There is overwhelming evidence that exercise is the most effective treatment tool for physical therapists when it comes to treating knee osteoarthritis. But can manual therapy also play a role in treatment?
Osteoarthritis is the most common chronic disease of the joints and occurs most frequently in the knees and hips. This is reflected in the fact that OA in these joints is expected to be the ninth leading cause of years of disability by 2030.
Discover new insights into PFJ OA
Manual therapy is one of the most common treatment instruments used by physiotherapists, but it is used far less often for osteoarthritis of the knee, as movement has been proven to be the most effective treatment option.
This does not prevent manual therapy from being generally endorsed by clinicians and patients alike. But should we still use it to manage OA? A new systematic review published in Medicina (Kaunas) aims to clarify the situation.
The aim of the systematic review was to evaluate the short-term and long-term effectiveness of manual therapy in patients with knee OA in terms of pain relief and the improvement of knee mobility (ROM) and functionality.
Methods
This systematic review was not registered with PROSPERO, which means that there is a potential reporting and publication bias in the search and review process. However, this review adhered to the PRISMA guidelines.
PubMed, PEDro, and CENTRAL were the databases used for the search, articles being considered if they were RCTs examining manual therapy in patients of all ages with clinically diagnosed OA in one knee.
Studies were excluded if they examined OA in both knees or used a mixed population, as in those with and without knee osteoarthritis. The following keywords were used for the search:
The keywords used were "knee OA", "knee arthritis", "MT", "mobilization", "ROM" and "WOMAC".
In all included studies, an exercise program was used in all groups of participants; this is important to know, as this influences and possibly increases the benefits of manual therapy.
The quality and bias of the included studies were assessed using the Cochrane Manual for Systematic Review of Interventions. ROM, pain, WOMAC, sensation and overall function were used as result measures.
Results and clinical implications
A total of six studies were included in the systematic review, the methodological quality of which was assessed as poor overall with a high risk of bias, whereby only two studies were of sufficient quality a study by Abbott et al. and Mutlu et al. The rest was bad or very bad, so that the applicability of the results is clearly restricted.
In addition, only two studies included a control group, with one of the control group sizes being 1/3 smaller (n = 17) than the intervention group, which in turn raises serious questions about the applicability of the results of this systematic review.
The number of participants varied greatly between the studies (n = 40-300) with a gender imbalance compared to women. The duration of the intervention also varied between 2–24 weeks with a follow-up period of 2–12 months, with some having no follow-up at all.
Brief summary of manual therapy for OA knees
In manual therapy, it is important that self-management is the central ethos for the treatment plan
Most of the studies included in this review were of poor quality with two out of six including a control group
Manual therapy seems to reduce pain more effectively than electrotherapy
There are some suggestions for manual therapy – MWM, PFM or patellar mobilization can relieve pain in the short term
Movement was featured in all studies and is probably the greatest contribution to improving pain and function
The most effective type / dose / frequency of manual therapy remains unclear
The highest quality study included in the review rated MWM or PJM or electrotherapy combined with exercise, which showed that when you combine something with training for OA knees, it does not turn into electrotherapy. Both MWM and PJM outperformed electrotherapy, but there was no control group. Since the treatment effect is minimal, this indicates that MWMs or PJMs did not significantly improve pain or function.
In addition to the other studies, the treatment effects, which can only be assumed, result from manual therapy a short-term improvement in pain and the musculoskeletal system, but the duration of these effects is difficult to estimate.
It goes without saying that it is best to continue to adhere to best practice guidelines and use exercise as the primary treatment for knee osteoarthritis. If the pain is difficult to control, manual therapy is worth considering, but how about hydrotherapy instead?
