Effectiveness of manual physical therapy and exercise in osteoarthritis ofthe knee. A randomized, controlled trial

Background: Few investigations include both subjective and objective measur ements of the effectiveness of treatments for osteoarthritis of the knee. B eneficial interventions may decrease the disability associated with osteoar thritis and the need for more invasive treatments. Objective: To evaluate the effectiveness of physical therapy for osteoarthr itis of the knee, applied by experienced physical therapists with formal tr aining in manual therapy. Design: Randomized, controlled clinical trial. Setting: Outpatient physical therapy department of a large military medical center. Patients: 83 patients with osteoarthritis of the knee who were randomly ass igned to receive treatment (n = 42; 15 men and 27 women [mean age, 60 +/- 1 1 years]) or placebo (n = 41; 19 men and 22 women [mean age, 62 +/- 10 year s]). Intervention: The treatment group received manual therapy, applied to the k nee as well as to the lumbar spine, hip, and ankle as required, and perform ed a standardized knee exercise program in the clinic and at home. The plac ebo group had subtherapeutic ultrasound to the knee at an intensity of 0.1 W/cm(2) with a 10% pulsed mode. Both groups were treated at the clinic twic e weekly for 4 weeks. Measurements: Distance walked in 6 minutes and sum of the function, pain, a nd stiffness subscores of the Western Ontario and McMaster Universities Ost eoarthritis Index (WOMAC). A tester who was blinded to group assignment mad e group comparisons at the initial visit (before initiation of treatment), 4 weeks, 8 weeks, and 1 year. Results: Clinically and statistically significant improvements in 6-minute walk distance and WOMAC score at 4 weeks and 8 weeks were seen in the treat ment group but not the placebo group. By 8 weeks, average 6-minute walk dis tances had improved by 13.1% and WOMAC scores had improved by 55.8% over ba seline values in the treatment group (P < 0.05). After controlling for pote ntial confounding variables, the average distance walked in 6 minutes at 8 weeks among patients in the treatment group was 170 m (95% CI, 71 to 270 m) more than that in the placebo group and the average WOMAC scores were 599 mm higher (95% CI, 197 to 1002 mm). At 1 year, patients in the treatment gr oup had clinically and statistically significant gains over baseline WOMAC scores and walking distance; 20% of patients in the placebo group and 5% of patients in the treatment group had undergone knee arthroplasty. Conclusions: A combination of manual physical therapy and supervised exerci se yields functional benefits for patients with osteoarthritis of the knee and may delay or prevent the need for surgical intervention.