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Abbott et al. Manual Therapy, Exercise Therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee; a randomized controlled trial. Osteoarthritis and Cartilage. 2013.

One thing that got me thinking more about manual therapy intervention was while I was doing home self-study via Medbridge and listening to Dr. Ben Hando’s presentation on evaluation and treatment of hip osteoarthritis. There are many points that could be spoken of from this lecture but I have chosen to pinpoint one in particular; the Abbott et al 2013 study. The authors looked at just what is in the title, the effects of pain, disability and function on intervention through usual care, usual care combined with exercise, usual care combined with manual therapy, or usual care combined with exercise and manual therapy. A mouthful I must say! To get to the nitty gritty, look closer at the graph below.

As show above in the picture, the WOMAC score is much improved (just not statistically significant) from JUST manual therapy to manual therapy AND exercise. This is somewhat surprising as I would suggest, and I’m sure you will too, that the combination of exercise and manual therapy yields the best results, right?! We have seen this come up in most systematic reviews on other parts of the body.

One concern that always comes to mind when I look at manual therapy interventions is the amount of time someone spends with the patient, especially providing a manual treatment. Another way of looking at this is when you see a massage therapist, that 60 minutes is glorious but are the results long-lasting…not usually but satisfaction is high. In this study, the participants received 50 minutes, yes 50 minutes, of manual therapy for each visit.

There are some concerns with this intervention:
Firstly, 50 minutes is crazy! I would die if I did this much manual therapy on a patient, especially on the hip. It is by far one of the heaviest body parts and you can’t argue that most of these patients are not thin. My 165 pound frame would look like the Hulk after this study…maybe they should have measured the strength of the therapists before and after too ! 🙂

Secondly, this time frame just doesn’t work clinically. I am one of few therapists who sees my patients 1 on 1 for 45 minutes and very, very unlikely I would spend this much time with someone doing manual therapy. Maybe it is because I try to choose the right treatment for them and not beat around the bush moving everything, but possibly I’m doing it all wrong.

Thirdly, this brings up another big question: I would understand that short term effects would be AWESOME if they received all of this attention, but the authors measured effects up to 1 year so definitely some long term results.

Fourthly, this may make you think twice about just exercising your patients in the clinic? Wouldn’t it be more cost effective and time-efficient to just perform MT in the clinic and prescribe HEP? Tough to say as you can’t follow an assess/re-assess model for more specific exercises nor determine the patient’s adherence.

Maybe this brings up more questions than answers but I’ll like to hear your feedback. What do you think of just manual therapy for hip OA providing superior results to combined effects? Would you tell your patient this?!

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Posted in Hip

5 comments

  1. This is my model, short 15-20 min manual therapy, a few corrective or MDT based exercises, as long as they’re doing them well, get them out the door and they can exercise at home. Very few pts are in my practice for more than 30 minutes for follow ups. You can still do test-retest in that time. 50 minutes to one area is overkill, a 60 min massage is for the entire body.

    1. Yeh Dr E, overkill is a good way to put it. Attention effect overload! My model is very similar. I didn’t get into this to watch people exercise, actually thought twice about doing PT on my first outpatient clinic when I saw this only (my volunteer hours were where I work now). Prescribing the right exercise is a vital component but if compliant, patient doesn’t need to do in front of me.

  2. Thanks for the great write up! I agree, 50 mins is crazy! My clinic model allows me to spend 30, 45 or 60 mins with a patient but the cost gets hight at the 45-60 min mark so I tell most clients to book in a 30 min with me. Doing a hip mob with movement or even stretching the hip capsule can be TIRING (and I would say I have decent strength). Also, there is a lot of research showing glut strengthening exercises are benificial for both hip and knee pain related to OA. Interesting results to this study I must say. Did it stipulate what kind of manual therapy was actually done?

    And how’s Medbridge? Liking it?

    1. Hey Jesse,
      Great to hear from you!

      From what I get out of the slides, the manual therapy was tailored to the clinical presentation…so probably a combination of long axis distraction, hip flexor stretching, joint mobilizations into IR, etc.

      I would like to see the study done again with just 15 minutes or so of manual therapy compared to exercise alone for 15 minutes, or manual for 7 min and exercise for 8 minutes. I think that will be more clinically relevant.

      Yeh I really do like Medbridge! My wife (who is a PT) is able to go on and learn what she likes and I can go and do my own thing too (I enjoy more the spine presentations right now). Great content, reputable instructors and cool interface to watch the instructor on one side of the screen while following along with a powerpoint on the other side of the screen.

      Hv

  3. Interesting post. Thanks. I thought I might put my two cents in as a licensed massage therapist to offer another perspective on this.

    First off, I know massage clinics are different settings than PT clinics so I am curious as to why the general perception here is that 50 min. manual is perceived as overkill? Is it a functional thing around the PT clinic (scheduling, billing, available tables, etc)? or is it just about the actual amount of manual therapy on the hip for 50 minutes? In the case of the latter, I frequently spend 50+ minutes on hips. Usually, because of circumstantial reasons it is not with patients who have OA, but for SIJD, lbp, or other closely associated injuries. Repeated sessions on the same patient for this length might not happen often, but I guess if I was seeing people for OA of the hip, I could imagine doing 50 minutes 1-2 times per week for 2-3 weeks. There’s A LOT of tissue there- distinct and palpable differences- that can be worked thoroughly. Its a very time consuming area of the body to work on.

    Secondly, I think that this is a great example of where a PT might want to keep a good medical/therapeutic/rehabilitative MT’s card on file. Its not exhausting for an MT to do 50 minutes of manual therapy on the hips. We’re used to it. I see 6-7 patients 5 days per week for 50+ minutes of manual therapy! Though if I weren’t conditioned and used to it, yes, this would be tiring and the treatment’s quality might suffer. In this situation, it would be totally appropriate to refer out to an MT. After all, manual therapy is exactly what we do.

    Thanks again for the post. I’ve been keeping up with your writing for a bit now and enjoy much of it.

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