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Manual Therapy Techniques

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Knee

SUMMARY:
Manual therapy interventions for the knee have been associated with improvements in pain, function and disability in individuals with knee osteoarthritis (OA). Very limited evidence also suggests that MT may be an option in the management of patellofemoral pain syndrome.

Knee Osteoarthritis (Knee OA):

Out of all knee disorders, research into the effectiveness of manual therapy interventions for knee OA has been studied most extensively. A recent systematic review by Jansen et. al. looked 3 interventions:  1) strengthening training alone, 2) exercise therapy alone, and what they described as 3) exercise therapy combined with "passive manual mobilizations" for patients with knee OA. They found 12 trials that compared any of these interventions against a control group.  The only comparison they found that was significant was the one showing improvement in pain with the addition of manual mobilization techniques to exercise when compared to exercise alone.  Another recent systematic review (French 2011) evaluating the effectivness of manual therapy for knee and hip osteoarthritis concluded that the "evidence should be considered inconclusive regarding the benefit of manual therapy on pain and function" for knee OA.  Only 3 RCT's were included in this review, but there was not enough homogeneity between study designs to perform a meta-analysis.  The 3 studies were all short-term chiropractic studies (about 3 week outcomes), and 1 of those was primarily massage therapy.  The review omitted the 2 Deyle studies (outlined below) from the review because of their pragmatic approach which "examined manual therapy in combination with exercise", instead of manual techniques alone. 

 In a study by Deyle et. al (2000) patients were randomized into receiving manipulative therapy (OMT) to the knee and lower quarter based on individual impairments and exercise compared to a placebo group getting sub-therapeutic ultrasound. There were significant decreases in pain and improvement in disability (approximately 50%) in the manipulative therapy and exercise group that were maintained out to one year. A follow on study by Deyle et. al. (2005) compared the same OMT and exercise program to a standardized home exercise program alone. Both groups had improvements in pain and disability, but the OMT group was significantly better (again approximately 50% improvement) with gains maintained out to one year. Patients receiving OMT treatment were 75% less likely to have a total knee replacement (TKR) then those in the control groups. A Numbers Needed to Treat analysis showed that 7 patients with knee OA needed to be treated with the OMT and exercise program in order to prevent 1 TKR.

A systematic review by the Ottawa Panel gave manual therapy an “A” for strength of evidence for management of pain in patients with knee OA (Scale from A-D). A recent evidence review by Bokarious (2010) stated that there was enough evidence to support the use of some manual therapy techniques in the treatment of knee OA.

Tucker compared OMT to NSAIDs (Meloxicam) in patients with knee OA. Both groups had significant improvement and both interventions were equally effective out to 3 weeks, however 3 subjects in the Meloxicam group dropped out due to deleterious gastrointestinal side effects. There were no side effects reported for the OMT group.

Another chiropractic study by Pollard showed short-term improvement (3 weeks) in visual analag pain scores with patients that received a protocol of manual therapy techniques compared to a control group receiving manual contact and interferential electrical stimulation.

Deyle, 2000, Ann Intern Med
Tucker, 2003, J of Chiropractic
Deyle, 2005, Phys Ther
Ottawa Panel Systematic Review, 2005, Phys Ther
Pollard, 2008, J Can Chiropr Assoc
Bokarius, 2010, Pain Practice
Jansen, 2011, J Physiother
French, 2011, Man Ther


Patellofemoral Pain Syndrome (PFPS)
The consensus for the use of OMT for PFPS is limited, however a case series reported some benefit in its use, especially as part of a multimodal approach.

In a small case series, 4 out of 5 patients with PFPS had a significant decrease in pain and improvement in function as measured by the Lower Extremity Functional Scale (LEFS) and Global Rating of Change (GROC) that were maintained out to 6 months. Their treatment included:
    1. Combination of thrust and non-thrust manipulation directed at the joints of the lower quarter (including lumbar spine)
    2. Trunk and hip stabilization exercises
    3. Patellar taping
    4. Foot orthotics
Iverson and colleagues developed a clinical prediction rule (CPR) to identify individuals with PFPS that were likely to respond favorably to lumbar spine manipulation. 22 of 49 subjects. Success was based on a 50% improvement in numeric pain rating. The five variables that were identified as predictors and formed the CPR were:
  1. Difference in hip internal rotation from one side to the other of > 14°
  2. Ankle dorsiflexion > 16°
  3. Navicular drop > 3mm
  4. No stiffness with sitting > 20 minutes
  5. Squatting is the most painful activity
The most robust predictor of success was a side-to-side difference in hip internal rotation > 14° (positive likelihood ratio 4.9). If this factor alone was present, the probability of success with treatment increased from 44% to 80%. If there were at least three of the five variables present then the probability of treatment success rose to 94%. This CPR had many limitations (potentially underpowered sample size) and the results should be interpreted with caution. The outcomes were only seen immediately post-manipulation and any substantial longer-term improvement has not been established.
van den Dolder, 2006, Aust J Physiother
Dyke, 2008, J Orthop Sports Phys Ther
Iverson, 2008, J Orthop Sports Phys Ther

OTHER CLINICAL EVIDENCE:
Moss, 2007, Manual Therapy
Brantingham, 2009, J Manipulative Physiol Ther
Beazell, 2009, N Am J Sports Phys Ther
Bokarious, 2010, Pain Practice
Page, 2011, Int J Rheum Dis

OTHER RELEVANT EVIDENCE:
Courtney, 2009, J of Pain

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