Gail D. Deyle

Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial.

Arthritis has been identified as the most common cause of disability in the United States (1, 2). Thirty-three percent of persons 63 to 94 years of age are affected by osteoarthritis of the knee, which often limits the ability to rise from a chair, stand comfortably, walk, and use stairs (3, 4). Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat osteoarthritis. Use of NSAIDs can lead to gastric complications, increased risk for hospitalization, and death (5). Other treatment options for persons with osteoarthritis of the knee include physical therapy exercise and treatment programs, cortisone injections, and joint replacement surgery. Puett and Griffin (6) reviewed 15 controlled trials of nonmedicinal, noninvasive therapies for hip and knee osteoarthritis from 1966 through 1993 (6). The authors concluded that exercise reduces pain and improves function in patients with osteoarthritis of the knee, but the optimal exercise regimen has not been determined. Fitness walking, aerobic exercise, and strength training have all been reported to result in functional improvement in patients with osteoarthritis of the knee (6-12). Unweighted treadmill walking has not been shown to decrease pain associated with osteoarthritis of the knee (13). Other researchers (14, 15) have concluded that exercise may benefit patients with osteoarthritis but advise that long-term studies are required to determine the appropriate amounts of exercise to avoid accelerating the underlying process of arthritis. Active and passive range-of-motion exercise is considered an important part of rehabilitation programs for patients with osteoarthritis (16-18). Physical therapists frequently use manual therapy procedures as part of comprehensive rehabilitation programs to help patients regain joint mobility and function (19). We evaluated the effectiveness of manual physical therapy for osteoarthritis of the knee, as applied by physical therapists with formal training in such an approach (20). Our hypothesis was that physical therapy consisting of manual therapy to the knee, hip, ankle, and lumbar spine combined with range-of-motion, strengthening, and cardiovascular exercises would be more effective than placebo for improving function, decreasing pain and stiffness, and increasing the distance walked in 6 minutes. Methods Patients Eighty-three patients with osteoarthritis of the knee were randomly assigned to receive treatment (n=42; 15 men and 27 women [mean age, 60 11 years]) or placebo (n=41; 19 men and 22 women [mean age, 62 10 years]). All patients were referred by physicians to physical therapy for osteoarthritis of the knee. Physicians at the various clinics in the medical center who normally see patients with osteoarthritis of the knee were informed of the study so that appropriate referrals could be made. If the patients met our inclusion criteria, they were offered the opportunity to participate. The main inclusion criterion was a diagnosis of osteoarthritis of the knee based on fulfillment of one of the following clinical criteria developed by Altman and colleagues [21]: 1) knee pain, age 38 years or younger, and bony enlargement; 2) knee pain, age 39 years or older, morning stiffness for more than 30 minutes, and bony enlargement; 3) knee pain, crepitus on active motion, morning stiffness for more than 30 minutes, and bony enlargement; or 4) knee pain, crepitus on active motion, morning stiffness for more than 30 minutes, and age 38 years or older. Altman and colleagues found this criteria to be 89% sensitive and 88% specific (21-23). Patients were required to be eligible for military health care, have had no surgical procedure on either lower extremity in the past 6 months, and have no physical impairment unrelated to the knee that would prevent safe participation in a timed 6-minute walk test or any other aspect of the study. Patients had to have sufficient English-language skills to comprehend all explanations and to complete the assessment tools. They were also required to live within a 1-hour drive of the physical therapy clinic. Patients who could not attend the required number of visits or had received a cortisone injection to the knee joint within the previous 30 days were not enrolled. Patients were instructed to keep taking any current medications and not to start taking new medications for osteoarthritis during the clinical treatment and 8-week follow-up. Therapy with any osteoarthritis medication must have been initiated at least 30 days before participation in the study. The study was approved by the institutional review board of Brooke Army Medical Center, Fort Sam Houston, Texas. All patients completed an informed consent form and were advised of the risks of the study, including increased symptoms, injuries from falls, and cardiovascular events. No external funding was received for this study. Procedure Patients who met the inclusion criteria were randomly assigned to one of two groups. Blank folders were numbered from 1 to 100 and were given concealed codes for the group of assignment, determined by a random-number generator. When a patient was eligible and gave consent to participate, the treating therapist drew the next folder from the file, which determined the group of assignment. The treatment group received a combination of manual physical therapy and supervised exercise. The placebo group received ultrasound at a subtherapeutic intensity. Neither group was aware of the treatment that the other group was receiving. Demographic data collected for each patient included age, sex, occupation, height, weight, duration of symptoms, presence of symptoms in one or both knees, previous knee surgery, medications, and present activity level. Knee radiographs were obtained and read by a radiologist who assigned a radiographic severity rating for osteoarthritis (24). Dependent variables measured in this study were the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (25) and distance covered during a timed 6-minute walk test. The WOMAC Osteoarthritis Index consists of 24 questions, each corresponding to a visual analogue scale. This test has been shown to be a reliable, valid, and responsive multidimensional outcome measure for evaluation of patients with osteoarthritis of the hip or knee (26). The timed 6-minute walk test measures the distance a patient walks in 6 minutes and has been demonstrated to be a reliable measurement of functional exercise capacity (27). All measurements of dependent variables were obtained by a trained research assistant who was blinded to group assignment. After research assistants obtained pretreatment values for the dependent variables, patients returned to the treating physical therapist for thorough standardized clinical examination of the knee, hip, ankle, and lumbar spine. Treatment was initiated according to group assignment. The treatment group received manual physical therapy as indicated by the results of the examination. The manual therapy treatment techniques, consisting of passive physiologic and accessory joint movements, muscle stretching, and soft-tissue mobilization, were applied primarily to the knee. The same treatments were also administered to the lumbar spine, hip, or ankle if these areas showed limitation in active or passive movement, were symptomatic, or were contributing to overall lower limb dysfunction (28-31). A minimal pain level was not exceeded in any treatment. The treatment group also performed a closely supervised standardized knee exercise program at each of the eight treatment sessions. This program consisted of active range-of-motion exercises for the knee, muscle strengthening exercises for the hip and knee, muscle stretching for the lower limbs, and riding a stationary bike. All of the activities were mutually reinforcing, with repeated gentle challenges to the end ranges of movement. An outline of the exercise program is shown in the Appendix Figure. The physical therapist increased the number of strengthening exercise bouts and the stationary bike riding time on the basis of patient tolerance. The current literature provides efficient methods to produce the desired effects of increasing strength, flexibility, and range of motion (32-35). At each session, the physical therapist examined the patient for adverse signs and symptoms, such as increased pain, joint effusion, and increased skin temperature over knee joints. These signs and symptoms of osteoarthritis had to be stable or decreasing before manual therapy or exercise was progressed. Patients exercised in a painless or minimally painful manner. If any post-treatment or exercise soreness lasted more than a few hours, the regimen was decreased accordingly for that patient. The placebo group received treatment by the physical therapist that consisted of subtherapeutic ultrasound for 10 minutes at an intensity of 0.1 W/cm2 and 10% pulsed mode (lowest setting and greatest cycle interruption) to the area of knee symptoms. The placebo group received the same subjective and hands-on objective reevaluation before and after each session as the treatment group. The amount of time directly spent with the treating therapist was approximately 30 minutes for both groups. The treatment group required an additional 30 to 45 minutes to perform their exercises in the clinic. Both groups were treated twice weekly for 4 weeks, for a total of eight clinic treatments. Patients in the treatment group also performed the same exercises at home, except for the closed-chain strengthening exercises, on the days on which they were not treated in the physical therapy clinic. They also walked at home each day at a comfortable pace and distance. The treating physical therapist instructed each patient in the performance of the exercises and provided a detailed handout containing instructions and photographs of the exercises. Each patient maintained a home exercise program

The Effectiveness of Manual Physical Therapy and Exercise for Mechanical Neck Pain : A Randomized Clinical Trial

Study Design. Randomized clinical trial. Objective. To assess the effectiveness of manual physical therapy and exercise (MTE) for mechanical neck pain with or without unilateral upper extremity (UE) symptoms, as compared to a minimal intervention (MIN) approach. Summary of Background Data. Mounting evidence supports the use of manual therapy and exercise for mechanical neck pain, but no studies have directly assessed its effectiveness for UE symptoms. Methods. A total of 94 patients referred to 3 physical therapy clinics with a primary complaint of mechanical neck pain, with or without unilateral UE symptoms, were randomized to receive MTE or a MIN approach of advice, motion exercise, and subtherapeutic ultrasound. Primary outcomes were the neck disability index, cervical and UE pain visual analog scales (VAS), and patient-perceived global rating of change assessed at 3-, 6-, and 52-weeks. Secondary measures included treatment success rates and post-treatment healthcare utilization. Results. The MTE group demonstrated significantly larger reductions in short- and long-term neck disability index scores (mean 1-year difference −5.1, 95% confidence intervals (CI) −8.1 to −2.1; P = 0.001) and short-term cervical VAS scores (mean 6-week difference −14.2, 95% CI −22.7 to −5.6; P = 0.001) as compared to the MIN group. The MTE group also demonstrated significant within group reductions in short- and long-term UE VAS scores at all time periods (mean 1-year difference −16.3, 95% CI −23.1 to −9.5; P = 0.000). At 1-year, patient perceived treatment success was reported by 62% (29 of 47) of the MTE group and 32% (15 of 47) of the MIN group (P = 0.004). Conclusion. An impairment-based MTE program resulted in clinically and statistically significant short- and long-term improvements in pain, disability, and patient-perceived recovery in patients with mechanical neck pain when compared to a program comprising advice, a mobility exercise, and subtherapeutic ultrasound.

Knee Extension and Stiffness in Osteoarthritic and Normal Knees: A Videofluoroscopic Analysis of the Effect of a Single Session of Manual Therapy

STUDY DESIGN Descriptive biomechanical study using an experimental repeated-measures design. OBJECTIVE To quantify the response of participants with and without knee osteoarthritis (OA) to a single session of manual physical therapy. The intervention consisted primarily of joint mobilization techniques, supplemented by exercises, aiming to improve knee extension. BACKGROUND While manual therapy benefits patients with knee OA, there is limited research quantifying the effects of a manual therapy treatment session on either motion or stiffness of osteoarthritic and normal knees. Methods The study included 5 participants with knee OA and 5 age-, gender-, and body mass index-matched healthy volunteers. Knee extension motion and stiffness were measured with videofluoroscopy before and after a 30-minute manual therapy treatment session. Analysis of variance and intraclass correlation coefficients were used to analyze the data. RESULTS Participants with knee OA had restricted knee extension range of motion at baseline, in contrast to the participants with normal knees, who had full knee extension. After the therapy session, there was a significant increase in knee motion in participants with knee OA (P = .004) but not in those with normal knees (P = .201). For stiffness data, there was no main effect for time (P = .903) or load (P = .274), but there was a main effect of group (P = .012), with the participants with healthy knees having greater stiffness than those with knee OA. Reliability, using intraclass correlation coefficient model 3,3, for knee angle measurements between imaging sessions for all loading conditions was 0.99. Reliability (intraclass correlation coefficient model 3,1) for intraimage measurements was 0.97. CONCLUSION End-range knee extension stiffness was greater in the participants with normal knees than those with knee OA. The combination of lesser stiffness and lack of motion in those with knee OA, which may indicate the potential for improvement, may explain why increased knee extension angle was observed following a single session of manual therapy in the participants with knee OA but not in those with normal knees. Videofluoroscopy of the knee appears reliable and relevant for future studies attempting to quantify the underlying mechanisms of manual therapy. J Orthop Sports Phys Ther 2014;44(4):273-282. Epub 25 February 2014. doi:10.2519/jospt.2014.4710.

Manual Physical Therapy for Injection-Confirmed Nonacute Acromioclavicular Joint Pain

STUDY DESIGN Prospective single-cohort study. OBJECTIVES To determine and document changes in pain and disability in patients with primary, nonacute acromioclavicular joint (ACJ) pain treated with a manual therapy approach. BACKGROUND To our knowledge, there are no published studies on the physical therapy management of nonacute ACJ pain. Manual physical therapy has been successful in the treatment of other shoulder conditions. METHODS The chief inclusion criterion was greater than 50% pain relief with an ACJ diagnostic injection. Patients were excluded if they had sustained an ACJ injury within the previous 12 months. Treatment was conducted utilizing a manual physical therapy approach that addressed all associated impairments in the shoulder girdle and cervicothoracic spine. The primary outcome measure was the Shoulder Pain and Disability Index. Secondary measures were the American Shoulder and Elbow Surgeon and global rating of change scales. Outcomes were collected at baseline, 4 weeks, and 6 months. The Shoulder Pain and Disability Index and American Shoulder and Elbow Surgeon scale values were analyzed with a repeated-measures analysis of variance. RESULTS Thirteen patients (11 male; mean ± SD age, 41.1 ± 9.6 years) completed treatment consisting of an average of 6.4 sessions. Compared to baseline, there was a statistically significant and clinically meaningful improvement for the Shoulder Pain and Disability Index at 4 weeks (P = .001; mean, 25.9 points; 95% confidence interval [CI]: 11.9, 39.8) and 6 months (P<.001; mean, 29.8 points; 95% CI: 16.5, 43.0), and the American Shoulder and Elbow Surgeon scale at 4 weeks (P<.001; mean, 27.9 points; 95% CI: 14.7, 41.1) and 6 months (P<.001; mean, 32.6 points; 95% CI: 21.2, 43.9). CONCLUSION Statistically significant and clinically meaningful improvements were observed in all outcome measures at 4 weeks and 6 months, following a short series of manual therapy interventions. These results, in a small cohort of patients, suggest the efficacy of this treatment approach but need to be verified by a randomized controlled trial. LEVEL OF EVIDENCE Therapy, level 4.

Differential Diagnosis of Fibular Pain in a Patient With a History of Breast Cancer

A 46-year-old avid female runner was referred to physical therapy for left ankle pain following an inversion injury sustained 1 month earlier while running. The patient had a history of breast cancer, but her health screening was otherwise unremarkable. The patient presented with a normal ankle examination, except for localized tenderness to palpation proximal to the distal tip of the left fibula. The physical therapist was concerned about the possibility of a fibular fracture and ordered ankle radiographs, which were read as normal by the radiologist. The physical therapist, however, observed a slight cortical irregularity of the distal fibula on the anterior-posterior radiograph that corresponded with the site of palpation tenderness, and consequently ordered a bone scan to differentiate active versus old pathology. The bone scan revealed an area of increased metabolic activity at the site of the cortical irregularity, so the physical therapist ordered magnetic resonance imaging, which revealed an incom...

Clinical Reasoning and Advanced Practice Privileges Enable Physical Therapist Point-of-Care Decisions in the Military Health Care System: 3 Clinical Cases

Background and Purpose Physical therapists frequently make important point-of-care decisions for musculoskeletal injuries and conditions. In the Military Health System (MHS), these decisions may occur while therapists are deployed in support of combat troops, as well as in a more traditional hospital setting. Proficiency with the musculoskeletal examination, including a fundamental understanding of the diagnostic role of musculoskeletal imaging, is an important competency for physical therapists. The purpose of this article is to present 3 cases managed by physical therapists in unique MHS settings, highlighting relevant challenges and clinical decision making. Case Description Three cases are presented involving conditions where the physical therapist was significantly involved in the diagnosis and clinical management plan. The physical therapists clinical privileges, including the ability to order appropriate musculoskeletal imaging procedures, were helpful in making clinical decisions that facilitate timely management. The cases involve patients with an ankle sprain and Maisonneuve fracture, a radial head fracture, and a pelvic neoplasm referred through medical channels as knee pain. Outcomes Clinical pathways from point of care are discussed, as well as the reasoning that led to decisions affecting definitive care for each of these patients. In each case, emergent treatment and important combat evacuation decisions were based on a combination of examination and management decisions. Discussion Physical therapists can provide important contributions to the primary management of patients with musculoskeletal conditions in a variety of settings within the MHS. In the cases described, advanced clinical privileges contributed to the success in this role.

Integration of Critically Appraised Topics Into Evidence-Based Physical Therapist Practice

SYNOPSIS Physical therapists frequently encounter situations that require complex differential-diagnosis decisions and the ability to consistently screen for serious pathology that may mimic a musculoskeletal complaint. By applying the evidence-based-practice process to diagnosis, screening, and referral, physical therapists can identify diagnostic and screening strategies that positively influence clinical decisions. A critically appraised topic document (a standard 1-page summary of the literature appraisal and clinical relevance in response to a specific clinical question) is a valuable tool in evidence-based practice. The creation of a critically appraised topic makes the educational process cumulative instead of duplicative, allowing the individual clinician to assimilate and consolidate knowledge after a search effort and improving search and appraisal skills. The purpose of this clinical commentary is as follows: (1) to describe the clinical reasoning process of 3 orthopaedic physical therapists that led to the development of specific clinical questions related to screening for nonmusculoskeletal pathology, (2) to describe the search and triage strategy that led each physical therapist to the current best evidence needed to rule out nonmusculoskeletal pathology in the patient, and (3) to discuss the advantages and disadvantages of a critically appraised topic, the implementation of this process, and the tailoring of search strategies to find diagnostic and screening strategies.

Manual Physical Therapy Following Immobilization for Stable Ankle Fracture: A Case Series

STUDY DESIGN Case series. BACKGROUND Ankle fractures commonly result in persistent pain, stiffness, and functional impairments. There is insufficient evidence to favor any particular rehabilitation approach after ankle fracture. The purpose of this case series was to describe an impairment-based manual physical therapy approach to treating patients with conservatively managed ankle fractures. CASE DESCRIPTION Patients with stable ankle fractures postimmobilization were treated with manual physical therapy and exercise targeted at associated impairments in the lower limb. The primary outcome measure was the Lower Extremity Functional Scale. Secondary outcome measures included the ankle lunge test, numeric pain-rating scale, and global rating of change. Outcome measures were collected at baseline (performed within 7 days of immobilization removal) and at 4 and 12 weeks postbaseline. OUTCOMES Eleven patients (mean age, 39.6 years; range, 18-64 years; 2 male), after ankle fracture-related immobilization (mean duration, 48 days; range, 21-75 days), were treated for an average of 6.6 sessions (range, 3-10 sessions) over a mean of 46.1 days (range, 13-81 days). Compared to baseline, statistically significant and clinically meaningful improvements were observed in Lower Extremity Functional Scale score (P = .001; mean change, 21.9 points; 95% confidence interval: 10.4, 33.4) and in the ankle lunge test (P = .001; mean change, 7.8 cm; 95% confidence interval: 3.9, 11.7) at 4 weeks. These changes persisted at 12 weeks. DISCUSSION Statistically significant and clinically meaningful improvements in self-reported function and ankle range of motion were observed at 4 and 12 weeks following treatment with impairment-based manual physical therapy. All patients tolerated treatment well. Results suggest that this approach may have efficacy in this population. LEVEL OF EVIDENCE Therapy, level 4.

Manual physical therapy and perturbation exercises in knee osteoarthritis

Abstract Objectives: Knee osteoarthritis (OA) causes disability among the elderly and is often associated with impaired balance and proprioception. Perturbation exercises may help improve these impairments. Although manual physical therapy is generally a well-tolerated treatment for knee OA, perturbation exercises have not been evaluated when used with a manual physical therapy approach. The purpose of this study was to observe tolerance to perturbation exercises and the effect of a manual physical therapy approach with perturbation exercises on patients with knee OA. Methods: This was a prospective observational cohort study of 15 patients with knee OA. The Western Ontario and McMaster Universities Arthritis Index (WOMAC), global rating of change (GROC), and 72-hour post-treatment tolerance were primary outcome measures. Patients received perturbation balance exercises along with a manual physical therapy approach, twice weekly for 4 weeks. Follow-up evaluation was done at 1, 3, and 6 months after beginning the program. Results: Mean total WOMAC score significantly improved (P = 0·001) after the 4-week program (total WOMAC: initial, 105; 4 weeks, 56; 3 months, 54; 6 months, 57). Mean improvements were similar to previously published trials of manual physical therapy without perturbation exercises. The GROC score showed a minimal clinically important difference (MCID)≥+3 in 13 patients (87%) at 4 weeks, 12 patients (80%) at 3 months, and 9 patients (60%) at 6 months. No patients reported exacerbation of symptoms within 72 hours following each treatment session. Discussion: A manual physical therapy approach that also included perturbation exercises was well tolerated and resulted in improved outcome scores in patients with knee OA.

Eosinophilic Granuloma in a Patient With Hip Pain

The patient was a 33-year-old man who was referred to a physical therapist following a right ankle sprain. While the patient reported decreased pain and improved function of his right ankle over the course of care, he complained of a new insidious onset of right anterior hip pain. Radiographs of the hip were negative. The patient was treated by the physical therapist 4 times over the next month with manual therapy and therapeutic exercises, which resulted in moderate but temporary relief. Given the lack of response to conservative management and the poor sensitivity of conventional radiographs for early stage pathology, the physical therapist ordered a bone scan, which revealed increased radiopharmaceutical uptake in the lesser trochanteric region of the hip. A computed axial tomography scan revealed a lytic lesion in the proximal right medial femur corresponding to the area of increased uptake on the bone scan, and magnetic resonance imaging demonstrated an intramedullary lesion of the proximal femur. Fo...