manual theramanual therapy for osteoarthritis of the hip or kneep

8/10/2019 Manual TheraManual therapy for osteoarthritis of the hip or kneep

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2.1. Inclusion criteria

Studies were included if they 1) were a randomised clinical trial

(RCT), 2) included subjects with clinical or radiographic diagnosis of

hip or knee OA, 3) one study group received manual therapy alone

compared to either no intervention or another intervention, and 4)

if pain and/or physical function outcomes were measured.

Manual therapy was dened for the purposes of the review as

manipulation (high velocity, low amplitude), mobilisation (low

velocity small or largeamplitude), massage or other manual therapy

techniques, excludingno-touch techniques (Reid andRivett, 2005).

2.2. Exclusion criteria

A study was excluded if it was not published as full-text, not inEnglish language, participants were post-surgery, it was not an RCT

or participants were not humans.

2.3. Data extraction and analysis

Data extraction was carried out independently by three

researchers (HF, AB, TC) using a standardised data extraction form,

which was modied from a Cochrane review group form (Cochrane

Cystic Fibrosis and Genetic Disorder Group, 2009). Means and stan-

dard deviations (SDs) for the relevant outcomes were extracted for

short-term (post-treatment) and long-term follow-up (at least six

months) and reported as standardised mean difference (SMD). Hed-

ges effect size (ES) which provides an adjustment for small sample

bias was used (Deeks et al., 2007). Change scores were used whereavailable. All data were entered in RevMan version 5 (Copenhagen:

The Nordic Cochrane Centre, 2008). Efforts were made to contact the

original authors to obtain the data and when this was not available,

pooled SDs were estimated from the condence interval (CIs) using

methods recommended by the Cochrane Collaboration (Higgins and

Green, 2009). Statistical signicance was set at p < 0.05. Cohens

effectsizeswereusedto describethe sizeof theeffect, where0.2e0.49

represented a small effect size, 0.5e0.79 represented a moderate

effect size and>0.8 denoted a large effect size (Cohen,1977).

2.4. Risk of bias assessment

Two authors (HF, AB or TC) independently assessed the risk of

bias for each article, using criteria recommended by the Cochrane

Back Pain Review Group (vanTulder et al., 2003).A study witha low

risk of bias was dened as a trial fullling 6 or more of the 11

criteria, whilst a study with less than 6 of the criteria was classied

as having a high risk of bias. In the case of disagreements authors

tried to reach consensus and if necessary a third author assessed

the article to resolve disagreements. Just one item in one study

required adjudication from the third author.

A qualitative analysis of the levels of evidence using the grading

system described by Tugwell and OShea (2004)and recommended

by the Cochrane Musculoskeletal Group was performed (Table 1).

3. Results

3.1. Trials

The search yielded 1209 potentially eligible studies. Following

the exclusion process (Fig. 1), eight articles which had manual

therapy as a treatment component remained. Four articles which

examined manual therapy in combination with exercise were

excluded (Bennell et al., 2005; Deyle et al., 2005, 2000; Stoneman,

2001). The four remaining studies included manual therapy as

a sole intervention and met the inclusion criteria.

3.2. Characteristics of the included studies

All four studies were single-centre trials conducted in the

Netherlands (Hoeksma et al., 2004), Australia (Pollard et al., 2008),

the USA (Perlman et al., 2006) and South Africa (Tuckeret al., 2003).

Three studies were parallel design (Hoeksma et al., 2004; Pollard

et al., 2008; Tucker et al., 2003), while one was a crossover

design where a control group received the intervention after an 8-

week period (Perlman et al., 2006).

Only one study had a long-term follow-up period of 29 weeks

(Hoeksma et al., 2004). One had a medium-term follow-up of 16

weeks (Perlman et al., 2006), however, as this was due to the cross-

over of control participants to the intervention, between-group datawere available only for the short-term follow-up, whilst two had

short-term follow-ups only (Pollard et al., 2008; Tucker et al., 2003).

Three studies recruited people with knee OA (Perlman et al.,

2006; Pollard et al., 2008; Tucker et al., 2003) and one recruited

participantswithhip OA(Hoeksma et al., 2004). Sample sizesranged

from 43 to 109 individuals. Two studies undertook power calcula-

tions to estimate sample size (Hoeksma et al., 2004; Perlman et al.,

2006). Recruitment of participants varied between studies. Two

usedmedia advertisements(Pollard et al., 2008; Tuckeret al., 2003),

one recruited fromorthopaedic and rheumatology clinics (Hoeksma

et al., 2004) and one recruited from primary care physicians, senior

livingfacilitiesand rheumatologycentres(Perlman etal., 2006).Two

studies recruited participants with mild to moderate OA (Pollard

et al., 2008; Tucker et al., 2003) and one included subjects of alldegrees of severity (Hoeksma et al., 2004). Perlman et al. (2006)

included those with WOMAC pain scores between 40 and 90 on

the100mm VASscale.One studyexcludedend-stage OAon thebasis

that the manipulation treatmentwas contra-indicated (Tuckeret al.,

2003). Mean baseline pain, as measured with VAS was lower than

40 mm (on a 100 mm scale) in three studies (Hoeksma et al., 2004;

Tucker et al., 2003; Pollard et al., 2008),but between 60 and 70mm

in the study byPerlman et al. (2006).Comparison of baseline func-

tion between thefourtrials was notpossibledueto thedifferences in

function outcomes used. Two studies (Hoeksma et al., 2004;

Perlman et al., 2006) used the American College of Rheumatology

criteria (Altman et al.,1991,1986) whilstthe other two (Pollard et al.,

2008; Tucker et al., 2003) used other criteria (Forman et al., 1983;

Manek and Lane, 2000) to diagnose OA.

Table 1

Levels of Evidence (Tugwell and OShea, 2004).

Level of evidence Description

Platinum At least two RCTs with sample size of at least 50 per group.

If studies did not nd a statistically signicant difference,

they must have been adequately powered for a 20% relative

difference in the relevant outcome. Both patients and

assessors must have been blinded for outcomes and

treatment allocation concealed. Withdrawals>

80% shouldhave had appropriate follow-up including imputations

based on methods such as last observation carried

forward (LOFC).

Gold At least one RCT fullling the same criteria as platinum.

Silver A randomised trial that did not meet the above criteria.

Could also include evidence from at least one study of

nonrandomised cohorts who did and did not receive

the therapy. A randomised trial with a head to head

comparison of agents was considered silver level,

unless a reference was provided to one of the agents

to a placebo showing at least a 20% relative difference.

Bronze At least one high-quality case series without controls,

including before/after studies where subjects acted as

their own controls or if the conclusion was based on

expert opinion from clinical experience.

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3.3. Interventions

The types of manual therapy differed between studies. Twoused

chiropractic manipulation (Pollard et al., 2008; Tucker et al., 2003).

Manipulation and muscle stretching delivered by physiotherapists

was used by Hoeksma et al. (2004), and massage therapy using

Swedish full-body therapeutic massage was provided by massage

therapists (Perlman et al., 2006). Details of the interventions are in

Table 2.

All four studies had two group allocations but comparisons

differed. One compared manual therapy to exercise therapy

(Hoeksma et al., 2004), one compared to Meloxicam (a non

steroidal anti-inammatory drug) (NSAID) (Tucker et al., 2003) and

one compared to a placebo intervention of palmar contact followed

Step 1Computer database search(n=2557)

Medline (PubMed) (n=591)

Medline (EBSCO) (n=258)

Medline (OVID) (n=268)

Cinahl (EBSCO) (n=234)

ISI (Web of Knowledge) (n=378)

Cochrane Library (n=109)PsychINFO (n=166)

PEDro (n=234)

AMED (n=53)

Embase (n=266)

Duplicate articles excluded (n=1348)

Step 2Screening of title for inclusionexclusion (n= 1209)

Unrelated articles excluded basedon title (n=1123)Not manual therapy ( n=634)

Not RCT (n=259)Not OA (n=73)Not lower limb (n=42)Not humans (n=13)Not written in english (n=26)Abstract only (n=76)

Retrieved abstracts for review (n=86)

Unrelated articles excluded byabstract (n=63)Not manual therapy (n=4)Not RCT (n=47)Not OA (n=2)Not written in english (n=8)

Abstract only (n=2)

Step 3Retrieved full articles for full qualityreview (n= 23)

Articles excluded (n=15)Not manual therapy (n 9)Not RCT (n =2)Not OA (n =2)Not written in english (n=1)

St ep 4Articles with manual therapycomponent (n=8)

Articles excluded (n=4)Multimodal treatment (n=4)

Articles included in systematic reviewmanual therapy alone (n=4)

Fig. 1. Flow diagram of selection process of studies.

H.P. French et al. / Manual Therapy 16 (2011) 109e117 111


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low back pain (Coelho et al., 2008). Pain was also measured using

the 100 mm numerical rating scale version of WOMAC, and

a comparable difference of 20.11 mm in pain severity was

reported between the two groups. This resulted in a large effect

size of 0.94 [95% CI 0.44,1.44]. An MCID of 9.7 mm has been

reported in the WOMAC pain subscale (Ehrich et al., 2000) so

these results indicate a signicant benet of manual therapy

compared with no treatment for pain relief. Effect sizes for

changes in self-report function using the WOMAC and 50 footwalk test were smaller at 0.60 [95% CI 0.11, 1.08] and 0.62 [95% CI

0.14, 1.11] respectively (Table 4). The mean difference for WOMAC

function subscale was 15.48 mm which was greater than the

established MCID of 9.3 mm (Ehrich et al., 2000), resulting in

a signicant effect size of 0.6 [95% CI 0.1, 1.08].

3.5.2. Comparison with placebo

One study with a high risk of bias ( Pollard et al., 2008) found

a mean difference of 10.2 mm on a 100 mm VAS scale in favour of

manual therapy. Although this was greater than 1.7 mm change

considered to be clinically important, it resulted in a non-signi-

cant effect size of 0.58 [95% CI 0.04,1.20]. Function was measured

using a self-report VAS of how well activities could be performed. A

mean difference of 2.7 cm in favour of the manual therapy groupwas reported, with a signicant large effect size of 0.81 [95% CI

0.17,1.43].

3.5.3. Comparison with exercise therapy

One study with a low risk of bias (Hoeksma et al., 2004) found

a mean difference in favour of manual therapy of 9.1 mm on

a 100 mm VAS scale of pain at rest in individuals with hip OA,

resulting in a small effect size of 0.48 [95% CI 0.08, 0.87]. A similar

result occurred for pain during walking (mean difference of 9.6 mm

and effect size of 0.48 [95% CI 0.09, 0.87]). Both of these were

greater than the previously identied MCID of 1.7 mm score

(Coelho et al., 2008). A mean change of 1.5 points was found in the

100 point Bodily Pain subscale of the SF-36 health survey. This is

lower than the MCID of 7.8 points found in patients with lower limb

OA (Angst et al., 2001) and resulted in a small and non-signicant

effect size of 0.13 [95% CI 0.26,0.52]. A mean difference of 12.1

points was found on the Harris Hip Score resulting in a large effect

size of 0.85 [95% CI 0.45,1.25], whilst walking speed over 80 m

resulted in a small effect size of 0.40 [95% CI 0.01,0.79], both in

favour of manual therapy. The Physical Function SF-36 subscale

effect size was 0.09 [95% CI 0.3,0.48] which was non-signicant,

whilst the Role Physical subscale had a non-signicant effect size of

0.39 [95% CI 0.78, 0.00] in favour of exercise therapy over

manual therapy.

This was the only study to evaluate the long-term effects of

manual therapy (Table 5). A mean difference for pain at rest was

7 mm and 12.7 mm for pain when walking resulting in effect sizes

of 0.22 [95% CI 0.2,0.64] and 0.48 [95% CI 0.06,0.90] respectively.

The effect size on pain at rest was reduced from short-term follow-up and was non-signicant, but increased for pain with walking

(Table 5). There was a marginal reduction in effect size for SF-36

Bodily Pain subscale (ES 0.07 [95% 0.35,0.49]) which remained

non-signicant. Effect sizes for Harris hip score and 80 m walk test

in favour of manual therapy reduced at long-term follow-up,

resulting in effect sizes of 0.49 [95% CI 0.07, 0.91] and 0.41 [95% CI

0.01, 0.83] respectively. This resulted in a non-signicant long-

term effect of manual therapy on walking speed, whilst Harris hip

score remained signicant. Effect sizes for both SF-36 physical

function (ES 0.18[95% CI0.24, 0.60]) and role physical (ES 0.05

[95% CI 0.37, 0.47]) subscales improved from short-term follow-

up but remained non-signicant (Table 5).

3.5.4. Comparison with Meloxicam (NSAID)One study with a high risk of bias (Tucker et al., 2003) found

a mean difference of 2.07 mm in favour of manual therapy on

a 100 mm Visual Analogue Scale (VAS) pain scale (ES 0.18 [95% CI

0.33,0.69]) and no difference between groups on a 0e10

Numerical Rating Scale (NRS) (ES 0.2 [95% CI0.31,0.71]). Both of

these effect sizes were non-signicant. A difference of 1.5 on an 11-

Table 3

Risk of bias assessment.

Hoeksma Perlman Pollard Tucker

Randomisation Yes Yes Yes Yes

Allocation concealment Yes Unclear Unclear Unclear

Blinding of patient No No No No

Blinding of care provider No No No No

Bl indin g o f outc ome assessor Yes Unc lear Unc lear No

Baseline comparability Yes Yes Unclear YesCo-interventions avoided or similar Yes Unclear Unclear Unclear

Simi lar ti mi ng o f outc ome assessment s Yes Yes Yes Yes

Acceptable drop-out rate Yes Yes Yes Yes

Intention-to-treat analysis Yes Yes Yes No

Compliance acceptable? Yes Unclear Unclear Unclear

Table 4

Effect Sizes at short-term follow-up (Post-intervention).

Author Outcome Outcome Measure Manual

Therapy (n)

Control (n) Effect Size [95%CI] Favours Manual Therapy

Studies with Low Risk of Bias

Hoeksma Pain VAS rest pain 53 50 0.48 [0.08, 0.87] Yes

Pain VAS walking pain 53 50 0.48 [0.09, 0.87] Yes

Pain SF-36 Bodily Pain subscale 53 50 0.13 [0.26, 0.52] No differ enc e

Function SF-36 Physical Function subscale 53 50 0.09 [0.3. 0.48] No difference

Function SF-36 Role Physical Subscale 53 50 0.39 [0.78, 0.00] No difference

Function Harris Hip Score 53 50 0.85 [0.45, 1.25] Yes

Function 80 metre walk test 53 50 0.40 [0.01, 0.79] Yes

Perlman Pain Pain VAS 34 34 0.86 [0.37, 1.36] Yes

Pain WOMAC Pain subscale 34 34 0.94 [0.44,1.44] Yes

Function WOMAC Function subscale 34 34 0.60 [0.11, 1.08] Yes

Function 50 foot walk test 34 34 0.62 [0.14, 1.11] Yes

Studies with High Risk Of Bias

Pollard Pain VAS 26 17 0.58 [0. 04, 1.20] No differe nce

Function VAS 26 17 0.81 [0.17, 1.43] Yes

Tucker Pain NRS 30 30 0.18 [0. 33, 0.69] No differe nce

Pain VAS 30 30 0.20 [0. 31, 0.71] No differe nce

Function Patient Specic Functional Scale 30 30 0.15 [0. 36, 0.66] No differe nce

VAS

Visual Analogue Scale, NRS

Numerical Rating Scale, SF-36

Short Form-36, WOMAC

Western Ontario and McMaster Universities Index of Osteoarthritis.



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point PSFS scale was found in favour of manual therapy, resulting in

an effect size of 0.15 [95% CI0.33,0.66] which was non-signicant.

4. Discussion

This is the rstknownsystematic reviewto evaluate the effectof

manual therapy in hip or knee OA. The small number of included

studies indicates the limited research to date. Although patients

were randomly allocated to groups in all trials, the method ofrandomisation in three of the trials which used variations of pre-

prepared sealed envelopes can be subject to bias compared with

computer-generated numbers (Pocock, 1983; Schulz, 1995). Blind-

ing of treatment providers and study participants was a aw in all

studies but is difcult to achieve in non-pharmacological studies

(Boutron et al., 2003, 2004). Therefore, none of the evidence could

be graded as platinum or gold grade (Table 1). It was unclear from

three studies (Perlman et al., 2006; Pollardet al., 2008; Tucker et al.,

2003) if allocation concealment was used. Effect estimates in

studies with subjective outcomes can be exaggerated with unclear

or lack of allocation concealment or blinding (Wood et al., 2008).

There were some differences in demographic characteristics of

the patients (Table 2). Mean age of patients in the trials by Hoeksma

et al. (2004)and Perlman et al. (2006)were higher than the othertwo studies. This may be related to the inclusion of patients with

more severe OA in these two trials as age is the strongest risk factor

for the development of OA (Sharma et al., 2006). There was

a greater proportion of females to males in three trials (Hoeksma

et al., 2004; Perlman et al., 2006; Tucker et al., 2003) which is

unsurprising as the prevalence of OA is higher in women ( Felson,

2006).

There was variation in the severity of patients included in the

four trials. It was not clear from the two studies which only

included patients with mild to moderate OA (Pollard et al., 2008;

Tucker et al., 2003) how this was ascertained. Hoeksma et al.

(2004) used a recognised radiographic severity scale (Kellgren

and Lawrence, 1957) to dene severity, whilst cut-off scores of

the self-report WOMAC outcome were used to include participantsbyPerlman et al. (2006)although no explanation of how and why

these criteria were chosen was provided. Currently, there are no

established clinical denitions of what constitutes mild, moderate

or severe OA although work is ongoing within international OA

research groups to create a composite measure based on pain,

physical function and structural changes to dene states of OA

severity (Gossec et al., 2007).

All four studies were heterogeneous regarding the types of

manual therapy and comparison interventions used. Findings

suggest that manual therapy may have a benecial short-term

effect in reducing pain and improving physical function for patients

with knee OA compared with no intervention, and in hip OA

compared with exercise therapy. There is also evidence that effects

of manual therapy on pain and function can be sustained long-term

(up to 6 months) in hip OA, although the size of the effect reduced

for most outcomes. Effect size varied between studies, with larger

effect sizes in the study where the contrast was no treatment

(Perlman et al., 2006) compared with an active intervention

(Hoeksma et al., 2004;Tucker et al., 2003). When manual therapy

was compared to placebo, although the effect size was large, the

condence intervals around the effect size resulted in a non-

signicant result (Pollard et al., 2008). A type II error may explain

these results, as sample size was small and no sample size esti-mation was done. Effect estimates can also be exaggerated in trials

of lower methodological quality (Moher et al., 1998).

Pain and physical function are recommended as core outcome

measures in rheumatology research (Bellamy et al., 1997). All

studies measured pain severity using a VAS but there was incon-

sistency in physical function measurement across all studies. A

range of physical function measures was used including disease-

specic measures (WOMAC, Harris Hip Score), general health (SF-

36 subscales, patient specic functional scale), functional tests (50

foot walk and 80 m walk) and VAS-scaled questions. Both Perlman

et al. (2006) and Hoeksma et al. (2004) used self-report and

physical performance based measures of function which is rec-

ommended as they measure difference aspects of function in OA

(Stratford and Kennedy, 2006).In this review a broad denition of manual therapy was used.

There is a lack of clear description of what constitutes manual

therapy in the literature. This is evidenced by different criteria for

inclusion of studies in recent systematic reviews of manual

therapy (Camarinos and Marinko, 2009; Ho et al., 2009; Miller

et al., 2010; Reid and Rivett, 2005). In this review, three studies

used manipulation (Hoeksma et al., 2004; Pollard et al., 2008;

Tucker et al., 2003) applied to the target joint, whilst one deliv-

ered whole body soft tissue massage (Perlman et al., 2006). Joint-

based techniques have a role in activating pain inhibitory cortical

systems (Skyba et al., 2003). Manual therapy has previously been

shown to induce immediate hypoalgesia in individuals with knee

OA, compared with placebo and control conditions, with concur-

rent improvements in function (Moss et al., 2006). Cadaveric(Arvidsson, 1990; Harding et al., 2003) and human (Byrd and Chern,

1997) studies demonstrated that some joint movement does occur

with manual therapy applied to the hip but the effect may depend

on the force applied (Byrd and Chern, 1997). Massage therapy is

purported to have an effect on pain threshold, possibly through

endorphin release. It can also increase blood ow which may

release local pain mediators (Ernst, 1999). Psychological inuences

may also play a role due to practitioner and patient interaction

(Williams et al., 2007).

Manual therapy dosage, which varied between the studies, may

have inuenced results. The two studies which showed greater

effect provided treatments over ve (Hoeksma et al., 2004) and

eight weeks (Perlman et al., 2006), whilst the other two studies

treatment duration was two (Pollard et al., 2008) and three weeks

Table 5

Effect Sizes at long-term follow-up.

Author Outcome Outcome Measure Used Manual

Therapy (n)

Con tro l (n) Effect S iz e [95% CI] Fav ours Manual

Therapy

Studies with Low Risk of Bias

Hoeksma Pain VAS Pain at rest 44 44 0.22 [0.2, 0.64] No difference

Pain VAS Pain with walking 44 44 0.48 [0.06, 0.90] Yes

Pain SF-36 Bodily Pain subscale 44 44 0.07 [0.35, 0.49] No difference

Function SF-36 Physical Function subscale 44 44 0.18 [0.24, 0.60] No differenceFunction SF-36 Role Physical Subscale 44 44 0.05 [0.37, 0.47] No difference

Function Harris Hip Score 44 44 0.49 [0.07, 0.91] Yes

Function 80 metre walk test 44 44 0.41 [0.01, 0.83] No difference

VAS Visual Analogue Scale, SF-36 Short Form-36, WOMAC Western Ontario and McMaster Universities Index of Osteoarthritis.

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Reginster JY. The prevalence and burden of arthritis. Rheumatology 2002;41(Suppl. 1):3e6.

Reid SA, Rivett DA. Manual therapy treatment of cervicogenic dizziness: a system-atic review. Manual Therapy 2005;10(1):4e13.

Salaf F, Carotti M, Grassi W. Health-related quality of life in patients with hip orknee osteoarthritis: comparison of generic and disease-specic instruments.Clinical Rheumatolology 2005;24(1):29e37.

Sarzi-Puttini P, Cimmino MA, Scarpa R, Caporali R, Parazzini F, Zaninelli A, et al.Osteoarthritis: an overview of the disease and its treatment strategies. Semi-nars in Arthritis and Rheumatism 2005;35(Suppl. 1):1e10.

Schulz KF. Subverting randomization in controlled trials. Journal of the AmericanMedical Association 1995;274(18):1456e8.

Sharma L, Kapoor D, Issa S. Epidemiology of osteoarthritis: an update. CurrentOpinion in Rheumatology 2006;18(2):147e56.

Skyba DA, Radhakrishnan R, Rohlwing JJ, Wright A, Sluka KA. Joint manipulationreduces hyperalgesia by activation of monoamine receptors but not opioid orGABA receptors in the spinal cord. Pain 2003;106(1e2):159e68.

Steultjens MP, Dekker J, van Baar ME, Oostendorp RA, Bijlsma JW. Range of jointmotion and disability in patients with osteoarthritis of the knee or hip. Rheu-matology 2000;39(9):955e61.

Steultjens MP, Dekker J, van Baar ME, Oostendorp RA, Bijlsma JW. Muscle strength,pain and disability in patients with osteoarthritis. Clinical Rehabilitation2001;15(3):331e41.

Stoneman PD. Effect of manual therapy and exercise on pain, stiffness and functionin persons with knee osteoarthritis. Brigham Young University; 2001.

Stratford PW, Kennedy DM. Performance measures were necessary to obtaina complete picture of osteoarthritic patients. Journal of Clinical Epidemiology2006;59(2):160e7.

Tucker M, Brantingham JW, Myburg C. Relative effectiveness of a non-steroidal anti-inammatory medication (Meloxicam) versus manipulation in the treatment ofosteo-arthritisof theknee.European Journal of Chiropractic2003;50(3):163e83.

TugwellP,Boers M, Brooks P, Simon L, StrandV, Idzerda L. OMERACT: aninternationalinitiative to improve outcome measurement in rheumatology. Trials 2007;8:38.

Tugwell P, OShea B. Evidence-based Rheumatology. London: BMJ Books; 2004.van de Veen EA, de Vet HC, Pool JJ, Schuller W, de Zoete A, Bouter LM. Variance in

manual treatment of nonspecic low back pain between orthomanual physi-cians, manual therapists, and chiropractors. Journal of Manipulative andPhysiological Therapeutics 2005;28(2):108e16.

van den Dolder PA, Roberts DL. Six sessions of manual therapy increase knee exionand improve activity in people with anterior knee pain: a randomisedcontrolled trial. Australian Journal of Physiotherapy 2006;52(4):261e4.

van Tulder M, Furlan A, Bombardier C, Bouter L. Updated method guidelines forsystematic reviews in the cochrane collaboration back review group. Spine2003;28(12):1290e9.

Vermeulen HM, Rozing PM, Obermann WR, le Cessie S, Vliet Vlieland TP.Comparison of high-grade and low-grade mobilization techniques in themanagement of adhesive capsulitis of the shoulder: randomized controlledtrial. Physical Therapy 2006;86(3):355e68.

Williams NH, Hendry M, Lewis R, Russell I, Westmoreland A, Wilkinson C.Psychological response in spinal manipulation (PRISM): a systematic review ofpsychological outcomes in randomised controlled trials. ComplementaryTherapies in Medicine 2007;15(4):271e83.

Wood L, Egger M, Gluud LL, Schulz KF, Juni P, Altman DG, et al. Empirical evidence ofbias in treatment effect estimates in controlled trials with different interven-tions and outcomes: meta-epidemiological study. British Medical Journal2008;336(7644):601e5.


manual theramanual therapy for osteoarthritis of the hip or kneep

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