Effectiveness of manual therapy vs conventional physical therapy with neuromuscular training in the management of knee osteoarthritis: A randomized clinical controlled trial

Background: Knee osteoarthritis is a prevalent degenerative joint disease that impairs mobility and causes significant pain, particularly in the aging population. Conservative management, including physical therapy, remains a cornerstone of treatment. The addition of Mulligan Mobilization with Movement (MWM) to conventional therapy has been proposed to improve outcomes, though its efficacy had not been robustly quantified. Objective: The objective of this study was to compare the efficacy of Mulligan MWM in conjunction with conventional physical therapy to conventional physical therapy alone in reducing pain and stiffness and improving functional outcomes in patients with grade 2 knee osteoarthritis. Methods: This randomized clinical trial included 28 participants with grade 2 knee osteoarthritis, randomly allocated into two groups: one receiving Mulligan MWM alongside conventional physical therapy and the other receiving only conventional physical therapy. The intervention lasted one month, with assessments conducted at baseline, two weeks, and four weeks using the Visual Analogue Scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) as outcome measures. Statistical analysis was performed using SPSS version 25. Results: The MWM plus physical therapy group exhibited a greater reduction in VAS scores (baseline: 6.71, SD 1.729 to week 4: 2.21, SD 1.051) compared to the physical therapy alone group (baseline: 7.14, SD 1.562 to week 4: 3.86, SD 0.663), with a significant mean difference (P<0.001). Similarly, WOMAC scores for pain, stiffness, and physical function significantly improved in the MWM group compared to the physical therapy group at week 4 (Pain: 2.79 vs. 6.86, Stiffness: 1.14 vs. 3.36, Function: 9.79 vs. 27.57, all P<0.001). Conclusion: Mulligan MWM combined with conventional physical therapy was more effective than conventional physical therapy alone in reducing pain, stiffness, and improving functional outcomes in patients with grade 2 knee osteoarthritis. These results support the inclusion of MWM in the management of knee osteoarthritis.

BackgroundKnee osteoarthritis (OA) is the most common kind of arthritis that occurs due to degeneration of the joint articular cartilage, producing pain, stiffness, and impaired movement. The objective of the study was to evaluate the short-term effectiveness of Kinesio taping (KT) plus conventional physical therapy (CPT) and CPT alone in subjects with knee OA.Materials and methodsForty male subjects were divided into two groups at random using a parallel assignment, double-blinded study design, viz., KT with CPT (transcutaneous electrical nerve stimulation and exercise therapy), and CPT alone for the period of 6 weeks of treatment. At baseline, third, and sixth weeks, the following outcome measures were taken, such as pain intensity (NPRS), knee range of motion (goniometry), Western Ontario and McMaster Osteoarthritis Index (WOMAC), and the Time Up and Go (TUG) test.Statistical analysisTo reveal the patient’s demographic profile concerning the outcome parameters, a descriptive statistic was applied. Furthermore, two-way mixed ANOVA and Tukey HSD post hoc tests were used to analyze within and between-group comparisons in SPSS 20.0.ResultsIn both groups, pain and knee flexion were significantly improved during the 6-week period of interventions (p < 0.05). WOMAC and TUG test scores improved only in the KT plus CPT group.ConclusionKT combined with CPT was found to be more effective than CPT alone in the third and sixth weeks of the treatment. In knee OA, this combination of treatments was found to reduce pain, enhance range of motion, and improve physical functioning.

Exercise therapy is a key intervention in the management of knee osteoarthritis (OA). This study aimed to test the 6-month effectiveness of Wu Qin Xi Qigong (WQXQ) exercise versus a conventional physical therapy (control group [CG]) on physical functioning in patients with early knee OA. This study was a 6-month follow-up from a randomized controlled trial. Participants with knee OA were randomly allocated to the WQXQ or CG. Data from the Berg Balance Scale, Timed Up and Go Test, 6-Minute Walk Test, 30-Second Chair Stand Test, the Western Ontario and McMaster Universities Osteoarthritis Index, knee extension strength and knee flexion strength were collected before and after the 6-month intervention. Both treatment groups demonstrated large (20%-50%) and clinically relevant reductions in activity limitations, pain and knee instability, which were sustained at 6 months post-treatment. No differences in effectiveness between experimental and control treatment were found on Timed Up and Go Test, 6-Minute Walk Test, knee extension strength and knee flexion strength except for a higher Berg Balance Scale score (P = 0.029) and lower Western Ontario and McMaster Universities Osteoarthritis Index pain score (P = 0.031) in the WQXQ group. Both WQXQ and conventional physical therapy exercise programs were highly effective in reducing activity limitations and pain, and promoting balance and muscle power. WQXQ was found to be more effective in promoting balance and reducing pain than conventional physical therapy exercise in patients with knee OA. Geriatr Gerontol Int 2020; 20: 899-903.

Study design :Quasi –experimental study. Objectives : To compare the effectiveness of Functional task training Versus EMG biofeedback, along with conventional physical therapy in the management of knee osteoarthritis. Background: Osteoarthritis is the most common disease affecting synovial joints characterized by degenerative structural remodeling of joint cartilage and of underlying subchondral bone, which again leads to pain and disability. The aim of the study was to compare the effectiveness of Functional task training Versus EMG biofeedback along with conventional physical therapy to reduce pain, improve strength and functional mobility in knee osteoarthritis Methods: In the 5- week intervention study, 30 participants diagnosed with knee osteoarthritis were divided into two groups by convenience sampling, Group A:(n=15) Functional task training along with conventional exercise program was applied and Group B:(n=15) EMG biofeedback along with conventional exercise program. For both groups, treatment consisted of 1 session/day, 5 days/week for 5 weeks. Data was collected and analyzed using SPSS 23. Results: A significant reduction in pain (p&lt;0.05), improvement in the strength of the quadriceps muscle (p&lt;0.05) and increase in knee function between (p&lt;0.05) pre- and post- treatment stages in both groups.

BackgroundThe 2013 Malaysian Clinical Practice Guidelines on the Management of Osteoarthritis (OA) recommend a linear step-up approach to manage knee OA. However, patients with knee OA often require a multimodal approach to address OA-related pain symptoms and functional limitations. This consensus aimed to provide doctors with an updated set of evidence-based, clinical experience-guided recommendations to manage knee OA.MethodsA multi-speciality expert panel consisting of nine Malaysian physicians from different healthcare settings who manage a diverse OA patient population was convened. Using a combination of the ADAPTE process and modified Delphi method, the panel reviewed current evidence on the management of knee OA and synthesised a set of nine recommendations on the management of knee OA, supported by an algorithm that summarises the consensus’ core messages.ResultsA multimodal intervention strategy is the mainstay of OA management and the choice of any single or multimodal intervention may vary over the course of the disease. Overall, a non-pharmacological core treatment set of patient education, weight loss and exercise is recommended for all patients. When pharmacotherapy is indicated, symptomatic slow-acting drugs for osteoarthritis are recommended at the early stage of disease, and they can be paired with physical therapy as background treatment. Concurrent advanced pharmacotherapy that includes non-steroidal anti-inflammatory drugs, intraarticular injections and short-term weak opioids can be considered if patients do not respond sufficiently to background treatment. Patients with severe symptomatic knee OA should be considered for knee replacement surgery. Management should begin with specific treatments with the least systemic exposure or toxicity, and the choice of treatment should be determined as a shared decision between patients and their team of healthcare providers.ConclusionsThis consensus presents nine recommendations that advocate an algorithmic approach in the management of patients living with knee OA. They are applicable to patients receiving treatment from primary to tertiary care providers in Malaysia as well as other countries.

(1) Background: Conclusions of meta-analyses of clinical studies may substantially influence opinions of prospective patients and stakeholders in healthcare. Nineteen meta-analyses of clinical studies on the management of primary knee osteoarthritis (pkOA) with stem cells, published between January 2020 and July 2021, came to inconsistent conclusions regarding the efficacy of this treatment modality. It is possible that a separate meta-analysis based on an independent, systematic assessment of clinical studies on the management of pkOA with stem cells may reach a different conclusion. (2) Methods: PubMed, Web of Science, and the Cochrane Library were systematically searched for clinical studies and meta-analyses of clinical studies on the management of pkOA with stem cells. All clinical studies and meta-analyses identified were evaluated in detail, as were all sub-analyses included in the meta-analyses. (3) Results: The inconsistent conclusions regarding the efficacy of treating pkOA with stem cells in the 19 assessed meta-analyses were most probably based on substantial differences in literature search strategies among different authors, misconceptions about meta-analyses themselves, and misconceptions about the comparability of different types of stem cells with regard to their safety and regenerative potential. An independent, systematic review of the literature yielded a total of 183 studies, of which 33 were randomized clinical trials, including a total of 6860 patients with pkOA. However, it was not possible to perform a scientifically sound meta-analysis. (4) Conclusions: Clinicians should interpret the results of the 19 assessed meta-analyses of clinical studies on the management of pkOA with stem cells with caution and should be cautious of the conclusions drawn therein. Clinicians and researchers should strive to participate in FDA and/or EMA reviewed and approved clinical trials to provide clinically and statistically valid efficacy.

Background Neck pain is among the most prevalent and costly musculoskeletal disorders. Manual therapy and exercise are two standard treatment approaches to manage neck pain. In addition, clinical practice guidelines recommend a multi-modal approach, including both manual therapy and exercise for the treatment of neck pain; however, the specific effects of these combined interventions have not recently been reported in the literature. Objective To perform a systematic review and meta-analysis to determine the effect of manual therapy combined with exercise on pain, disability, and quality of life in individuals with nonspecific neck pain. Design Systematic Review and Meta-Analysis Methods Electronic database searches were completed in PubMed, CINAHL, Cochrane, EMBASE, Ovid, and SportDiscus, with publication dates of January 2000 to December 2022. The risk of bias in the included articles was completed using the Revised Cochrane Risk of Bias Tool (RoB 2). Raw data were pooled using standardized mean differences and mean differences for pain, disability, and quality of life outcomes, and forest plots were computed in the meta-analysis. Results Twenty-two studies were included in the final review. With moderate certainty of evidence, three studies demonstrated no significant difference between manual therapy plus exercise and manual therapy alone in pain (SMD of −0.25 (95% CI: −0.52, 0.02)) or disability (−0.37 (95% CI: −0.92, 0.18)). With a low certainty of evidence, 16 studies demonstrated that manual therapy plus exercise is significantly better than exercise alone for reducing pain (−0.95 (95%CI: −1.38, −0.51)). Similarly, with low certainty of evidence, 13 studies demonstrated that manual therapy plus exercise is significantly better than exercise alone for reducing disability (−0.59 (95% CI: −0.90, −0.28)). Four studies demonstrated that manual therapy plus exercise is significantly better than a control intervention for reducing pain (moderate certainty) (−2.15 (95%CI: −3.58, −0.73)) and disability (low certainty) (−2.39 (95% CI: −3.80, −0.98)). With a high certainty of evidence, four studies demonstrated no significant difference between manual therapy plus exercise and exercise alone in quality of life (SMD of −0.02 (95% CI: −0.21, 0.18)). Conclusion Based on this systematic review and meta-analysis, a multi-modal treatment approach including exercise and manual therapy appears to provide similar effects as manual therapy alone, but is more effective than exercise alone or other interventions (control, placebo, ‘conventional physical therapy’, etc.) for the treatment of nonspecific neck pain and related disability. Some caution needs to be taken when interpreting these results given the general low to moderate certainty of the quality of the evidence.

BackgroundThe main symptoms of patients with knee osteoarthritis (OA) are defined as pain, muscle weakness and functional impairments. Muscle strengthening exercises are recommended in core treatment of conservative management of...

In this issue of the Annals , Jones et al 1 (pp 172) report the results of a randomised clinical trial (RCT) of canes for knee osteoarthritis. Current recommendations on...

Commentary Medical practitioners are presented with substantial data regarding potential interventions for musculoskeletal problems. The American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines (CPGs) organize and summarize the available data regarding numerous nonoperative and operative treatments for musculoskeletal problems, including the management of knee osteoarthritis (OA). While the recommendations of the CPGs are often somewhat limited by the lack of quality research, the 2013 AAOS CPG cited moderate evidence against the routine use of hyaluronic acid (HA) injections for the management of symptomatic knee OA. The study by Zhu et al. provides an excellent evaluation of the use of HA injections in Medicare patients, both before and after the CPG was published, as well as an analysis of the financial impact of continued HA use. Knee OA remains highly prevalent and is a substantial economic burden in the United States. Intra-articular injections have long been a mainstay in the nonoperative treatment of the disease; however, recent publications have demonstrated some concerns with corticosteroid injections, particularly when they are performed close to the time of total knee arthroplasty (TKA)1. Unfortunately, similar risk has been demonstrated with HA injections2. The data surrounding the clinical efficacy of HA injections also are quite variable, but in most comparative studies, little benefit is seen over the use of nonsteroidal anti-inflammatory drugs, corticosteroid injections, biologics, or even normal saline solution3,4. The most important finding of the present study is that despite the moderate recommendation against the routine use of HA in the 2013 AAOS CPG, as well as its high cost and questionable clinical efficacy when compared with numerous other treatments, there has not been a significant decline in the use of HA in Medicare beneficiaries. This finding is supported by and expands on an earlier survey study that reported HA to be the most popular choice for management of moderate-grade knee OA5. This finding, while not surprising, is disappointing as it is clear that either the message of the CPG is not being effectively disseminated to the practitioners who are managing knee OA with HA injections, or the evidence is simply being ignored due to a lack of other options for this challenging population of patients. A second important finding of this study is the substantial financial burden that HA injections continue to pose on the health-care system. A cost averaging >$300 million a year is significant and worthy of highlighting. Zhu et al. demonstrated that this cost steadily increased throughout the study period and likely will continue to increase. Given the lack of demonstrated clinical efficacy in large systematic reviews and high-level studies, it is hard to justify these costs for HA use. Recent studies have shown that even emerging treatments such as biologics and platelet-rich plasma (PRP) may be more cost-effective than HA injections6. A finding of the study that may explain some of the discordance between the AAOS recommendations and HA utilization is that advanced practice providers (APPs) contributed significantly to the national increase in utilization that was seen over the study period. Many practices have transitioned interventions such as injections to APPs. It is very possible that evidence from the CPG has not effectively been distributed to APPs. The true cause is likely multifactorial. There are many patients with advanced knee OA who are simply not ready for TKA or are not good candidates for TKA since the requirements for optimization of medical comorbidities continue to become stricter. Many patients will not find any relief from corticosteroid injections, and as long as HA injections are available, they represent another possible therapeutic option, despite the evidence against the routine use of HA. While biologics such as PRP have shown promising benefits in the management of knee OA, insurance companies still do not cover this cost, and many patients cannot afford cash payments for prolonged treatment. Value-based care continues to be the focus of health-care practitioners, health systems, and insurers. When CPGs offer conclusive recommendations based on available evidence, it is worthwhile to evaluate their effects on practice patterns. The trends observed in the study by Zhu et al. demonstrated that despite the high cost and low clinical efficacy of HA injections, in addition to a CPG recommending against its routine use, there has been no appreciable decline in the use of HA injections among Medicare beneficiaries within the 5 years following publication of the CPG. This highlights the importance of wide dissemination of CPGs to physicians and APPs, as well as the need for more cost-effective treatments for knee OA.

The aim of the current review was to assess the evidence for the effectiveness of cervical spine manipulation and mobilisation in the treatment of non-specific neck pain. A review of the literature was performed in a systematic format, based upon a structured search of six computerised bibliographic databases, together with manual searching of selected journals and reference lists to identify randomised clinical trials (RCTs) researching the effectiveness of manual therapy in the treatment of non-specific neck pain. The methodological quality of the studies was assessed using a set of pre-defined criteria adapted from Koes et al. (Koes BW, Assendelft WJJ, van der Heijden GJMG, Bouter LM, Knipschild PG. Spinal manipulation and mobilisation for back and neck pain: a blinded review. BMJ 1991; 303 :1298–303) and updated in the light of recent literature.A total of 12 RCTs met the selection criteria. The scores achieved for methodological quality of the studies ranged from 25 points to 67 points out of a possible 100 points. Only four RCTs scored above 50 points: two of these reached a positive conclusion about the effectiveness of spinal manual therapy in the treatment of non-specific neck pain, and two a negative conclusion. Eight RCTs scored below 50 points; six of these reached a positive conclusion and two a negative conclusion.RCTs researching the effectiveness of manual therapy for non-specific neck pain demonstrate methodological shortcomings in both design and reporting. The effectiveness of spinal manual therapy on non-specific neck pain remains inconclusive. The available evidence favoured spinal manual therapy when it was used in conjunction with exercise, particularly in the treatment of patients with chronic non-specific neck pain. Further, well-designed RCTs are needed to draw valid conclusions about the effectiveness of spinal manual therapy on nonspecific neck pain. In such future RCTs, placebo treatments should be designed to be indistinguishable (as far as possible) from manual therapy, and without the specific effects of active therapy. Furthermore, psychosocial factors should be considered prior to randomisation of patients by using appropriate measures.

Background: Lateral Ankle Sprain (LAS) is the most common musculoskeletal injury among highly active and non-active populations. Physiotherapy plays a significant role in reducing pain and improving range of motion (ROM) and functional outcomes in people with LAS. Aims and Objectives: The study's main objective is to compare the effects of manual therapy (Mulligan's MWM) and conventional physiotherapy (PRICE and therapeutic exercises) and conventional physiotherapy alone on pain, ankle ROM, and function in subjects with LAS. Study Design: A randomized clinical trial was used, and 40 patients diagnosed with acute and sub-acute grade I or II LAS were randomly allotted to two experimental groups. Setting: The patients who met the selection criteria were recruited from the Team Physio Clinic, Pudukkottai, Tamilnadu, from January 2020 to June 2021. Materials and Methods: The experimental group I (n=20) received Mulligan's MWM and conventional physiotherapy, whereas those assigned to the experimental group II (n=20) received conventional physiotherapy alone. The treatment duration for both groups was four weeks. Outcome measures such as pain intensity, ankle dorsiflexion ROM, and foot and ankle disability index (FADI) were used. Statistics: The Shapiro-Wilk test was applied to examine whether the data had a normal distribution. A paired 'ttest' was used to compare the pre-and post-intervention mean scores within a group. Further, an unpaired 't-test' was used to compare the mean scores of both experimental groups at pre-and post-intervention stages. The data analysis was carried out using SPSS at a 5% level of significance. Results: Both experimental groups significantly reduced pain and improved ankle dorsiflexion ROM and function following the treatment duration. There is a significant difference between the two experimental groups in reducing pain and improving ankle dorsiflexion ROM and function at the postintervention stage. Conclusion: MWM with conventional physiotherapy is significantly more effective than conventional physiotherapy alone in reducing pain and improving ankle dorsiflexion ROM and function in acute and subacute grade I or II LAS.

Background: The iliotibial band is a long, non elastic collagen structure which crosses both hip and knee joints on the lateral thigh. The normal aging process brings changes in normal muscle functions including strength, endurance, agility and flexibility. Tight muscles further contribute to early degeneration of the joint. Routine physiotherapy includes hamstring, rectus femoris, and tendoachilis in the management of osteoarthritis. Thus, study aims to evaluate & compare effects of physical therapy intervention to improve the length of tight iliotibial band with respect to improvement in functional outcomes along with conventional physical therapy intervention. Materials and Methods: 60 subjects having knee osteoarthritis with iliotibial muscle tightness participated in the study. They were divided into 2 groups: Group A and Group B, of 30 subjects each. Group A was given-iliotibial band stretching in Ober's test position and Conventional physical therapy (Ultrasound + Exercises). Group B was given- Conventional physical therapy only. Both the groups received the treatment for a period of 5 days. Results: Results showed a statistically significant improvement on inter group comparison in the pain scores (on VAS) for walking, medial mobility of patella and Q angle. (p<0.001) Conclusion: Conventional physical therapy is effective in improving pain and functional activities but Iliotibial band stretching has an added effect on functional activity of walking.

Chronic shoulder pain (CSP) is a common condition with various etiologies, including rotator cuff disorders, adhesive capsulitis, shoulder instability, and shoulder arthritis. It is associated with substantial disability and psychological distress, resulting in poor productivity and quality of life. Physical therapy constitutes the mainstay treatment for CSP, but several barriers exist in accessing care. In recent years, telerehabilitation has gained momentum as a potential solution to overcome such barriers. It has shown numerous benefits, including improving access and convenience, promoting patient adherence, and reducing costs. However, to date, no previous randomized controlled trial has compared fully remote digital physical therapy to in-person rehabilitation for nonoperative CSP. The aim of this study is to compare clinical outcomes between digital physical therapy and conventional in-person physical therapy in patients with CSP. We conducted a single-center, parallel-group, randomized controlled trial involving 82 patients with CSP referred for outpatient physical therapy. Participants were randomized into digital or conventional physical therapy (8-week interventions). The digital intervention consisted of home exercise, education, and cognitive behavioral therapy (CBT), using a device with movement digitalization for biofeedback and asynchronous physical therapist monitoring through a cloud-based portal. The conventional group received in-person physical therapy, including exercises, manual therapy, education, and CBT. The primary outcome was the change (baseline to 8 weeks) in function and symptoms using the short-form of Disabilities of the Arm, Shoulder, and Hand questionnaire. Secondary outcome measures included self-reported pain, surgery intent, analgesic intake, mental health, engagement, and satisfaction. All questionnaires were delivered electronically. A total of 90 participants were randomized into digital or conventional physical therapy, with 82 receiving the allocated intervention. Both groups experienced significant improvements in function measured by the short-form of the Disabilities of the Arm, Shoulder, and Hand questionnaire, with no differences between groups (-1.8, 95% CI -13.5 to 9.8; P=.75). For secondary outcomes, no differences were observed in surgery intent, analgesic intake, and mental health or worst pain. Higher reductions were observed in average and least pain in the conventional group, which, given the small effect sizes (least pain 0.15 and average pain 0.16), are unlikely to be clinically meaningful. High adherence and satisfaction were observed in both groups, with no adverse events. This study shows that fully remote digital programs can be viable care delivery models for CSP given their scalability and effectiveness, assessed through comparison with high-dosage in-person rehabilitation. ClinicalTrials.gov (NCT04636528); https://clinicaltrials.gov/study/NCT04636528.

Study Design: Meta-analysis. Objectives: We aimed to analyze the impact of cultured expansion of autologous mesenchymal stromal cells (MSCs) in the management of osteoarthritis of the knee from randomized controlled trials (RCTs) available in the literature. Materials and Methods: We conducted independent and duplicate electronic database searches including PubMed, Embase, Web of Science, and Cochrane Library until August 2021 for RCTs analyzing the efficacy and safety of culture-expanded compared to non-cultured autologous MSCs in the management of knee osteoarthritis. The Visual Analog Score (VAS) for pain, Western Ontario McMaster University’s Osteoarthritis Index (WOMAC), Lysholm score, Knee Osteoarthritis Outcome Score (KOOS), and adverse events were the analyzed outcomes. Analysis was performed in R-platform using OpenMeta [Analyst] software. Results: Overall, 17 studies involving 767 patients were included for analysis. None of the studies made a direct comparison of the culture expanded and non-cultured MSCs, hence we pooled the results of all the included studies of non-cultured and cultured types of MSC sources and made a comparative analysis of the outcomes. At six months, culture expanded MSCs showed significantly better improvement (p < 0.001) in VAS outcome. Uncultured MSCs, on the other hand, demonstrated significant VAS improvement in the long term (12 months) in VAS (p < 0.001), WOMAC (p = 0.025), KOOS score (p = 0.016) where cultured-expanded MSCs failed to demonstrate a significant change. Culturing of MSCs did not significantly increase the complications noted (p = 0.485). On sub-group analysis, adipose-derived uncultured MSCs outperformed culture-expanded MSCs at both short term (six months) and long term (12 months) in functional outcome parameters such as WOMAC (p < 0.001, p = 0.025), Lysholm (p < 0.006), and KOOS (p < 0.003) scores, respectively, compared to their controls. Conclusions: We identified a void in literature evaluating the impact of culture expansion of MSCs for use in knee osteoarthritis. Our indirect analysis of literature showed that culture expansion of autologous MSCs is not a necessary factor to obtain superior results in the management of knee osteoarthritis. Moreover, while using uncultured autologous MSCs, we recommend MSCs of adipose origin to obtain superior functional outcomes. However, we urge future trials of sufficient quality to validate our findings to arrive at a consensus on the need for culture expansion of MSCs for use in cellular therapy of knee osteoarthritis.