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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. 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 |
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:
2. Trunk and hip stabilization exercises 3. Patellar taping 4. Foot orthotics |
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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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