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?!