RRS Education Research Reviews DATABASE

Research Review by Dr. Shawn Thistle©

Date:

Dec. 2006

Study Title:

Massage therapy for osteoarthritis of the knee: A randomized controlled trial

Authors:

Perlman AI et al.

Publication Information:

Archives of Internal Medicine 2006; 166: 2533-2538.

Summary:

Osteoarthritis (OA) has recently been reported to be more physically limiting than lung disease, heart disease, or diabetes mellitus (Centers for Disease Control and Prevention – USA). In 2004 in the United States alone, the total cost of OA was estimated at $60 billion (with a “B”!).

Hip and knee OA are very common and extremely limiting. A dynamic process, OA involves an imbalance in tissue homeostasis affecting cartilage, synovial tissue, subchondral none, and adjacent joint structures.

The end result can be total loss of joint space requiring surgical repair or joint replacement. Conventional treatments for this condition include oral pain medications, exercise therapy, heat and cold, and corticosteroid injections.

Manual therapies including physiotherapy, chiropractic, and massage therapy are all thought to be potentially useful for treating OA but there is a general dearth of scientific evidence to support any of them. In the treatment of OA, massage therapy is proposed to increase local blood flow to affected joints, improve the tone of supporting musculature, enhance joint flexibility, and relieve pain.

This study is one of the first I have seen published in a major medical journal investigating the efficacy of massage therapy for knee osteoarthritis. Sixty-eight adults were included in this randomized 8 week trial if they met the following inclusion criteria:
  • at least 35 years of age
  • radiographically established OA of the knee (meeting American College of Rheumatology criteria)
  • a pre-randomization score of 40-90 on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)
  • a score of 40-90mm on a 100mm visual analogues scale (VAS)
Exclusion criteria were standard for this type of study, and included:
  • presence of rheumatoid arthritis, fibromyalgia, recurrent or active pseudogout, cancer, or other serious medical condition
  • asthma requiring the use of corticosteroids
  • signs or a history of liver or kidney failure
  • use of oral corticosteroids in the previous 4 weeks
  • intra-articular hyaluronate within the previous 6 months
  • arthroscopic surgery or significant injury to the knee within the previous 6 months
  • a rash or open wound over the knee
Patients were randomized into two groups – one received 8 weeks of massage therapy intervention and the other group received usual care on a wait-list, followed by the massage intervention. Massage treatments were one hour in length, and included a standard set of techniques (with no specified order) including: pétrissage (compression or manipulation of soft tissue between the fingers and thumb), effleurage (gliding of the hands over skin and soft tissues), and tapotement (percussion-based therapy with hands striking soft tissue in a repetitive, rhythmic fashion).

Treatments occurred twice weekly for the first 4 weeks with one weekly treatment in weeks 5-8. The usual care group received conventional medical care including pain medications, exercises (not described), and hot and cold therapy.

The outcome measures utilized in this study were the WOMAC scale, VAS, a timed 50ft walking test, and knee ROM measured via goniometer. Measures were taken at the beginning of the study, at 8 weeks, and at 16 weeks (for the usual care group that received the massage intervention after).

Pertinent Results:

  • the study groups were comparable at baseline – with a slightly higher mean WOMAC pain score in the treatment group
  • the treatment group improved in all outcomes measured – the largest improvements were seen in pain, followed by stiffness, and physical function (all subscales of the WOMAC)
  • the treatment group also improved in VAS and clinical assessment measures (walking test and ROM)
  • no significant changes were observed in the control group in any domain (these patients then achieved similar improvements after crossing over into the massage group at week 8)
  • at the 16 week assessment, improvements in the treatment group persisted
  • only one subject reported an adverse event – increased discomfort after a treatment which prevented them from returning to the trial

Conclusions & Practical Application:

This study provides preliminary evidence that a course of massage therapy can have a positive influence on symptoms and functional deficits associated with osteoarthritis of the knee. These benefits seem to last, at least for the additional 8 week follow-up period used in this study.

I felt the use of a wait-list control group was appropriate as no suitable massage “placebo” has been developed and tested. The use of Swedish massage in this study is also appropriate, as it is the most common method and is applicable to the type of massage many of us have available in our offices.

This study has some limitations. First, patients in this study were primarily white women around age 50, so generalizing these results to other patient populations may be premature.

Second, this study was 16 weeks in duration, while OA is a chronic condition. Future work should investigate longer interventions, perhaps in combination with exercise once initial pain levels diminish. OA is generally managed, not cured. This would closely represent what most manual practitioners advocate in their offices.

The potential for massage as an adjunct treatment for OA is evident. Pharmaceutical treatments for OA (the COX-2 inhibitors specifically) have recently been correlated with higher adverse event rates than previously thought (cardiovascular, gastrointestinal, renal, and hepatotoxic effects).

With the growing evidence for acupuncture in the treatment of knee OA, the addition of massage to a treatment regimen may further benefit patients, and allow them to access their extended health care plans.

Further studies are required to determine the best multidisciplinary approach for this condition, and many others.

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