Effectiveness of Manual Physical Therapy and Exercise in Osteoarthritis of the Knee: A Randomized, Controlled Trial.

Effectiveness of Manual Physical Therapy and Exercise in Osteoarthritis of the Knee: A Randomized, Controlled Trial Deyle GD, Henderson NE, Matekel RL, et al (Brooke Army Medical Center; US Army-Baylor University, Graduate Program in Physical Therapy, Fort Sam Houston, Tex; Madigan Army Medical Center, Tacoma, Wash), Ann Intern Med. 2000;132:173-181.

The purpose of this study was to evaluate the effectiveness of physical therapy in patients with osteoarthritis of the knee. Eighty-three patients with osteoarthritis of the knee were randomly assigned to receive treatment (n=42; 15 men and 27 women, mean age=60 [+ or -] 1 years) or placebo treatment (n=41; 19 men and 22 women, mean age=62 [+ or -] 10 years).

The treatment group received manual physical therapy applied to the lumbar spine, hip, knee, or ankle as indicated by the results of a clinical examination. The manual therapy techniques included passive physiologic and accessory joint movements, muscle stretching, and soft tissue mobilization. In addition to a home exercise program, the treatment group performed a supervised standardized exercise program at the clinic, which consisted of active range-of-motion exercises, muscle strengthening and stretching exercises, and stationary cycling. Patients in the treatment group exercised in a painless or minimally painful manner.

The placebo group received subtherapeutic ultrasound to the area of knee symptoms for 10 minutes at an intensity of 0.1 W/[cm.sup.2] and 10% pulsed mode. Patients in both groups were treated at an outpatient physical therapy clinic twice per week for 4 weeks. After 8 physical therapy treatments, patients in the treatment group were instructed to continue with their home exercise program, and patients in the placebo group were instructed to continue with their normal daily activities.

The dependent variables assessed in this study were the distance covered during the timed 6-minute walk test and the score on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The WOMAC consists of 24 questions pertaining to patient self-perceptions of pain, stiffness, and physical function; each question corresponds to a visual analog scale. All measurements of the dependent variables were obtained by a tester who was unaware of group assignments at the initial visit and at 4 weeks, 8 weeks, and 1 year after the initial visit.

Thirty-three patients in the treatment group and 36 patients in the placebo group completed all treatments and were tested at the initial visit and at 4 and 8 weeks. Although no significant differences were noted between the treatment and placebo groups for either of the dependent variables at the time of the initial visit, the 6-minute walk distances and WOMAC scores were significantly better for the treatment group when compared with the placebo group at 4 and 8 weeks. At 8 weeks, after potentially confounding variables were controlled, the average distance walked in 6 minutes was 170 m greater and the average WOMAC scores were 599 mm higher for patients in the treatment group when compared with patients in the placebo group.

For the dependent variables, only the treatment group demonstrated significant improvements over time, with improvements at 8 weeks in average 6-minute walk distances and improvement in WOMAC scores of 13.1% and 55.8%, respectively, over baseline values. At 1 year, the improvements that patients in the treatment group (n=29) exhibited on the 6-minute timed walk test and WOMAC were still evident; 5% of patients in the treatment group and 20% of patients in the placebo group received a total knee arthroplasty.

The authors concluded that a combination of manual physical therapy and home/supervised exercise was more effective than placebo treatments in decreasing pain and stiffness and improving 6-minute walking distances and physical function in patients with osteoarthritis of the knee. They also concluded that manual physical therapy and exercise may also delay or prevent the need for a total knee arthroplasty.

Michael Ross, PT, OCS United States Air Force Academy Colorado Springs, Colo