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1 February 2000 Volume 132 Number 3

Annals of Internal Medicine

Effectiveness of Manual Physical Therapy and Exercise in
Osteoarthritis of the Knee
A Randomized, Controlled Trial
Gail D. Deyle, MPT; Nancy E. Henderson, PhD, MPT; Robert L. Matekel, MPT; Michael G. Ryder, MPT;
Matthew B. Garber, MPT; and Stephen C. Allison, PhD, MPT, ECS

Background: Few investigations include both subjective group had clinically and statistically significant gains over
and objective measurements of the effectiveness of treat- baseline WOMAC scores and walking distance; 20% of
ments for osteoarthritis of the knee. Beneficial interven- patients in the placebo group and 5% of patients in the
tions may decrease the disability associated with osteo- treatment group had undergone knee arthroplasty.
arthritis and the need for more invasive treatments. Conclusions: A combination of manual physical therapy
Objective: To evaluate the effectiveness of physical ther- and supervised exercise yields functional benefits for pa-
apy for osteoarthritis of the knee, applied by experienced tients with osteoarthritis of the knee and may delay or
physical therapists with formal training in manual therapy. prevent the need for surgical intervention.
Design: Randomized, controlled clinical trial. Ann Intern Med. 2000;132:173-181.
Setting: Outpatient physical therapy department of a For author affiliations, current addresses, and contributions, see
large military medical center. end of text.
Patients: 83 patients with osteoarthritis of the knee who
were randomly assigned to receive treatment (n ⫽ 42; 15
men and 27 women [mean age, 60 ⫾ 11 years]) or placebo
(n ⫽ 41; 19 men and 22 women [mean age, 62 ⫾ 10 years]).
A rthritis has been identified as the most com-
mon cause of disability in the United States (1,
2). Thirty-three percent of persons 63 to 94 years of
Intervention: The treatment group received manual age are affected by osteoarthritis of the knee, which
therapy, applied to the knee as well as to the lumbar spine, often limits the ability to rise from a chair, stand
hip, and ankle as required, and performed a standardized comfortably, walk, and use stairs (3, 4).
knee exercise program in the clinic and at home. The Acetaminophen and nonsteroidal anti-inflamma-
placebo group had subtherapeutic ultrasound to the knee tory drugs (NSAIDs) are commonly used to treat
at an intensity of 0.1 W/cm2 with a 10% pulsed mode. Both osteoarthritis. Use of NSAIDs can lead to gastric
groups were treated at the clinic twice weekly for 4 weeks. complications, increased risk for hospitalization, and
Measurements: Distance walked in 6 minutes and sum death (5). Other treatment options for persons with
of the function, pain, and stiffness subscores of the West- osteoarthritis of the knee include physical therapy
ern Ontario and McMaster Universities Osteoarthritis In- exercise and treatment programs, cortisone injec-
dex (WOMAC). A tester who was blinded to group assign- tions, and joint replacement surgery.
ment made group comparisons at the initial visit (before Puett and Griffin (6) reviewed 15 controlled trials
initiation of treatment), 4 weeks, 8 weeks, and 1 year.
of nonmedicinal, noninvasive therapies for hip and
Results: Clinically and statistically significant improve- knee osteoarthritis from 1966 through 1993 (6). The
ments in 6-minute walk distance and WOMAC score at 4 authors concluded that exercise reduces pain and
weeks and 8 weeks were seen in the treatment group but improves function in patients with osteoarthritis of
not the placebo group. By 8 weeks, average 6-minute walk the knee, but the optimal exercise regimen has not
distances had improved by 13.1% and WOMAC scores had
been determined. Fitness walking, aerobic exercise,
improved by 55.8% over baseline values in the treatment
group (P ⬍ 0.05). After controlling for potential confound-
and strength training have all been reported to re-
ing variables, the average distance walked in 6 minutes at sult in functional improvement in patients with os-
8 weeks among patients in the treatment group was 170 m teoarthritis of the knee (6 –12). Unweighted tread-
(95% CI, 71 to 270 m) more than that in the placebo group mill walking has not been shown to decrease pain
and the average WOMAC scores were 599 mm higher (95% associated with osteoarthritis of the knee (13).
CI, 197 to 1002 mm). At 1 year, patients in the treatment Other researchers (14, 15) have concluded that ex-
1 February 2000 • Annals of Internal Medicine • Volume 132 • Number 3 173

age 38 years or radiographic severity rating for osteoarthritis (24). and responsive multidimensional outcome sensitive and 88% specific (21–23). crepitus Osteoarthritis Index (WOMAC) score (25) and dis- on active motion. injuries of-motion. Our hypothesis was that physical Sam Houston. previous knee surgery. scale. All patients were re. and cardiovascular exer. as applied The study was approved by the institutional re- by physical therapists with formal training in such view board of Brooke Army Medical Center. Procedure Patients who met the inclusion criteria were ran- Methods domly assigned to one of two groups. Texas. they were cluded age. Fort an approach (20). formed consent form and were advised of the risks hip. and lumbar spine combined with range. Therapy with function (19). 60 ⫾ 11 the treating therapist drew the next folder from the years]) or placebo (n ⫽ 41. which determined the group of assignment. Patients were instructed to keep ical therapists frequently use manual therapy pro. 19 men and 22 women file. have had no surgical procedure on test measures the distance a patient walks in 6 either lower extremity in the past 6 months. and increasing the distance walked in 6 minutes. and bony enlargement.ercise may benefit patients with osteoarthritis but skills to comprehend all explanations and to com- advise that long-term studies are required to deter. sex. thritis of the knee. 15 men and 27 women [mean age. at least 30 days before participation in the study. strengthening. any osteoarthritis medication must have been initiated We evaluated the effectiveness of manual physi. When a pa- knee were randomly assigned to receive treatment tient was eligible and gave consent to participate. morning stiffness for questions. medications. including increased symptoms. ankle. 3) knee pain. decreasing pain and stiffness. 174 1 February 2000 • Annals of Internal Medicine • Volume 132 • Number 3 . tained by a trained research assistant who was Patients had to have sufficient English-language blinded to group assignment. The main of symptoms. tion to the knee joint within the previous 30 days grams for patients with osteoarthritis (16 –18). Physicians at the various clinics The placebo group received ultrasound at a sub- in the medical center who normally see patients therapeutic intensity. 62 ⫾ 10 years]). taking any current medications and not to start tak- cedures as part of comprehensive rehabilitation ing new medications for osteoarthritis during the programs to help patients regain joint mobility and clinical treatment and 8-week follow-up. deter- Eighty-three patients with osteoarthritis of the mined by a random-number generator. of the study. plete the assessment tools. duration offered the opportunity to participate. and of the knee based on fulfillment of one of the present activity level. cal therapy for osteoarthritis of the knee. and minutes and has been demonstrated to be a reliable have no physical impairment unrelated to the knee measurement of functional exercise capacity (27). from falls. study so that appropriate referrals could be made. manual physical therapy and supervised exercise. and cardiovascular events. and bony enlargement. clinic. Patients who could not attend the required Active and passive range-of-motion exercise is number of visits or had received a cortisone injec- considered an important part of rehabilitation pro. each corresponding to a visual analogue more than 30 minutes. younger. No external cises would be more effective than placebo for im. and bony enlargement. or 4) knee pain. Phys. (n ⫽ 42. Blank folders were numbered from 1 to 100 and were given con- Patients cealed codes for the group of assignment. morning stiffness for more than 30 tance covered during a timed 6-minute walk test. Altman and colleagues found this criteria to be 89% valid. This test has been shown to be a reliable. proving function. The WOMAC Osteoarthritis Index consists of 24 crepitus on active motion. minutes. and age 38 years or older. morning stiffness for more than 30 the Western Ontario and McMaster Universities minutes. weight. If Demographic data collected for each patient in- the patients met our inclusion criteria. 2) knee pain. Neither group was aware of with osteoarthritis of the knee were informed of the the treatment that the other group was receiving. The treatment group received a combination of ferred by physicians to physical therapy for osteoar. age Dependent variables measured in this study were 39 years or older. [mean age. measure for evaluation of patients with osteoarthri- Patients were required to be eligible for military tis of the hip or knee (26). that would prevent safe participation in a timed All measurements of dependent variables were ob- 6-minute walk test or any other aspect of the study. They were also required mine the appropriate amounts of exercise to avoid to live within a 1-hour drive of the physical therapy accelerating the underlying process of arthritis. presence of symptoms in one or both inclusion criterion was a diagnosis of osteoarthritis knees. occupation. Knee radiographs were ob- following clinical criteria developed by Altman and tained and read by a radiologist who assigned a colleagues (21): 1) knee pain. height. All patients completed an in- therapy consisting of manual therapy to the knee. The timed 6-minute walk health care. funding was received for this study. were not enrolled.

for a total of eight clinic treatments. with repeated gentle chal. consisting of passive taining instructions and photographs of the exer- physiologic and accessory joint movements. At each in pain and stiffness. This program consistent with regular performance of the home consisted of active range-of-motion exercises for the exercises. Both groups were treated twice weekly for 4 for the multivariate analysis of variance were group weeks. All of the activities were ercises (Appendix Figure). The independent variables clinic. Mann–Whitney U tests. These signs and symptoms of os. pliance with the home exercise sessions. formed by using SPSS for Windows. exercised in a painless or minimally painful manner.5 fore and after each session as the treatment group. Treatment was initi. The placebo group received treatment by the Statistical Analysis physical therapist that consisted of subtherapeutic Independent t-tests. patients re. knee surgery was recorded. (SPSS. Patients tails of the study made the decisions for surgery. the exercises and provided a detailed handout con- apy treatment techniques. group were instructed to continue their normal daily lenges to the end ranges of movement. the gen- supervised standardized knee exercise program at eral knowledge of the exercise program seemed each of the eight treatment sessions. The placebo group received the same ences between groups. possible that the logs were completed in the ab- The treatment group also performed a closely sence of performing the exercises. hip. and review- if these areas showed limitation in active or passive ing treatment attendance records.1 chi-square tests were used to analyze ratio.. The treatment group required an additional 2 ⫻ 3 mixed-model multivariate analysis of variance 30 to 45 minutes to perform their exercises in the with an ␣ level of 0. chain strengthening exercises. Each patient maintained a home exercise pro- stretching. they were not treated in the physical therapy clinic. on the days on which ough standardized clinical examination of the knee.05. ankle. Illinois). and ultrasound for 10 minutes at an intensity of 0. patients were instructed to continue the home knee. strength recovery and account for daily fluctuations flexibility. Descriptive data The amount of time directly spent with the treating analysis and tests for the assumptions of normality therapist was approximately 30 minutes for both and homogeneity of variance were followed by a groups. of the exercise program is shown in the Appendix Therapists and patients had no further contact Figure. The treating physical ther- group received manual physical therapy as indicated apist instructed each patient in the performance of by the results of the examination. Patients in both groups who had not received injec- If any post-treatment or exercise soreness lasted tions in the knee or a surgical intervention again more than a few hours. muscle stretching for the lower limbs. The same treatments were was assessed by inspection of home exercise logs. The physical therapist increased the number after completion of the eight sessions. (two levels) and time (three levels). the physical therapist examined the patient Both groups of patients returned for additional for adverse signs and symptoms. and soft-tissue mobilization. hip. Orthopedic surgeons teoarthritis had to be stable or decreasing before who were unaware of group assignment or the de- manual therapy or exercise was progressed. ordinal. accordingly for that patient. The manual ther. It is mal pain level was not exceeded in any treatment. from the ini- greatest cycle interruption) to the area of knee tial measurement session to detect significant differ- symptoms. The home exer- movement. however. the regimen was decreased completed the WOMAC and 6-minute walk test. and lumbar spine. Inc. An outline activities. session. The two depen- 1 February 2000 • Annals of Internal Medicine • Volume 132 • Number 3 175 . W/cm2 and 10% pulsed mode (lowest setting and and categorical variables. or were contributing cise treatment logs reflected a high degree of com- to overall lower limb dysfunction (28 –31). Chicago. version 7. joint effusion. were symptomatic. Compliance primarily to the knee. also administered to the lumbar spine. and increased skin temperature number of patients in each group who required over knee joints. At the 1-year follow-up visit. A mini. muscle cises. such as increased tests at 1 year. the pain. muscle strengthening exercises for the hip and sions. days after the last clinic treatment and at the same The current literature provides efficient methods to time of day as the pretreatment test to allow full produce the desired effects of increasing strength. They also walked at home each day at a comfort- ated according to group assignment. or ankle interviews with patients at testing times. After completing the eight treatment ses- knee. A post-treat- of strengthening exercise bouts and the stationary ment retest was scheduled by the testers at least 2 bike riding time on the basis of patient tolerance. except for the closed- turned to the treating physical therapist for thor. and range of motion (32–35). Patients in the placebo mutually reinforcing. All data analysis was per- subjective and hands-on objective reevaluation be. respectively. The treatment able pace and distance. After research assistants obtained pretreatment Patients in the treatment group also performed values for the dependent variables. were applied gram compliance log for all exercises. and exercises and add the closed-chain strengthening ex- riding a stationary bike. the same exercises at home.

sex.8 – 437.3 ⫾ 418.2 ⫾ 96.9) Placebo group 1093. Analyses of 6-minute walk 6-minute walk distances measured at week 8 were distances and WOMAC scores were conducted on entered as dependent variables.1–1255.0 – 472. Values from the initial testing session were mean scores between groups and across the three used for all 15 predictors.4 –1202.4) 462. 4 weeks.7 Mean body mass index.2 (730.9 – 444.6 –527.025.0) 402.0 – 453.0 (442. † Some sets of values may not total 100% because of rounding.0) 505.2 ⫾ 31.3 ⫾ 147.0 ⫾ 463. and extension range-of-motion procedure to examine pairwise comparisons of scores.7 ⫾ 455. WOMAC ⫽ Western Ontario and McMaster Universities Osteoarthritis Index.Table 1. at 1 year among all patients who were entered into 9 in the treatment group [21%] and 5 in the placebo the study.1 ⫾ 5. and 8 weeks.1 62. m 431. Post hoc analyses of toms. In each ate analysis of variance was performed for each regression model. An intention-to-treat 33 in the treatment group and 36 in the placebo chi-square analysis was used to determine group group completed all treatment and testing at base- differences in the number of surgical interventions line. the assignment.5 (931.4 ⫾ 5.0) 484.1 36.2) Placebo group 402.5 355.8 –1147.4 (447.7 30. and 8 weeks.1 ⫾ 6. mm 1046.2 402.2 Mean duration of symptoms.4) * Includes only patients who completed testing at 8 weeks (33 in the treatment group and 36 in the placebo group). 176 1 February 2000 • Annals of Internal Medicine • Volume 132 • Number 3 . Subsequent post hoc 2 ⫻ 3 univari.4 ⫾ 9.1 1347.9) 921. Baseline Characteristics of Study Patients* Variable Patients Who Completed the Study Patients Who Did Not Complete the Study Treatment Group Placebo Group Treatment Group Placebo Group (n ⫽ 33) (n ⫽ 36) (n ⫽ 9) (n ⫽ 5) Mean age.9 (368.1 26. and initial WOMAC scores. weight. The WOMAC scores and data collection times. group [12%]) dropped out of the study. ‡ Based on reference 29. Results Paired t-tests were used to compare average scores at 8 weeks and 1 year for the 55 study patients who Of the 83 patients initially enrolled in the study.7 (891.0 –572.8 –1112.0 ⫾ 12. % Men 36 50 33 20 Women 64 50 67 80 Bilateral symptoms. y 59.1 (359.9 59. height. Fourteen patients (17%. % 83 81 78 80 Days of vigorous physical activity per week 0 18 40 50 40 ⬍3 36 43 25 20 ⱖ3 46 17 25 40 Severity of radiographic findings†‡ 0 9 9 25 0 1 31 18 13 50 2 22 38 25 50 3 31 29 38 0 4 6 6 0 0 * Values following the plus/minus sign are the SD. For univariate analysis of variance.2 57.2 ⫾ 120. provided data at those times. dent variables were WOMAC scores and 6-minute separate multiple regression models were created walk distances. the subset of 69 study patients for whom those data were available at baseline.9 ⫾ 104. for each of the two dependent variables.4 ⫾ 7. knee flexion. % 33 36 67 20 Medication use. mm Treatment group 1046. The WOMAC Scores and Distance Walked in 6 Minutes at Baseline and at 4 and 8 Weeks* Test Baseline Week 4 Week 8 Mean WOMAC score (95% CI).0 1093.7 Sex.4 Mean distance walked in 6 minutes. mo 81. WOMAC ⫽ Western Ontario and McMaster Universities Osteoarthritis Index. bilaterality of symp- neity-of-covariance assumption.6 ⫾ 10. duration of degrees of freedom were conservatively adjusted to symptoms.0 (390. In the To investigate potential confounding variables.7 62.4 1418.8 21.3) 409. treatment group.7 (366.7 ⫾ 88. use of medications. 4 patients withdrew because of Table 2. 15 possible predictors were in- dependent variable. kg/m2 31. age. self-rating of physical activity level. days compensate for potential violations of the homoge.9 – 611.8 373.0 ⫾ 30.5 ⫾ 497. per week of aerobic activity.6 ⫾ 130.3 (720.2 (438. 6-minute walk performed by using the Tukey multiple comparison distances.0 Mean WOMAC score.1) 934. severity of radiographic significant group ⫻ time interaction effects were findings.0 31.4 (312.7–525.0 ⫾ 14.8) Mean distance walked in 6 minutes (95% CI). with a Bonferroni corrected ␣ cluded in a forced-entry analysis: treatment group level of 0. m Treatment group 431.3) 487. 4 weeks.

Average WOMAC in the treatment group was eliminated from testing scores were 416 mm better in the treatment group at 1 year because of a bony mass in the hip.6% in the pla- variate analysis of variance revealed a group ⫻ time cebo group (P value not significant) (Figure 1). the reduction in variables. The 14 patients who did not return In the placebo group. These repeated the 6-minute walk test and WOMAC eval- 1 February 2000 • Annals of Internal Medicine • Volume 132 • Number 3 177 . were grounds for removal for the dependent variables measured at baseline.8% lower in the treatment The assumptions of normality and homogeneity group (P ⬍ 0. Flurbiprofen 1 (3) 0 (0) Ibuprofen 4 (12) 7 (21) The 69 patients who completed the study attended Nabumetone 6 (18) 2 (6) all clinical appointments and reported for testing at Naproxen 5 (15) 2 (6) Naproxen sodium 0 (0) 1 (3) baseline. At 8 weeks.unrelated medical reasons.05) (Table 2). Piroxicam 0 (0) 2 (6) Baseline characteristics of patients who com.8% lower in the placebo of variance were met for both of the dependent group (P ⬎ 0.05). Mann–Whitney U tests. average (Table 1). and chi. Table 2 shows mean values with 95% CIs * Use of medication was documented but not controlled in this study.1% at 8 weeks (P ⬍ 0. weeks.3% at 4 weeks (P ⬍ 0. suggesting that changes Therefore.05) and by square tests revealed statistical significance only for 13. 1 sustained a knee injury Table 3. and 8 weeks.039). than in the placebo group at 4 weeks and were 472 The remaining 29 patients in the treatment group mm better at 8 weeks (P ⬍ 0. n (%) ified after receiving a cortisone injection to the knee. application of the randomization scheme re. and 2 had transportation difficulties. and 8 weeks.8% in the available at baseline and at 4 and 8 weeks. multi. 1 patient developed cardiac (n ⫽ 33) (n ⫽ 36) problems. In the treatment as measured by several variables. 4 weeks. and WOMAC scores (P ⬍ 0. 4 from the study. No pa. However. were not statistically significant. In Treatment Group Placebo Group the placebo group. Twenty cebo administration on these outcome variables. 1 was disqual. tients in the treatment group (P ⫽ 0. set (Table 1). WOMAC scores were 51. the raw scores before controlling for potential con- sulted in reasonably homogenous groups at the out. One additional patient weeks (P ⬍ 0.05) and 15. Acetaminophen 1 (3) 6 (18) Aspirin 4 (12) 0 (0) tients were excluded because of lack of compliance Diclofenac sodium 1 (3) 0 (0) with or intolerance to either treatment regimen. For the 69 patients for whom data were WOMAC scores from baseline was 55. For patients who completed all aspects of the between-group differences were based on analysis of study. patients in the the average distances walked (Figure 2) reflect the placebo group had more knee surgeries than pa- differential effect over time of treatment and pla. percent of the 41 patients in the placebo group had Post hoc pairwise comparisons of mean WOMAC undergone a total knee arthroplasty compared with scores and 6-minute walk distances revealed that only 5% of the 42 patients in the treatment group. 2 had transportation difficulties. the average distance the initial WOMAC scores. Medication Use in the Treatment and Placebo Groups* in an altercation. The nonparallel All 83 patients were contacted 1 year after en- plots of the WOMAC average scores (Figure 1) and rollment into the study. the average distance walked in 6 minutes pendent t-tests.05). such as cortisone injections or surgical procedures. changes across time for for the 4-week or 8-week visit seemed to differ average scores for either of the dependent variables substantially from those who completed the study.001). Other co-inter- ventions. and 1 withdrew for unknown reasons. the patients from both groups who completed the Fifteen percent of patients in the placebo group and study were homogeneous at initial testing (P ⬎ 5% of patients in the treatment group had received 0. Patients who had was 82 m better in the treatment group than in the had a total knee replacement or an injection into placebo group at 4 weeks and was 78 m better at 8 the knee were not retested.001). 1 acquired plantar fasciitis. Prednisone 1 (3) 0 (0) Salicylate 1 (3) 3 (9) pleted the study and those who did not are given in Table 1. By 1 year. ual physical therapy and maintained these improve- tion effects for 6-minute walk distances (P ⫽ 0. only the treatment group experienced in average scores over time depended on treatment improvements in both outcome measures after 4 group assignment. Medication use is shown in Table 3. improved by 12. group. At 4 weeks. the average 6-minute walk distance steroid injections to the knees. interaction effect (P ⫽ 0. which were about 30% walked by the placebo group did not meaningfully worse in patients who did not complete the study change (P ⬎ 0. inde. treatment group (P ⬍ 0.001) ments over the 4 weeks after clinical treatment. founding variables with multiple regression analysis. 1 was caring for a terminally ill husband and declined Medication Patients Who Completed the Study to return.05) (Figure 2).05) and 14. However.05) (Table 2). Subsequent univariate analysis of weeks of clinical treatment with exercise and man- variance also demonstrated group ⫻ time interac.05).

28. In the treatment group. white provements in self-perceptions of pain.7 m]) or average WOMAC score plete the study than in those who completed the (69. white circles represent eration of 14 potential confounding variables. ⫺113.9 to 7. The observed improvements are most likely attrib- utable to the physical therapy intervention. Among patients who completed the study. 4 weeks. It is also unlikely that other causes unrelated to the intervention were responsi- ble for the observed improvements.9 mm (CI. average WOMAC reported dropout rates in similar trials of exercise scores in the treatment group were still reduced at for osteoarthritis of the knee are 9. and circles represent the placebo group. Average WOMAC scores at baseline. no meaningful change was seen from 8 weeks were substantially higher in patients from both the to 1 year for the average distance walked (⫺22. stiffness. Black circles represent the treatment group. 25% (36).5 m) and dropout rate might significantly affect the interpre- the average increase in WOMAC scores was 169. aver- age WOMAC scores and average 6-minute walk times were clinically and statistically significantly better in the treatment group than in the placebo group at 8 weeks. those in the though regression models that include fewer than 10 treatment group had a greater average improvement in WOMAC scores compared with placebo recipients by week 8 (P ⬍ 0. stiffness. 26% (7). in distance walked from 8 weeks to 1 year was a causing the patients to withdraw.1 m treatment and the placebo groups who did not com- [CI.8 m (95% CI.0 tation of our results.9 mm]). In placebo recip. Lower scores indicate perceived improvement in pain. the reasons given for mm (CI. Discussion Patients with osteoarthritis of the knee who were treated with manual physical therapy and exercise Figure 2. If vention.9 mm). On average. 17% (11).8% (10). controlled clinical trial to guard against confounding influences. 15% (9). it is unlikely that the desirable outcomes were caused by the passage of time or by tester bias.5 to 532. and 8 of the regression analyses with simultaneous consid- weeks. sults of our regression analysis confirm the usual protections provided in a randomized. and testers who were blinded to group assignment) and given the lack of improve- ment in the placebo group. However. Among patients who completed the study. because initial WOMAC scores ients. Among patients who completed the study. and 8 weeks. distance walked compared with placebo recipients by week 8 (P ⫽ 0. group (21%) than in the placebo group (12%). utes. the average change the treatment itself had led to negative outcomes. therapy. Previously with scores collected at baseline. ⫺30. 211. 8 patients had had be less likely to complete a regimen of physical surgery and 6 had had injections.2 mm [CI. uation to determine whether the improvements seen The dropout rate was higher in the treatment at 8 weeks were still evident 1 year after the inter. weeks. relatively homogenous groups at the outset. given the results Figure 1. 197 to 1002 mm) better in the treatment group than in the placebo group and the average distance walked in 6 minutes was 170 m (CI.3 mm). ⫺51. Al- the placebo group. 20% (8).2 to 14. 4 experienced clinically and statistically significant im. and 52% (37). those in the treatment group had a greater average improvement in functional ability and the distance walked in 6 min. and function. Average distance walked in 6 minutes at baseline. Twenty-two patients in the placebo group were Patients with higher initial WOMAC scores may available for testing at 1 year. compared withdrawal were unrelated to treatment. 71 to 270 m) more. However.2 to 309. 178 1 February 2000 • Annals of Internal Medicine • Volume 132 • Number 3 . WOMAC ⫽ West- patients per predictor may not be reliable. Given the design of the study (which included random assignment to study groups.001). The beneficial effects of treatment persisted at 4 weeks and 1 year after the conclusion of clinical treatment. However. Black circles represent the treatment group. after controlling for potential confounding variables with multiple regression anal- ysis.6 to 251. this differential negligible ⫺7. 1 year by 371.001). 8-week WOMAC scores were 599 mm (CI. the re- ern Ontario and McMaster Universities Osteoarthritis Index.

unweighting the knee 4 home visits in addition to 36 clinical visits (11). One study required 24 telephone contacts and sulting in pain relief. and the number of patients receiving surgery in the two function than did clinical exercise alone for im. scores at 1 year remained better sources. 1 February 2000 • Annals of Internal Medicine • Volume 132 • Number 3 179 . Ytterberg (18) stressed the importance of targeting peutic regimen were responsible for the failure to the clinical treatment and appropriately dosing the complete all visits during the treatment phase. pain. This rapid walk test was maintained in the treatment group. Despite the deterioration in of osteoarthritis. As military health system beneficiaries. term follow-up may answer some of these questions. who had not undergone surgery was seeking it. Continued relief over a these changes can be compared with those in con. joint during walking has not been demonstrated to Previous reports of average improvement with relieve pain in patients with osteoarthritis of the exercise have ranged from 8% to 27% decreases in knee (13). of symptoms after only two to three clinical treat- At 1 year. we do not believe that aspects of the thera. Longer- change. examine the effectiveness of a physical therapy in- cent randomized clinical trial found that a combi. Of note. It seems logical that if the articular sur- pain and 10% to 39% improvements in function faces or subchondral bone were the primary pain (10. therefore pertain only to patients who comply with Patients frequently reported 20% to 40% relief the therapeutic regimen and attend treatment sessions. which allowed the therapist apy can decrease pain and stiffness and increase to focus treatment on the specific structures that functional capacity in patients with osteoarthritis of produced pain and limited function for each patient. Perhaps the repeated challenge to the end than those obtained at baseline (P ⬍ 0. assignments. Because short-term physical ther- ually applied treatment. and active range-of-movement exercises. sidered to be clinically important (38).study. provements were 60% for pain. joint replacement. most fixed or unchangeable aspects of the pathology ercise and treatment. all performance. but it ade. range of movement. manually applied passive clinic visits. Periarticular connective and mus- the WOMAC scores in this group from 8 weeks to cular tissue could be implicated as symptom 1 year (P ⫽ 0. decrease pain. pain. it represents a cost-effective way to im- The comprehensive exercise program may also have prove patient function. tance and decreasing pain.039).02). However. responsible for at least part of the pain are not the formance persisted in the absence of supervised ex. Many patients with osteoarthritis typically receive The greater overall improvement compared with very little physical therapy before undergoing total results of previous studies may be due to the man. provides a strong stimulus to connective tissue. To prevent increasing inflammation.001). beyond 1 year are unknown. and stiffness and boredom with the program. Most important. The total improvement in WOMAC score generators. re- 36). our results arthritis of the knee. primary findings were based on analyses of data and cardiovascular fitness for patients with osteo- from patients who completed the study. Such perform multiple exercises with the same therapeu. as occurs with closed-chain The benefits of treatment were achieved in eight strengthening exercises. Patients were asked at pingement syndrome of the shoulder. average subscale im. Our exercise to improve joint motion. Physical therapy may also delay or defer the need tients with osteoarthritis of the knee. addressed more of the impairments found in pa. another 1 year if they were seeking knee surgery. The effects of the manual therapy patients had equal access to orthopedic surgery. gical intervention. but they were unaware of patients’ group nation of manual therapy and clinical exercise pro. groups would be compared. The surgeons were also unaware that vided greater improvements in strength. the benefits of exercise in 36 to 48 clinical visits (7–10. treatment may defer or decrease the need for sur- tic effect or exercise more than once each day. walking under decreased loads would in our study averaged 56%. The procedures cannot be separated from either the surgeons were aware that a study was under way to clinical or home exercise programs. a re. reduction of symptoms implies that the structures indicating that the objective gains in functional per. no patient chronic inflammatory joint condition (39). We conclude that a combination of manual phys- quately addressed the lower limb physical findings ical therapy and supervised exercise is more effec- that are common in patients with osteoarthritis of tive than no treatment in improving walking dis- the knee. 54% for stiffness. tervention. patients did not in patients with osteoarthritis of the knee. Most previous studies have demonstrated movement. improved performance in the 6-minute ments of manual therapy and exercise. The effects of the physical therapy intervention and 54% for functional ability. muscular strength. longer period may depend in part on patient com- trol patients who experienced no meaningful pliance with the home exercise program. We observed fewer knee our study precludes determination of which aspect replacement surgeries in the treatment group (P ⫽ of the treatment program produced the changes in 0. Changes of 20% to 25% are generally con. The design of for total joint replacement. 11). dysfunction. the knee. The exercise program was simple.

Garber. Graduate Program in Physical Therapy.B. Baillieres Clin apy terms are based on those used in references 29 and 40. Kazis L. Com- mander. R. 1994. Ryder. Brooke Army Medical Center. gail. Henderson. phone. facilitating move- ment. 1994. M. Fort Sam Houston. improving repair. or D depending on which one they could perform pain-free. Henderson. The epidemiology of knee osteoarthritis: results from the Fra- resistance.E.D. 4. Henderson. Impairment: A temporary or permanent loss or abnor- mality of physiologic or anatomic structure. 272:1735-6. N. allowing motion to occur at 6. TX 78234-6138. N. Texas.E. Rheumatol. Deyle.E. S. Drafting of the article: G. Requests To Purchase Bulk Reprints (minimum. Author Contributions: Conception and design: G. †Patients performed closed-chain exercises B. Matekel. The Framingham Osteoarthri- faces that cannot be performed actively in the absence of tis Study. Anderson J. Tacoma. Garber. 1991-1992. Meenan RF.L. Deyle. Ryder. Tacoma. including but not limited to mobilization. Henderson. Brooke Army Medical Center.L. Ann Intern Med. TX 78234-6200.D. Felson DT. Attn: MCHE-PT (Col. N. therapies for hip and knee osteoarthritis. Final approval of the article: G. M. or stability of contractile and noncontractile tissue.D.G. Fort Sam Houston. Griffin MR.C. 3. Statistical expertise: G. 1990. Manual therapy: A clinical approach involving skilled. M. Fort Sam Houston. N. Ryder. and Madigan Army Medical Center. with the distal segment fixed. Garber. Army Orthopaedic Physical Therapy Residency. and improving function. that are used by the physical therapist to diagnose and treat soft tissues and joint structures for the purpose of modulating pain. increasing range of motion. Army-Baylor University. M. TX 78234-6200. Fort Sam Hous- ton. Deyle.20:42-50. mingham Osteoarthritis Study. Arthritis Rheum. WA 98431-5000. also known as joint play or glide.G.B. N. References Glossary 1. Critical revision of the article for important intellectual con- tent: G.L. Exercise and the musculoskeletal system. 1994. N. R. Washington.G. S. LTC Allison: U. R. Ryder.B.L.acponline. Matekel. Matekel.mil. 215-351-2657. M. Appendix Figure.121:133-40.D.B. Henderson. Panush RS. Ryder.B.E. M. specific hands-on techniques.army. Pharmacologic treatment of osteoarthritis. Castelli W. Prevalence of disabilities and associated health conditions—United States. Current Author Addresses: COL Deyle: Attn: MCHE-PT (COL Deyle). Analysis and interpretation of the data: G. Physiological movement: Movements that can be per- formed actively under voluntary muscle control. Patient exercise program. S.B.8:79-102. Matekel. 3851 Roger Brooke Drive.E. TX 78234-6200. 2. 180 1 February 2000 • Annals of Internal Medicine • Volume 132 • Number 3 . Deyle). Mobilization: Skilled passive movement applied a joint or the related soft tissues at varying speeds and intensities. Reprints Coordinator.D. Henderson.S. M. prevalence of knee osteoarthritis in the elderly.C. M.D. Deyle. Felson DT. Ryder. The Accessory movements: All movements at articular sur. 1987. e-mail. Requests for Single Reprints: COL Gail D.C. inducing relaxation. reducing or eliminating soft tissue inflammation. e-mail. Matekel. Deyle.G. From the Centers for Disease Control and Prevention. AMEDD Center and School. Allison. Collection and assembly of data: R. 1992. S. Allison. *The number of exer- cise bouts were increased according to the patient’s tolerance. 3851 Roger Brooke Drive. Mr. Attn: Physical Therapy. Allison. Army-Baylor Uni- versity. Pinals RS.E.G. M. R.C. MPT. Clin Ther. Fort Sam Houston. The definitions of the following manual physical ther. Garber.S.deyle@amedd. M. R. Naimark A. 100 copies): Bar- bara Hudson.L. bhudson@mail. extensibility. 3851 Roger Brooke Drive.org. Closed-chain exercise: Exercises that are performed 5. From Brooke Army Medical Center and U.S. Sem Arthritis Rheum. Published trials of nonmedicinal and noninvasive the proximal segments. Puett DW.14:336- 46.30:914-8.L. C. M. Garber. M.G. Ryder and CPT Garber: U. COL Henderson and MAJ Matekel: Madigan Army Medical Center. Deyle. Matekel. Lane NE. JAMA. Brooke Army Medical Center. Deyle. Allison. Garber.

Goldsmith CH.21:2106- Development of criteria for the classification and reporting of osteoarthritis. Effects of a muscle exercise program on exer- 18. 2d ed.87:S74-8. 34. Guyatt GH. 1994.26:1435-440. Daly MP. a home exercise program on muscle and functional capacity of patients with 20. Classification of osteoarthritis of the knee. et tice. Allegrante JP. Taylor knee. Baillieres Clin cise capacity in subjects with osteoarthritis.277:25-31. 1993.19:617-33. Lawrence JS. Ther. Phys Med Rehabil. MacKenzie CR. DiNubile NA. Afable RF. 16. Supervised fitness walking in patients with osteoarthritis of the 27. Bole G. 1997. et al. and McMaster Universities Osteoarthritis Index. Bellamy N. The effect of time on static stretch on the flexibility of 17.16:494-501. Clinical presentation and treatment of arthritis in the the hamstring muscles. Abrams M. Maitland GD. its effect on muscular and functional performance of patients with knee 23. Haas F. Bole GG Jr.75: Rheumatol. Clin Geriatr Med. Kulig K. Prentice WE. 1994. 1957. Am J Phys Rehabil. Peripheral Manipulation. Charl. Phys Ther. Ekblom B. 1986. 1 February 2000 • Annals of Internal Medicine • Volume 132 • Number 3 181 . Grahn R. 1988. Fisher NM. Arch Phys Med Rehabil.9:783-801. Applegate W. Am J Sports Med. al. Principles of Manual Medicine. 1994. Exercise: a cause of osteoarthritis? Rheum Dis Clin 30. Hicks J. Baker PK. Stitt LW. Diagnostic and Therapeutic Criteria 39.1:249-57. Sullivan MJ. 25. 8. 13:263-8. Buckwalter JA. Ontario: 9. MS: American Academy of Orthopaedic Manual Physical Thera. JAMA. 1994. Arch Rheum Dis. Nordenborg T. Rejeski WJ. Pendergast DR. osteoarthritis. Development of clinical criteria for osteoarthritis. London. Borenstein D. London: Butterworths. 12. 792-7. 22. 1991.74:845-50. et al. DR. Lane NE. Zachazewski JE. The 6-minute walk: a new measure of exercise capacity in patients 11. important patient relevant outcomes to antirheumatic drug therapy in pa- 10. 1996. J Rheumatol. 29. 1991.10:33-62. 1989. Rehabilitation of the elderly patient with arthritis. 1985. Exercise for patients with inflammatory arthritis. Pendergast DR. Clin Geriatr Med. Ettinger WH Jr. Brandt KD. 1991. A comparative study of signal versus aggregate methods of outcome pists.74:840-7. tients with osteoarthritis of the hip or knee. 5th ed.72:367-74. 7. 15. Fisher NM. Pendergast DR. 19.27:10-2. A randomized. Muscle rehabilitation: 1987. aged. Irion JM. 1996. 31. Buchanan WW. Mor. A comparison between two techniques. Koopmeiners MB. 32. 1996. 26. Wilkins. J Rheumatol. 1986. Western Ontario 21. Arch Phys Med Rehabil. Panush RS. Kovar PA. J Rheumatol.73:413-20. 24. A comparison of supervised exercise and supervised Committee of the American Rheumatism Association. 1994. Ford PM.116:529-34. mill exercise and pain in elderly people with osteoarthritis of the knee. Quillen WS. Fisher NM. Greenwald 40. Messier SP. Radiological assessment of osteoarthrosis. 13. Peterson MG. 1994. Athletic Injuries and Rehabilita- RA. Gresham GE. Nesher G. Campbell J. DW. exercise with a health education program in older adults with knee osteo. 35. Rouse L. The Fitness Arthritis and Seniors Trial. Bellamy N. Brandt K. Horrigan D. Holtz HA. Altman RD. Journal of Sports 37. Calkins E. 36. 3d ed.8:161-89. Techniques of manual therapy for the knee. Hicks JE.6:40-61. Kame VD. Strength training. Gresham GE. Greenman PE.76:387-94. 1993. 1998. Altman RD. J Orthop Sports Phys Ther. Phys Sweden: Alfta Rehab. Mahowald ML. Bloch DA. 1993. Maitland GD.10:659-75. Pugsley SO. Fisher NM. Quantitative evaluation of Rehabilitation. Ortho. Clin Sports Med. Quantitative effects of physical therapy on muscular and functional per. Barr S. controlled trial. Kellgren JH. 38. Arthritis Rheum. Improvement of muscle 14. Med Sci Sports Exerc. Suppl.74:1319-26. et al. Altman R. Biloxi. Burns R. son ME. Asch E. 1991. tion. Kean WF. Magee DJ. Ettinger WH Jr. Exercise for arthritis. 2000. Berman BM. 1992. Bang MD. Bloch D. measurement based on the WOMAC osteoarthritis index. Tichenor CJ. paedic Manual Physical Therapy Document Describing Advanced Clinical Prac. et al. 12. Hamberg J. WOMAC Osteoarthritis Index: A User’s Guide. Is exercise good or bad for arthritis in the elderly? flexibility. 1 Alfta. Chalmers A. Criteria for classification of clinical osteoarthritis.15:1833-40. Buchanan WW. Mangione KK. Can Med Assoc J. Vertebral Manipulation. Fallen EL. Pendergast 1995. Effects of a quantitative progres. Baltimore: Williams & North Am. Mechanical unweighting effects on tread. mann. [In press]. Fisher NM. A randomized trial comparing aerobic exercise and resistance 28. Gresham G. loskeletal Medicine. Gutin B. 1994. 1988. Axen K. Muscle Stretching in Manual Therapy. Evjenth O. Vali- formance in subjects with osteoarthritis of the knees. v. Krug HE. exercise combined with manual physical therapy on patients with shoulder 29:1039-49. Cooke DV.132:919-23. impingement syndrome. 1994. Boston: Butterworth-Heine- arthritis. Bandy WD. Thompson PJ. Deyle GD. dation study of WOMAC: a health status instrument for measuring clinically 1993. Arch Phys Med Rehabil. Pendergast DR. Philadelphia: WB Saunders. Wallin D. gan T. McCord P. Moore TL.14:3-6. Ann Intern Med. Ytterberg SR. J Rheumatol osteoarthritis. South Med J. Journal of Muscu- role of exercise as an intervention. Ann sive rehabilitation program applied unilaterally to the osteoarthritic knee. 1992. Physical disability from knee osteoarthritis: the 33. Bellamy N. with chronic heart failure. 1985.