Exercise and manual physiotherapy arthritis research trial (EMPART): a multicentre randomised controlled trial

Abstract

BackgroundOsteoarthritis (OA) of the hip is a major cause of functional disability and reduced quality of life. Management options aim to reduce pain and improve or maintain physical functioning. Current evidence indicates that therapeutic exercise has a beneficial but short-term effect on pain and disability, with poor long-term benefit. The optimal content, duration and type of exercise are yet to be ascertained. There has been little scientific investigation into the effectiveness of manual therapy in hip OA. Only one randomized controlled trial (RCT) found greater improvements in patient-perceived improvement and physical function with manual therapy, compared to exercise therapy.Methods and designAn assessor-blind multicentre RCT will be undertaken to compare the effect of a combination of manual therapy and exercise therapy, exercise therapy only, and a waiting-list control on physical function in hip OA. One hundred and fifty people with a diagnosis of hip OA will be recruited and randomly allocated to one of 3 groups: exercise therapy, exercise therapy with manual therapy and a waiting-list control. Subjects in the intervention groups will attend physiotherapy for 6–8 sessions over 8 weeks. Those in the control group will remain on the waiting list until after this time and will then be re-randomised to one of the two intervention groups. Outcome measures will include physical function (WOMAC), pain severity (numerical rating scale), patient perceived change (7-point Likert scale), quality of life (SF-36), mood (hospital anxiety and depression scale), patient satisfaction, physical activity (IPAQ) and physical measures of range of motion, 50-foot walk and repeated sit-to stand tests.DiscussionThis RCT will compare the effectiveness of the addition of manual therapy to exercise therapy to exercise therapy only and a waiting-list control in hip OA. A high quality methodology will be used in keeping with CONSORT guidelines. The results will contribute to the evidence base regarding the clinical efficacy for physiotherapy interventions in hip OA.Trial RegistrationNumber: NCT00709566

Effects of exercise and manual therapy on pain associated with hip osteoarthritis: a systematic review and meta-analysis

“…Since two studies in the pooled analysis included participants who were on waiting lists for total hip arthroplasty,21 27 a sensitivity analysis was conducted to determine their impact. The pooled data from the four remaining studies22 23 25 26 supported a similar positive benefit of land-based exercise (SMD −0.47, 95% CI −0.69 to −0.25; I 2 =0%, χ 2 =2.37; p=0.50). Four studies16 18 21 24 involving 179 participants showed no benefit of land-based exercise compared to minimal control in the short term when pain outcomes were assessed using the WOMAC pain subscale (SMD −0.40, 95% CI −1.06 to 0.25; I 2 =65%, χ 2 =8.52; p=0.04; figure 2C).…”

“…Thirteen studies compared exercise therapy +/− education to a minimal control,13 16–27 four compared different types of exercise therapy,16 18 28 29 three compared manual therapy and exercise therapy to exercise therapy alone,20 22 30 four compared manual and exercise therapy to a minimal control,20 22 30 31 two compared manual therapy to exercise therapy,20 32 and one compared different types of manual therapy 33. The mean age of participants in included studies ranged from 52 to 77 years, mean body mass index ranged from 21.7 to 33.8 kg/m 2 , and hip OA mean symptom duration ranged from 24 months to 102 months.…”

“…At the medium-term time point (4–12 months), pooled data from three studies13 20 22 involving 237 participants revealed no significant benefit for exercise therapy compared with control when pain outcomes were assessed using the WOMAC pain subscale (SMD −0.23, 95% CI −0.48 to 0.03; I 2 =0%, χ 2 =0.85; p=0.65; figure 3A). Similarly, pooled data from two studies13 24 involving 191 participants and long-term follow-ups (>12 months) reported no benefits of exercise when pain outcomes were assessed using the WOMAC pain subscale (SMD −0.22, 95% CI −0.51 to 0.06; I 2 =0%, χ 2 =0.21; p=0.65; figure 3B).…”

“…However, pooled evidence from three studies22 30 31 (248 participants) found no significant effect of combined manual and exercise therapy over minimal control in the short term (≤3 months or 13 weeks) when pain outcomes were assessed using the VAS (SMD −0.38, 95% CI −0.88 to 0.13; I 2 =74%, χ 2 =7.76; p=0.02; figure 4A). Similarly, pooled evidence from two studies30 31 reported no medium-term (4–12 months) benefit of combined manual and exercise therapy over minimal control when pain outcomes were assessed using the VAS (SMD −0.07, 95% CI −0.50 to 0.36; I 2 =42%, χ 2 =1.74; p=0.19; figure 4B).…”

Prevalence of Hip Osteoarthritis in Chiropractic Practice in Denmark: A Descriptive Cross-Sectional and Prospective Study

“…This trial has generated an interest both inside and outside the chiropractic profession for initiating randomized clinical trials involving manual treatment for this patient group. [15][16][17][18][19] However, so far, diagnosis and management of patients with hip OA in chiropractic practice are documented only through case reports, case series, and pilot studies, 17,20,21 although textbooks describe specific manual chiropractic treatment methods for the hip joint. 22,23 Furthermore, it is not known just how common hip OA is in chiropractic practice or how often a doctor of chiropractic (DC) is the first health care person to diagnose a patient with hip OA.…”