAC Scale, Timed Up and Go Test, Functional Reach Test, 40 m Fast Paced Walk Test, Stair Climb Test, 30 s Chair Stand Test.

RESULTS

The results of the study revealed a significant improvement among most of the studied outcome measures in the intervention group, hence the designed supervised physiotherapy protocol was found effective in relieving multiple physiological impairments associated with this whole joint disease.

Physical Rehabilitation in Zoological Companion Animals

Animal physical rehabilitation is one of the fast-growing fields in veterinary medicine in recent years. It has become increasingly common in small animal practice and will continue to emerge as an essential aspect of veterinary medicine that plays a vital role in the care of animals with physical impairments or disabilities from surgery, injuries, or diseases.1 This is true now more than ever because of the increasing advances in lifesaving treatments, the increased lifespan of companion animals, and the growth of chronic conditions, of which many are associated with movement disorders. The American Association of Rehabilitation Veterinarians (AARV) defines APR as "the diagnosis and management of patients with painful or functionally limiting conditions, particularly those with injury or illness related to the neurologic and musculoskeletal systems." Rehabilitation not only focuses on recovery after surgical procedures but also on improving the function and quality of life in animals suffering from debilitating diseases such as arthritis or neurologic disorders. The overall goal of APR is to decrease pain, reduce edema, promote tissue healing, restore gait and mobility to its prior activity level, regain strength, prevent further injury, and promote optimal quality of life. Typically, a multimodal approach with pharmaceutical and nonpharmaceutical interventions is used by APR therapists to manage patients during their recovery. The purpose of this article aims to provide knowledge and guidance on physical rehabilitation to help veterinarians in the proper return of their patients with ZCA safely after injury and/or surgery.

Effectiveness and safety of manual therapy for knee osteoarthritis: An overview of systematic reviews and meta-analyses

Background

Manual therapy has been used as an alternative approach to treat knee osteoarthritis (KOA) for many years. Numerous systematic reviews (SRs) or meta-analyses (MAs) were published to evaluate its effectiveness and safety. Nevertheless, the conclusions of SRs/MAs are inconsistent, and the uneven quality needs to be critically appraised.

Objectives

To conduct a comprehensive overview of the effectiveness and safety of manual therapy for KOA and the quality of relevant SRs/MAs, thus providing critical evidence and valuable direction for future researchers to promote the generation of advanced evidence.

Methods

The pre-defined search strategies were applied to eight electronic databases from inception to September 2022. Suitable SRs/MAs were included in accordance with the inclusion and exclusion criteria. The methodological quality, risk of bias, reporting quality, and evidence quality were assessed by two independent reviewers who used respectively the A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR-2), the Risk of Bias in Systematic Reviews (ROBIS), the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 Version (PRISMA 2020), and Grades of Recommendations, Assessment, Development and Evaluation (GRADE) based on the method of narrative synthesis. We excluded the overlapping randomized controlled trials (RCTs) and performed a re-meta-analysis of the total effective rate.

Results

A total of eleven relevant SRs/MAs were included: nine SRs/MAs were rated critically low quality, and two were rated low quality by AMSTAR-2. According to ROBIS, all SRs/MAs were rated low risk in Phase 1 (assessing relevance) and Domain 1 (study eligibility criteria) of Phase 2. Three SRs/MAs (27.27%) were rated low risk in Domain 2 (identification and selection of studies). Ten SRs/MAs (90.91%) were rated low risk in Domain 3 (data collection and study appraisal). Five SRs/MAs (45.45%) were rated low risk in Domain 4 (synthesis and findings). And five SRs/MAs (45.45%) were rated low risk in Phase 3 (risk of bias in the review). By PRISMA 2020, there were some reporting deficiencies in the aspects of abstract (2/11, 18.18%), search strategy (0/11, 0%), preprocessing of merging data (0/11, 0%), heterogeneity exploration (6/11, 54.55%), sensitivity analysis (4/11, 36.36%), publication bias (5/11, 45.45%), evidence quality (3/11, 27.27%), the list of excluded references (3/11, 27.27%), protocol and registration (1/11, 9.09%), funding (1/11, 9.09%), conflict of interest (3/11, 27.27%), and approach to relevant information (0/11, 0%). In GRADE, the evidence quality was defined as moderate quality (8 items, 21.05%), low quality (16 items, 42.11%), and critically low quality (14 items, 36.84%). Among the downgraded factors, risk of bias, inconsistency, imprecision, and publication bias were the main factors. A re-meta-analysis revealed that manual therapy can increase the total effective rate in KOA patients (risk ratio = 1.15, 95% confidence interval [1.12, 1.18], p < 0.00001; I² = 0, p = 0.84). There are four reviews that narratively report adverse effects, and no severe adverse reactions occurred in the manual therapy group.

Conclusions

Manual therapy may be clinically effective and safe for patients with KOA. However, this conclusion must be interpreted with caution because of the generally unsatisfactory study quality and inconsistent conclusions of the included SRs/MAs. Further rigorous and normative SRs/MAs are expected to be carried out to provide robust evidence for definitive conclusions.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/#myprospero, identifier: CRD42022364672.

The Benefits of Adding Manual Therapy to Exercise Therapy for Improving Pain and Function in Patients With Knee or Hip Osteoarthritis: A Systematic Review With Meta-analysis

OBJECTIVE: To evaluate if there was an additional benefit of combining manual therapy (MT) and exercise therapy over exercise therapy alone on pain and function in patients with hip or knee osteoarthritis. DESIGN: Intervention systematic review LITERATURE SEARCH: We (1) searched 4 databases from inception to June 20, 2021; (2) hand searched a reference list of included trials and relevant systematic reviews; and (3) contacted 2 researchers in the field. STUDY SELECTION CRITERIA: We included randomized controlled trials that compared MT and exercise therapy to similar exercise therapy programs alone in patients with hip or knee osteoarthritis. DATA SYNTHESIS: The data were combined using random-effects meta-analyses where appropriate. The certainty of evidence for each outcome was judged using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. RESULTS: We included 19 trials. There was very low to moderate certainty of evidence that MT added benefit in the short term for pain, and combined pain, function, and stiffness (WOMAC global scale), but not for performance-based function and self-reported function. In the medium term, there was low- to very-low-certainty evidence that MT added benefit for performance-based function and WOMAC global score, but not for pain. There was high-certainty evidence that MT provided no added benefit in the long term for pain and function. CONCLUSION: There was very low to moderate certainty of evidence supporting MT as an adjunct to exercise therapy for pain and WOMAC global scale, but not function in patients with knee or hip osteoarthritis in the short term. There was high certainty of evidence of no benefit for additional MT over exercise therapy alone in the long term. J Orthop Sports Phys Ther 2022;52(10):675-684. Epub: 27 July 2022. doi:10.2519/jospt.2022.11062.

Hip abductor versus adductor strengthening for clinical outcomes in knee symptomatic osteoarthritis: A randomized controlled trial

BACKGROUND

Hip adductors and abductors are weak in patients with knee osteoarthritis (KOA). However, most studies have not investigated selective adductor strengthening.

OBJECTIVE

To compare the effects of adding selective hip abductors versus adductors strengthening to lower limb multimodal exercise program for pain, self-reported function, knee-related quality of life, medication ingested and performance-based tests in patients with symptomatic KOA.

DESING

Randomized controlled trial.

METHODS

Sixty-six patients with KOA were randomly assigned to two treatment groups: hip abductor group (HABG) or hip adductor group (HADG). Both groups performed a lower limb multimodal exercise program. HABG and HADG groups added three hip abduction and three hip adduction exercises, respectively. Intensity of pain through numeric pain scale, Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales, Lequesne questionnaire, global perceived effect scale, medication ingested, performance-based tests were assessed at baseline, after 6 weeks, and 6 months.

RESULTS

No significant between-group differences were found in primary outcomes: pain intensity (mean difference = -1.15, 95%CI -2.44 - 0.12, P = 0.07), KOOS-pain (mean difference = 1.64, 95%CI -6.79 - 10.07, P = 0.70) and KOOS-function in daily living (mean difference = -0.12, 95%CI, -8.78 - 8.54, P = 0.97) in 6 weeks. Groups did not differ in any secondary outcome after 6 weeks or after 6 months (P > 0.05).

CONCLUSIONS

There is no difference between adding hip abductors or adductors strengthening to lower limb multimodal exercise program in improving pain, self-reported function, quality of life, medication ingested and performance-based tests in patients with KOA.

A Systematic Review of Psychometric Properties of Knee-Related Outcome Measures Translated, Cross-Culturally Adapted, and Validated in Arabic Language

During the previous two decades, patient-reported outcome measures (PROMs) have been well tested, and the tools were validated in different languages across the globe. This systematic review aimed to identify the knee disease-specific outcome tools in Arabic and evaluate their methodological quality of psychometric properties of the most promising tools based on the COSMIN checklist and PRISMA guidelines. Articles published in English, from the inception of databases until the date of search (10 August 2022), were included. Articles without at least one psychometric property (reliability, validity, and responsiveness) evaluation, and articles other than in the English language, were excluded from the study. The key terms [“Arabic” AND “Knee” AND (“Questionnaire” OR “Scale”)] were used in three databases, i.e., PubMed, Scopus, and Web of Science (WoS) in the advanced search strategy. Key terms were either in the title or abstract for PubMed. Key words were in the topic (TS) for WoS. COSMIN (COnsensus-based Standards for the selection of health Measurement Instruments) risk of bias checklist was used to evaluate the methodological quality of psychometric properties of the Arabic knee-related outcome measures. A total of 99 articles were identified in PubMed, SCOPUS, and WoS. After passing inclusion and exclusion criteria, 20 articles describing 22 scales from five countries were included in this review. The instruments validated in the Arabic language are Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), knee injury and osteoarthritis outcome score (KOOS), knee outcome survey- activities of daily living scale (KOS-ADLS), Oxford knee score (OKS), anterior knee pain scale, osteoarthritis of knee and hip health-related quality of life (OAKHQoL) scale, Lysholm knee score (LKS), international documentation committee subjective knee form (IKDC), intermittent and constant osteoarthritis pain (ICOAP) questionnaire, Kujala patellofemoral pain scoring system (PFPSS), anterior knee pain scale (AKPS) and osteoarthritis quality of life questionnaire (OAQoL),. All were found to have good test-retest reliability (Intra Correlation Coefficient), internal consistency (Cronbach’s alpha), and construct validity (Visual Analog Scale, Short Form-12, RAND-36, etc.). Of 20 instruments available to assess self-reported knee symptoms and function, 12 were validated in the Saudi Arabian population. Among them, KOS-ADLS is the best PROM to be used in various knee conditions, followed by KOOS and WOMAC. The assessed methodological quality of evidence says that the knee Arabic PROMs are reliable instruments to evaluate knee symptoms/function.

Osteoarthritis of the Knee in Middle-age Athletes: Many Measures are Practiced, but Lack Sound Scientific Evidence

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.

Effectiveness of Interventions Based on Pain Neuroscience Education on Pain and Psychosocial Variables for Osteoarthritis: A Systematic Review

Osteoarthritis (OA) is the most common joint condition. It affects more than 300 million people worldwide, who suffer from pain and physical disability. Objective: To determine the results of cognitive educational interventions for pain management and psychosocial variables in adults with OA. Method: A systematic review was conducted based on searches in MEDLINE, OVID, LILACS, Scopus, PEDro, OTseeker, The Cochrane Library, EBSCO, and Google Scholar. The search strategy included the main terms neuroscience education and osteoarthritis, without any re-strictions with regard to dates or study type (PROSPERO register CRD42021222763). Results: We included four articles that implemented the intervention in 1–6 sessions, addressing concepts related to goal orientation and providing strategies for understanding pain. The results suggest that there is an improvement between the groups (PNE) when compared, but this cannot necessarily be attributed to pain neuroscience education (PNE), as small effect sizes for variables such as pain catastrophizing and kinesiophobia were observed. The response in the modulation of acute pain following the surgical procedure may produce a variation in the responses and this may be mediated by medications. Conclusion: The study revealed an improvement in favor of the groups managed with PNE, although more studies documenting the topic are warranted.

Overview of Registered Clinical Trials on Manual Therapy: Possible Implications of Genetic Testing for Personalized Treatment

BACKGROUND/AIM

Manual therapy (MT) is a frequently applied intervention offering individualized treatment in the clinic. In addition to the traditional approaches of MT, measuring molecular response to MT may offer better understanding of MT outcomes in order to provide specific personalized treatment. The aim of this study was to summarize MT-related registered clinical trials, as well as to search for any evidence on MT and genetics.

PATIENTS AND METHODS

A comprehensive search was conducted within the Clinical Trials database with predefined keywords mining for all types of MT-related clinical trials.

RESULTS

From the 47 trials, 20 had results and 27 had no results. MT alleviated pain and improved function almost in all trials. One registered clinical trial had investigated molecular outcomes of MT.

CONCLUSION

MT is an effective and individualized treatment offering option in the management of several conditions. Interestingly, a clinical trial was found investigating molecular genetics and MT pinpointing an already existing link between genetics and MT. Therefore, further clinical trials may focus on genetics and MT for providing specific personalized treatment in future.

Efficacy of massage therapy in improving outcomes in knee osteoarthritis: A systematic review and meta-analysis

BACKGROUND

and purpose: Massage therapy is being used for knee osteoarthritis. However, level-1 evidence is lacking. This systematic review and meta-analysis aimed to synthesize evidence on the effect of massage therapy on knee osteoarthritis.

METHODS

PubMed, Embase, Ovid, Springer, and Google Scholar databases were searched up to May 8, 2021 for randomized controlled trials comparing massage with controls for knee osteoarthritis. Review manager was used for a random-effect meta-analysis. Risk of bias was assessed using the Cochrane collaboration risk assessment tool and certainty of evidence using Grading of Recommendations Assessment, Development, and Evaluation (GRADE).

RESULTS

Twelve studies with 737 participants were included. After 1-4 weeks of therapy, there was a significant reduction in pain and stiffness scores in the massage group and after 6-8 weeks of therapy, there was a significant reduction in stiffness and functionality scores. There was no significant difference in outcomes with long-term therapy. A statistically significant reduction in stiffness scores was seen with aromatherapy massage. Aromatherapy massage was not superior to standard massage. The overall quality of evidence according to GRADE was low to moderate for standard massage therapy and very low for aromatherapy.

CONCLUSION

Massage therapy may lead to some improvement in pain, stiffness, and functionality scores in the short term but not in long term. Aromatherapy massage was not found to be any better than standard massage therapy. Current evidence is limited by methodological heterogeneity amongst trials and small sample size of the studies.

Comprehensive Rehabilitation of the Athlete: A Specific and Purposeful Approach

There is a need to improve the quality of rehabilitation in sports medicine to return athletes to optimal function safely and quickly, reducing the risk of reinjury. This paper describes a planning paradigm to guide clinical reasoning during individual treatment sessions and a model for planning the rehabilitation program from acute injury to return to play. The design of a rehabilitation program should be a collaborative, team effort, and accounting for the specific needs of the athlete. As the athlete progresses from acute injury management all the way back to full competition, the rehabilitation professional emphasizes the components of pain management, motion, motor control, and force production in varying degrees based upon phases of tissue healing and the athlete's response. Utilizing high-value, evidence-based treatments maximize both the effectiveness and efficiency of rehabilitation to restore and improve upon preinjury levels of physical performance.

Manual Therapy: Always a Passive Treatment?

The use of manual therapy as an intervention has garnered intense debate, one that is 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 treatments, some with passive components and some that are primarily passive in certain scenarios. But manual therapy can be an integral part of highly active treatment strategies. We implore investigators to describe manual therapy interventions in sufficient detail so that they can be reproduced and thereby help the end users of research (including clinicians) to better assess the value of such interventions. This Viewpoint challenges the assumption that manual therapy is always a passive treatment of low value. J Orthop Sports Phys Ther 2021;51(10):474-477. Epub 1 Jul 2021. doi:10.2519/jospt.2021.10330.

The Role of Chiropractic Care in Providing Health Promotion and Clinical Preventive Services for Adult Patients with Musculoskeletal Pain: A Clinical Practice Guideline

Objective: To develop evidence-based recommendations on best practices for delivery of clinical preventive services by chiropractors and to offer practical resources to empower provider applications in practice. Design: Clinical practice guideline based on evidence-based recommendations of a panel of practitioners and experts on clinical preventive services. Methods: Synthesizing the results of a literature search for relevant clinical practice guidelines and systematic reviews, a multidisciplinary steering committee with training and experience in health promotion, clinical prevention, and/or evidence-based chiropractic practice drafted a set of recommendations. A Delphi panel of experienced practitioners and faculty, primarily but not exclusively chiropractors, rated the recommendations by using the formal consensus methodology established by the RAND Corporation/University of California. Results: The Delphi consensus process was conducted during January-February 2021. The 65-member Delphi panel reached a high level of consensus on appropriate application of clinical preventive services for screening and health promotion counseling within the chiropractic scope of practice. Interprofessional collaboration for the successful delivery of clinical preventive services was emphasized. Recommendations were made on primary, secondary, tertiary, and quaternary prevention of musculoskeletal pain. Conclusions: Application of this guideline in chiropractic practice may facilitate consistent and appropriate use of screening and preventive services and foster interprofessional collaboration to promote clinical preventive services and contribute to improved public health.

Efficacy of Specified Manual Therapies in Combination with a Supervised Exercise Protocol for Managing Pain Intensity and Functional Disability in Patients with Knee Osteoarthritis

PURPOSE

The current study aimed to determine the efficacy of specified manual therapies in combination with a supervised exercise protocol for managing pain intensity and functional disability in patients with knee osteoarthritis.

METHODS

The study was based on a two-arm parallel-group randomized controlled trial design, including a total of 32 participants with knee osteoarthritis randomly divided into groups A and B. Group A received a supervised exercise protocol; however, group B received specified manual therapies in combination with a supervised exercise protocol. Pain and functional disability were measured with the numeric pain rating scale (NPRS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), respectively. Data were collected at baseline (pre-intervention), 2 weeks, and 4 weeks post-intervention. To evaluate the efficacy of specific manual therapies with supervised exercise compared to supervised exercise alone, an unpaired t-test and repeated measures ANOVA were used to analyze the data, keeping the level of significance at p<0.05.

RESULTS

A significant (p<0.05) mean difference (∆MD) was found within group A and group B for both outcomes when we compared their baseline scores with 2-week (group A, NPRS: ∆MD=-1.56 and WOMAC: ∆MD=14.94; group B, NPRS: ∆MD=2.06 and WOMAC: ∆MD=22.19) and 4-week post-intervention scores (group A, NPRS: ∆MD=0.62 and WOMAC: ∆MD=6.75; group B, NPRS: ∆MD=0.75 and WOMAC: ∆MD=11.12). In addition, significant mean differences (p<0.05) reported for both outcomes when we compared their scores between groups A and B at 2 weeks (∆MD: NPRS=0.69; WOMAC=10.87) and 4 weeks post-intervention (∆MD: NPRS=0.31; WOMAC=8.00). Furthermore, a post hoc Scheffe analysis for the outcomes NPRS and WOMAC revealed the superiority of group B over group A.

CONCLUSION

The specified manual therapies, in combination with a supervised exercise protocol, were found to be more effective than a supervised exercise protocol alone for improving pain and functional disability in patients with knee osteoarthritis.

The Combination of Exercise and Manual Therapy Versus Exercise Alone in Total Knee Arthroplasty Rehabilitation: A Randomized Controlled Clinical Trial

BACKGROUND

Total knee arthroplasty (TKA) is one of the most commonly performed orthopedic surgeries in the lower extremity. However, patient dissatisfaction and functional disability are mostly experienced because of pain and limited range of motion (ROM). Although manual therapy is commonly implemented to improve ROM and modulate pain in the management of musculoskeletal disorders, there is a lack of evidence about its clinical effectiveness on postoperative TKA rehabilitation.

OBJECTIVE

To investigate the effectiveness of an exercise program combined with manual therapy compared with an exercise program only for pain, ROM, function, quality of life, and patient satisfaction outcomes.

DESIGN

A randomized controlled clinical trial.

SETTING

Rehabilitation unit of a university hospital.

PARTICIPANTS

Forty-two patients (68.45 ± 6.3 years) scheduled for unilateral TKA as a treatment of severe osteoarthritis.

INTERVENTIONS

Joint and soft tissue mobilizations in addition to exercise therapy were provided to the mobilization group (n = 21) while the control group received exercise therapy only (n = 21).

MAIN OUTCOME MEASURES

The outcome measures were numeric pain-rating scale, knee ROMs, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, 10-meter walk test (10MWT), 5-times sit to stand test (5SST), and Short Form-12 (SF-12).

RESULTS

Improvements in pain outcomes were significantly higher in the mobilization group than in the control group (P = .001, F [3, 33] = 7.06) and the between-group difference in change score was 1.3 points (P = .001). Although the between-group difference in change score was 12.8° for knee flexion at 2 months (P = .001), the overall group-by-time interactions were not significant for flexion and extension ROMs (P = .175, F [3, 33] = 1.75 and P = .57, F [2, 34] = 0.56, respectively). Additionally, there were statistically meaningful group-by-time interactions on total WOMAC score (P = .006, F [2, 34] = 5.29), 10MWT (P = .002, F [3, 33] = 5.98), and SF-12 mental component summary (P = .01, F [2, 34] = 4.92) favoring the mobilization group. Also, patient satisfaction was higher in the mobilization group (P = .02).

CONCLUSIONS

A structured exercise program combined with manual therapy can be more beneficial in improving pain, function, and patient satisfaction compared to exercise program alone for postoperative TKA patients.

Musculoskeletal Conditions in Patients With Diabetes: A Narrative Review

Diabetes mellitus (DM) is a multisystem disease that affects millions of people worldwide. The vascular and cardiac effects of DM have been well-studied, but little is known about the prevalence of musculoskeletal (MSK) conditions in patients with DM. This review provides an in-depth analysis of a cross-sectional study investigating the presence of several common MSK disorders in patients with DM. This review also analyzes current literature to update health care professionals about the MSK conditions associated with DM.

Best Practices for Chiropractic Management of Patients with Chronic Musculoskeletal Pain: A Clinical Practice Guideline

Objective: To develop an evidence-based clinical practice guideline (CPG) through a broad-based consensus process on best practices for chiropractic management of patients with chronic musculoskeletal (MSK) pain. Design: CPG based on evidence-based recommendations of a panel of experts in chronic MSK pain management. Methods: Using systematic reviews identified in an initial literature search, a steering committee of experts in research and management of patients with chronic MSK pain drafted a set of recommendations. Additional supportive literature was identified to supplement gaps in the evidence base. A multidisciplinary panel of experienced practitioners and educators rated the recommendations through a formal Delphi consensus process using the RAND Corporation/University of California, Los Angeles, methodology. Results: The Delphi process was conducted January-February 2020. The 62-member Delphi panel reached consensus on chiropractic management of five common chronic MSK pain conditions: low-back pain (LBP), neck pain, tension headache, osteoarthritis (knee and hip), and fibromyalgia. Recommendations were made for nonpharmacological treatments, including acupuncture, spinal manipulation/mobilization, and other manual therapy; modalities such as low-level laser and interferential current; exercise, including yoga; mind-body interventions, including mindfulness meditation and cognitive behavior therapy; and lifestyle modifications such as diet and tobacco cessation. Recommendations covered many aspects of the clinical encounter, from informed consent through diagnosis, assessment, treatment planning and implementation, and concurrent management and referral. Appropriate referral and comanagement were emphasized. Conclusions: These evidence-based recommendations for a variety of conservative treatment approaches to the management of common chronic MSK pain conditions may advance consistency of care, foster collaboration between provider groups, and thereby improve patient outcomes.

Beneficial effects of manually assisted chiropractic adjusting instrument in a rabbit model of osteoarthritis

Osteoarthritis (OA) is a degenerative disease characterized by injury of all joint tissues. Our previous study showed that in experimental osteoporosis, chiropractic manipulation (CM) exerts protective effects on bone. We here assessed whether CM might ameliorate OA by improving subchondral bone sclerosis, cartilage integrity and synovitis. Male New-Zealand rabbits underwent knee surgery to induce OA by anterior cruciate ligament injury. CM was performed using the chiropractic instrument ActivatorV 3 times/week for 8 weeks as follows: force 2 setting was applied to the tibial tubercle of the rabbit right hind limb (TM-OA), whereas the corresponding left hind limb received a false manipulation (FM-OA) consisting of ActivatorV firing in the air and slightly touching the tibial tubercle. After sacrifice, subchondral bone integrity was assessed in the tibiae by microCT and histology. Cartilage damage and synovitis were estimated by Mankin's and Krenn's scores, respectively, and histological techniques. Bone mineral density and content in both cortical and trabecular compartments of subchondral bone decreased in OA rabbits compared to controls, but partially reversed in the TM-OA group. Trabecular bone parameters in the latter group also showed a significant improvement compared to FM-OA group. Moreover RANKL, OPG, ALP and TRAP protein expression in subchondral bone significantly decreased in TM-OA rabbits with respect to FM-OA group. CM was associated with lower Mankin's and Krenn's scores and macrophage infiltrate together with a decreased protein expression of pro-inflammatory, fibrotic and angiogenic factors, in TM-OA rabbits with respect to FM-OA. Our results suggest that CM may mitigate OA progression by improving subchondral bone as well as cartilage and synovial membrane status.

Effects of Trigger Point Dry Needling for the Management of Knee Pain Syndromes: A Systematic Review and Meta-Analysis

Background: To evaluate the effect of trigger point dry needling alone or as an adjunct with other interventions on pain and related disability in people with knee pain. Methods: Several electronic databases were searched for randomized controlled trials where at least one group received dry needling for knee pain. Studies had to include human subjects and collect outcomes on pain and pain-related disability in musculoskeletal knee pain. Data were extracted by two reviewers. The risk of bias was assessed by the Cochrane Guidelines, methodological quality was assessed with the Physiotherapy Evidence Database (PEDro) score, and the quality of evidence by using the GRADE approach. Standardized mean differences (SMD) were calculated. Results: Ten studies (six patellofemoral pain, two knee osteoarthritis, two post-surgery knee pain) were included. The meta-analysis found moderate effect sizes of dry needling for reducing pain (SMD −0.53, 95% CI −0.87 to −0.19) and improving related disability (SMD −0.58, 95% CI −1.08 to −0.09) as compared to a comparison group at short-term. The main effect was observed for patellofemoral pain (SMD −0.64, 95% CI −1.17 to −0.11). No significant effects were observed at mid- or long-term follow-ups. The risk of bias was generally low, but the heterogenicity and the imprecision of the results downgraded the level of evidence. Conclusion: Low to moderate evidence suggests a positive effect of trigger point dry needling on pain and related disability in patellofemoral pain, but not knee osteoarthritis or post-surgery knee pain, at short-term. More high-quality trials investigating long-term effects are clearly needed.