Research Review By Dr. Daniel Avrahami©

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Date Posted:

May 2012

Study Title:

Full Kinetic Chain Manual and Manipulative Therapy Plus Exercise Compared With Targeted Manual and Manipulative Therapy Plus Exercise for Symptomatic Osteoarthritis of the Hip: A Randomized Controlled Trial

Authors:

Brantingham JW, Parkin-Smith G, Cassa TK et al.

Author's Affiliations:

Department of Research, Cleveland Chiropractic College, Los Angeles; School of Chiropractic & Sports Science, Murdoch University, Australia; Faculty of Science, Department of Chiropractic, Macquarie University, Sydney, Australia; Department of Chiropractic and Somatology, Durban University of Technology, South Africa.

Publication Information:

Archives of Physical Medicine & Rehabilitation 2012; 93: 259-67.

Background Information:

Mild to moderate hip osteoarthritis (OA) is extremely prevalent in the patients we treat as musculoskeletal specialists, representing a leading cause of disability and morbidity. This condition can present as an isolated complaint, or be intimately related to low back pain and a myriad of other problems. Pharmaceuticals are often effective for treating symptoms but have little influence on the progression of the joint degeneration associated with hip OA. Joint replacement can be an effective approach in severe cases but remains premature and unnecessary for mild to moderate hip OA. Manual and manipulative therapy (MMT), exercise therapy, or combinations of both, are commonly used successfully by musculoskeletal practitioners in many disciplines to treat symptomatic hip OA.

The “full kinematic chain” approach, where joints and soft tissues within the kinematic chain of the affected joint are also treated, is often used by musculoskeletal practitioners who offer MMT in clinical practice (1, 2). Even though many clinicians have found clinically beneficial results, this approach has not been validated for the treatment of hip OA.

This study’s objective was to determine the short-term effectiveness of full kinematic chain MMT plus exercise compared with targeted hip MMT plus exercise for symptomatic mild to moderate hip OA.

Pertinent Results:

  • Between-group statistical analysis of the primary outcome (WOMAC) and the secondary outcomes (HHS and OTE) did not reveal any significant differences (weighted ANCOVA; P = .45, P = .79, P = .88, respectively) between the 2 intervention groups on primary and secondary analysis, implying similar scores in both groups.
  • There was minimal difference (range, 1% – 5%; < MCID value of 20%) between groups when comparing estimated means at the 5-week and 3-month follow-up points.
  • There was a potential within-group difference, although no presumptions concerning effectiveness of the individual treatment groups can be inferred, because no control or placebo group was included in this trial.

Clinical Application & Conclusions:

The outcomes of this trial, a first of its kind for this type of treatment for hip OA, demonstrate that there were neither statistically significant nor clinically meaningful differences when comparing the experimental group (full kinematic chain MMT plus exercise) with the comparison group (targeted hip MMT plus exercise).

The results from this study provide guidance for clinicians that use MMT. The full kinematic chain approach may have benefits in other areas of practice, but does not appear to have any benefit over targeted treatment of patients with mild or moderate hip OA.

The within-group changes, in the short-term and at 3 months, demonstrated possibly positive outcomes for the use of MMT for hip OA. However, the results from this study only provide insight into the potential benefit of MMT and are not evidence of effectiveness. Therefore, we must be cautious when interpreting these findings. As the old adage goes - ‘more research is needed’ – this has never been more applicable than with a full kinematic chain MMT approach towards treating a specific targeted treatment area.

Study Methods:

This study was a parallel-group randomized trial with 3-month follow-up. The study was performed in two chiropractic outpatient teaching clinics. Patients were recruited via convenience sample of eligible participants (N = 101 for analysis) with symptomatic hip OA. Those who consented were randomly allocated to receive either the experimental or comparison treatment, respectively.

Eligibility criteria were as follows:
  1. Diagnosis of symptomatic mild to moderate hip OA based on the diagnostic criteria of the American College of Rheumatology and the Kellgren-Lawrence grade for hip OA (subjects with grade 1-3 were included, those with grade 4 changes were excluded);
  2. hip pain with less than 15° of internal rotation and less than 115° flexion or hip pain with greater than 15° internal rotation with morning stiffness of less than 60 minutes;
  3. age of 40 years and older and 85 years or younger;
  4. ability to stand and walk without assistance for most (three-quarters) of the day, as keeping active and performing exercises would otherwise be difficult; and
  5. a fall risk assessment: one leg standing test of more than 5 seconds to qualify for the Berg Balance Scale, and a Berg Balance Scale score of more than 45.
Exclusion criteria:
  1. Kellgren-Lawrence grade 4 hip degenerative changes on plain-film radiograph, indicating severe hip OA and being more amenable to surgical intervention;
  2. possibility of serious pathologic or psychiatric disorders;
  3. possibility of a disorder that would prevent the participant from performing exercises or receiving MMT;
  4. history of lumbar herniated disk or low back injury;
  5. very poor scores for the Berg Balance Scale; or
  6. bilateral symptomatic hip OA.
The Participants in the experimental group received full kinematic chain MMT plus exercise while those in the comparison group received targeted hip MMT plus exercise. Participants in both groups received 9 treatments over a 5-week period.

Comparison Group – Targeted Hip MMT + Exercise: Targeted hip MMT (using high-velocity, low-amplitude thrust-type manipulation in a long-axis manner with the hip in internal rotation) with pre- and post-treatment stretch of the same hip, provided at each treatment session. Participants were advised to keep active and slowly increase their exercise routine, as able. No treatment was provided between the ninth visit (final session in week 5 – 9 treatments) and 3-month follow-up.
hip_manipulation Experimental Group – Full Kinematic Chain MMT + Exercise: In addition to targeted hip MMT, joint mobilization and joint manipulation were applied to joints and soft tissues in the kinematic chain on the side of the affected hip (low back, knee, and ankle at the clinician’s discretion). General advice was provided in the same fashion as for the comparison group, with no additional treatment provided between the ninth visit (week 5) and 3-month follow-up.

The core set of full kinematic chain MMT procedures is summarized in the list below (treating clinicians could choose at their discretion):
  1. Hip axial elongation manipulation
  2. Spinal or SI manipulation
  3. Knee flexion and extension mobilization
  4. Knee axial elongation manipulation (mobilization or manipulation)
  5. Patellar mobilization
  6. Mortise separation (mobilization or manipulation of cuboid, etc.)
  7. A-P distal fibula
  8. STJ eversion, inversion
  9. D-P small tarsals (like mortice separation)
  10. Forefoot figure of 8 mobilizations
  11. Intermetatarsal glide (no forced end ROM thrust with knee OA)
  12. Axial elongation of the toes or MTPJs
  13. Plantar snap move (plantar to dorsal)
  14. If indicated proximal fibular mobilization or HVLA adjustment
The main outcome measures used in this study were the Western Ontario and McMaster Osteoarthritis Index (WOMAC), Harris hip score (HHS), and Overall Therapy Effectiveness, alongside estimation of clinically meaningful outcomes.

Primary analysis was between group analysis of WOMAC data, while secondary analysis was between-group analysis of the HHS and OTE data. In both primary and secondary analyses, weighted ANCOVA was used because ANCOVA accounts for the possibility of undetected differences between sample means at baseline and accommodated for possible data variance caused by the selected covariates of patient age and duration of symptoms. If a significant difference(s) was detected between datasets using ANCOVA, Tukey honestly significant difference analysis was conducted automatically to establish where the difference(s) lay.

All statistical analyses were conducted, including confidence intervals (CIs), at a 95% confidence level (?=.05), using 2-tailed tests. A difference in between-group means of 20% or more in the primary outcome measure (minimally clinically important difference (MCID)) alongside a between-group effect size index of .20 or more in the primary outcome measure, was considered clinically meaningful in this trial.

Study Strengths / Weaknesses:

Since there is no control group or a placebo treatment, it is impossible to determine if there were any significant within group effects. The natural history of symptomatic hip OA is characterized by fluctuating signs and symptoms which may account for some of the improvement seen in each treatment group. In addition, readers should remember that as a pragmatic trial, the results from this study do not permit conclusions to be drawn about the effect of individual treatments used as part of the treatment package in each group.

The study authors did recommend including Kellgren-Lawrence grade 4 hip OA patients within future studies to determine if there might be benefit for the patients with more progressive hip OA.

Additional References:

  1. Deyle GD, Allison SC, Matekel RL, et al. Physical therapy treatment effectiveness for osteoarthritis of the knee: a randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program. Phys Ther 2005; 85: 1301-17.
  2. Brantingham JW, Globe GA, Jensen ML, et al. A feasibility study comparing two chiropractic protocols in the treatment of patellofemoral pain syndrome. J Manipulative Physiol Ther 2009; 32: 536-48.