Exercise and manual physiotherapy arthritis research trial (EMPART): a multicentre randomised controlled trial

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 Consensus on Exercise Reporting Template (CERT) applied to exercise interventions in musculoskeletal trials demonstrated good rater agreement and incomplete reporting

OBJECTIVE

To determine inter-rater agreement and utility of the Consensus on Exercise Reporting Template (CERT) for evaluating reporting of musculoskeletal exercise trials.

STUDY DESIGN AND SETTING

Two independent reviewers applied the CERT to a random sample of 20 exercise trials published 2010 to 2015 identified from searches of PEDro, CENTRAL, and PubMed. Reviewers recorded whether each item criterion was met and detailed missing data, and appraisal time percent agreement and the Prevalence and Bias Adjusted Kappa (PABAK) statistic were used to measure inter-rater agreement.

RESULTS

The trials included a range of musculoskeletal conditions (back/neck pain, hip/knee osteoarthritis, tendinopathies). For percent agreement, inter-rater agreement was high (13 items ≥80%) and for PABAK substantial (nine items: 0.61-0.80) and excellent (three items: 0.81-1.0). Agreement was lower for starting level decision rule (percent agreement: 55%, PABAK 0.30); tailoring of exercise (%A: 65%, PABAK 0.40 [95% CI: 0.00 to 0.80]); exercise equipment (percent agreement: 70%, PABAK 0.30); and motivation strategies (percent agreement: 70%, PABAK 0.40). Sixty percent of descriptions were missing information for ≥50% of CERT items. Mean appraisal time was 30 minutes, and the majority of interventions required access to other published papers.

CONCLUSIONS

The CERT has good inter-rater agreement and can comprehensively evaluate reporting of exercise interventions. Most trials do not adequately report intervention details, and information can be difficult to obtain. Incomplete reporting of effective exercise programs may be remedied by using the CERT when constructing, submitting, reviewing, and publishing articles.

Capacidade funcional de idosos com osteoartrite submetidos a fisioterapia aquática e terrestre

INTRODUÇÃO: A Osteoartrite (OA) é uma doença articular crônico-degenerativa que, quando sintomática, progride num padrão que inclui incapacidade para marcha e redução da Capacidade Funcional (CF), sendo sua manutenção um requisito importante para um envelhecimento saudável. Desse modo, vários recursos terapêuticos, entre eles a Fisioterapia Aquática (FA) e a Fisioterapia Terrestre (FT) surgem como alternativas para o tratamento dessa enfermidade. OBJETIVO: Avaliar o impacto da FA e da FT na CF de idosos com diagnóstico de OA de joelho. MATERIAIS E MÉTODOS: Quinze voluntários com diagnóstico clínico e radiográfico de OA de joelho com idade entre 60 a 80 anos foram distribuídos aleatoriamente entre os grupos: FA (n = 5), que realizou cinesioterapia em imersão; FT (n = 5), que realizou cinesioterapia em solo; e grupo controle (GC) (n = 5), que não recebeu qualquer tipo de intervenção fisioterapêutica. A CF foi avaliada com base na velocidade da marcha usual, por meio de células fotoelétricas, nos movimentos de caminhar e subir e descer escadas. RESULTADOS: Observou-se que os participantes da FA apresentaram melhora significativa no tempo da marcha usual (p = 0,007), marcha rápida (p = 0,02), subir escadas (p = 0,02) e descer escadas (p = 0,01), houve resultado satisfatório na FT apenas para descer escadas (p = 0,04). Não foram encontradas diferenças significativas no GC. CONCLUSÃO: Por meio dos resultados obtidos neste estudo, conclui-se que a FA seja a mais indicada para tratamento da OA, com resultados significativos na melhora da CF.

Non-surgical treatment of hip osteoarthritis. Hip school, with or without the addition of manual therapy, in comparison to a minimal control intervention: protocol for a three-armed randomized clinical trial

Background

Hip osteoarthritis is a common and chronic condition resulting in pain, functional disability and reduced quality of life. In the early stages of the disease, a combination of non-pharmacological and pharmacological treatment is recommended. There is evidence from several trials that exercise therapy is effective. In addition, single trials suggest that patient education in the form of a hip school is a promising intervention and that manual therapy is superior to exercise.

Methods/Design

This is a randomized clinical trial. Patients with clinical and radiological hip osteoarthritis, 40-80 years of age, and without indication for hip surgery were randomized into 3 groups. The active intervention groups A and B received six weeks of hip school, taught by a physiotherapist, for a total of 5 sessions. In addition, group B received manual therapy consisting of joint manipulation and soft-tissue therapy twice a week for six weeks. Group C received a self-care information leaflet containing advice on "live as usual" and stretching exercises from the hip school. The primary time point for assessing relative effectiveness is at the end of the six weeks intervention period with follow-ups after three and 12 months.

Primary outcome measure is pain measured on an eleven-point numeric rating scale. Secondary outcome measures are the hip dysfunction and osteoarthritis outcome score, patient's global perceived effect, patient specific functional scale, general quality of life and hip range of motion.

Discussion

To our knowledge this is the first randomized clinical trial comparing a patient education program with or without the addition of manual therapy to a minimal intervention for patients with hip osteoarthritis.

Trial registration

ClinicalTrials NCT01039337

Strength training alone, exercise therapy alone, and exercise therapy with passive manual mobilisation each reduce pain and disability in people with knee osteoarthritis: a systematic review

QUESTION

What are the effects of strength training alone, exercise therapy alone, and exercise with additional passive manual mobilisation on pain and function in people with knee osteoarthritis compared to control? What are the effects of these interventions relative to each other?

DESIGN

A meta-analysis of randomised controlled trials.

PARTICIPANTS

Adults with osteoarthritis of the knee. INTERVENTION TYPES: Strength training alone, exercise therapy alone (combination of strength training with active range of motion exercises and aerobic activity), or exercise with additional passive manual mobilisation, versus any non-exercise control. Comparisons between the three interventions were also sought.

OUTCOME MEASURES

The primary outcome measures were pain and physical function.

RESULTS

12 trials compared one of the interventions against control. The effect size on pain was 0.38 (95% CI 0.23 to 0.54) for strength training, 0.34 (95% CI 0.19 to 0.49) for exercise, and 0.69 (95% CI 0.42 to 0.96) for exercise plus manual mobilisation. Each intervention also improved physical function significantly. No randomised comparisons of the three interventions were identified. However, meta-regression indicated that exercise plus manual mobilisations improved pain significantly more than exercise alone (p = 0.03). The remaining comparisons between the three interventions for pain and physical function were not significant.

CONCLUSION

Exercise therapy plus manual mobilisation showed a moderate effect size on pain compared to the small effect sizes for strength training or exercise therapy alone. To achieve better pain relief in patients with knee osteoarthritis physiotherapists or manual therapists might consider adding manual mobilisation to optimise supervised active exercise programs.

Measuring patient satisfaction with exercise therapy for knee osteoarthritis: evaluating the utility of the physiotherapy outpatient survey

OBJECTIVES

To assess patient satisfaction with exercise for knee osteoarthritis (OA).

METHODS

A convenience sample of 27 patients recruited to a randomized controlled trial (RCT) comparing open kinetic chain and closed kinetic chain exercises for knee OA were reassessed at nine months post-randomization. Clinical outcomes included self-report and physical performance measures of function and pain severity. Patients also completed the Physiotherapy Outpatient Survey (POPS), which is a multi-dimensional measure of patient satisfaction with physiotherapy.

RESULTS

There was no significant difference in satisfaction between the two intervention groups. Overall mean satisfaction for the entire cohort was 4.07 of a maximum score of 5 (standard deviation (SD) = 0.52). Lower levels of satisfaction with outcome (mean = 3.56, SD = 0.8) were reported compared with other domains of expectations, communication, organization and the therapist (mean = 3.79-4.49; SDs = 0.42-0.92). Both intervention groups improved from baseline on clinical outcomes of pain, self-report function and walking distance, with no significant differences between the two groups.

CONCLUSIONS

High levels of satisfaction were reported in this subsample of knee OA patients participating in an RCT evaluating the effects of different exercise approaches for knee OA. Satisfaction varied depending on the satisfaction domain, with lower satisfaction with outcome compared with other aspects of care. The POPS questionnaire can be used to measure the multi-dimensional aspects of satisfaction with physiotherapy.

Conservative management of a young adult with hip arthrosis

STUDY DESIGN

Case report.

BACKGROUND

Clinical practice guidelines regarding the conservative management of degenerative hip conditions in older adults routinely incorporate therapeutic exercise and manual therapy. However, the application of these recommendations to young, active adults is less clear. The purpose of this case report is to describe the management of a young adult with advanced hip arthrosis using a multifaceted rehabilitation program.

CASE DESCRIPTION

A 28-year-old female with severe left hip degeneration, as identified with diagnostic imaging, was referred to physical therapy. Reduced hip range of motion and strength, sacroiliac joint asymmetries, and a modified Harris Hip Score of 76 were observed. She was seen for 12 visits over a 3-month period and treated with an individualized program including manual therapy, therapeutic exercise, and neuromuscular re-education.

OUTCOME

Substantial improvements were noted in pain, hip range of motion, and strength and function (modified Harris Hip Score of 97). In addition, she discontinued the use of anti-inflammatory medications and returned to her prior level of activity. Improvements were maintained at a 3-month follow-up, with symptom recurrence managed using a self-mobilization technique to the left hip and massage to the left iliopsoas.

DISCUSSION

Degenerative hip conditions are common among older adults but are relatively rare in the younger population. Although it is likely that this patient will experience a return of her symptoms and functional limitations as her hip disease progresses, the immediate improvements may delay the need for eventual surgical management. These outcomes suggest that physical therapy management should be considered in those with an early onset of degenerative hip disease and are consistent with results previously reported in the older population.

LEVEL OF EVIDENCE

Therapy, level 4.