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I tried to warn you in advance – so here is the article.
Have a read – post your thoughts on the results/conclusions, and clinicial applicability.
Discuss the quality of the study (PEDRO scale, or similar to review key components of a “well done study”).
How do you weigh this evidence with your decision making, does it, should it change practice pattern/decision making?
Updated guidelines:
Clinical Practice Guidelines
Hip Pain and Mobility Deficits—Hip Osteoarthritis: Revision 2017Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association
Interventions – Manual Therapy
2017 Recommendation
Clinicians should use manual therapy for patients with mild to moderate hip osteoarthritis and impairment of joint mobility, flexibility, and/or pain. Manual therapy may include thrust, nonthrust, and soft tissue mobilization. Doses and duration may range from 1 to 3 times per week over 6 to 12 weeks in patients with mild to moderate hip osteoarthritis. As hip motion improves, clinicians should add exercises including stretching and strengthening to augment and sustain gains in the patient’s range of motion, flexibility, and strength.
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Agreed- very well done study.
Met just about everything on the PEDro scale: RCT, patients and assessors blinded, concealed allocation, specified inclusion & exclusion criteria, between group analysis, similar baseline characteristics between groups, outcome measures obtained from all at baseline and >85% at 13 weeks, included treatment effects and “measures of variability”
Other methodological strengths- robust inclusion of valid & reliable outcome measures, power analysis, long term follow up, large sample size
Correlates to clinical application- started with increased frequency of treatment and decreased as progressed, manual treatments and exercises in line with standard of care and (somewhat) patient specific, included subjective and objective outcome measures to track progress
I found it interesting that the active treatment group had higher percentage of people that correctly identified their group compared to a relatively low percentage of people in the sham group. Gives good insight as to the power of belief in treatment seeing that there were fairly similar reductions in pain and improvements in function between groups.
I think that just because there was no difference between the groups that we still don’t have something to offer these people- they did find a reduction in pain and improvement in function with PT. While they did provide interventions similar to PT practice patterns, looking at the specific interventions and percentage of time they were used identifies a few exercises and manual therapy techniques that were used >50% of the time. Was this done out of ease, specific patient presentation, PT preference? Obviously we don’t have the answer to this question but I feel like this is where clinical reasoning comes in to make sure that treatment is individualized to each patient in hopes for improved outcomes.
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Reading this article was a great review of the PEDro scale. I feel like doing a quick screen of these items provides a lot of insight on the strength of an article and where the holes may be. The authors did a great job of checking all boxes they could control and even looked for other confounders like activity level, comorbidities, and previous treatments.
From a clinical perspective, this is definitely an article to cause reflection. If focused PT did no better than ultrasound gel can we ethically offer treatment to this population? Are we wasting the patient’s time trying to improve strength and ROM when it may improve on its own over time?
In reflection I think about the natural history of OA and the fact that it typically waxes and wanes over time. People usually seek care when it is at a more severe point. Then, whether due to regression to the mean or in response to treatment methods, patients’ symptoms improve they are able to continue activity. Maybe we should take the role of an educator with these patients rather than trying to treat each one with an extensive protocol. We should focus on providing education about pain, osteoarthritis, prognosis, activity recommendations, etc. There’s a lot of information that we can provide this population to help them cope with their symptoms easier.
Does that mean that every patient with OA can’t benefit from some manual techniques, exercises, whatever other form of PT we can provide? Not necessarily. Maybe there’s a subgroup of patients that would benefit from more extensive PT.
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This RCT checks off the boxes regarding a well-done study. Much can be appreciated regarding the exhaustive subjective and objective baseline testing, as well as the use of randomization, concealed allocation, and blinding (all but the treating therapists). Also, this study clearly stated their purpose and stuck to that purpose without attempting to push their agenda or misconstrue the data. It was also refreshing that the allocated treatment times were consistently matched for both groups.
I found it worthwhile that this study poked holes in my preferred treatment approach (a combination of manual and exercise therapy). After all, we, as clinicians, come with biases and preferred treatment approaches. It is not uncommon for these biases to become overly rigid. With that, although this study will not cause me to completely abandon my current method of treating, it does help remind me of the importance of carrying with me humility and a healthy sense of skepticism.
This study also brings to mind the importance of communicating with the patient. It is up to us to capture their insight and assure that our treatments align with their idea of therapy. If we fail to capitalize on patient buy-in or neglect to explain how our treatments will work to achieve their goals, then we’re likely missing the boat.
Taylor, I like your perspective, “Maybe we should take the role of an educator with these patients rather than trying to treat each one with an extensive protocol. We should focus on providing education about pain, osteoarthritis, prognosis, activity recommendations, etc. There’s a lot of information that we can provide this population to help them cope with their symptoms easier.”
Before we put our dirty paws on the patient, we should be spending an appropriate amount of time educating them, and helping them to achieve a clear understanding that wear-and-tear in a joint occurs as a normal byproduct of living.
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Taylor- Good points to think about! I had the same thought for sure of well they did have a reduction in pain with PT, but if it was no more than a passive modality then what role do we need to play in this situation and is it something we can still justify as skilled care? I still think yes, but, like you and Steve said, it might be more/just as important to focus on education and communication.
Maybe I just didn’t dive deep enough into the data, but when reading the study I struggled with identifying specific characteristics of the subjects that might help us as clinicians identify which patient might benefit from more “extensive” PT vs something more hands off like you alluded to. Only thing I really came up with is that about 50% of the subjects were classified as grade 2 on the radiographic severity scale, so maybe we can provide greater benefit to those in the mild stage? Feel like that requires some more digging in the research to back up though.
Anything jump out to you or anyone else?-
Thanks Anna,
I definitely did not find any characteristics that I would say identified a “extensive care” population. Just a thought about our interventions still having a place in some patients, just (based on this study) not all.
Other studies about the affect of manual therapy or exercise have been A vs A+B or pitting different styles of the intervention against each other. This is the only study that has a realistic sham in place. All that previous studies, including this one, have shown is that typically this gets better with time. I’d be curious to see a future study replicate something similar to this with a qualitative aspect. The authors mention contact with a care provider being beneficial, but it would be interesting to understand patient perspectives to reinforce this.
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I agree with y’all that this study was incredibly well done according to the PEDro scale. They very clearly outlined the inclusion/exclusion criteria, the concealed allocation, blinded subjects and assessors, multiple key outcomes, and between-group statistical comparisons.
As far as clinical applicability, I don’t think this article will dramatically change the way I treat patients with hip OA, but I think it’s a great reminder to include components other than manual therapy and exercise into the plan of care. Like Taylor and Steve were saying, this population may need a lot more education in general about the disease process, prognosis, and activity guidelines to improve their baseline. And I agree with Anna that we still have skills and services to offer these patients, especially since there was an improvement in pain and function in both of the groups in the RCT.
Staying on the clinical applicability of this article, I thought the exclusion criteria was super limiting for this study compared to patients that we see walking into the clinic. I understand that they were ruling out comorbidities and reducing the margin of error, but the patients included in the RCT were patients that did not participate in 30+ minutes of walking, “structured” exercise >1x/week, and had been hurting more than 3 months, among others. I’m curious if these outcomes are still applicable with patients who are more active and more similar to patients that we see clinically. Anybody got any thoughts on that?
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Lauren- yeah that’s true… may be another thing to consider when weighing this article into clinical reasoning on what patient characteristics to look for for those who might better benefit from this treatment.
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This was (maybe unfortunately for us) a very well done article based on the PEDro scale.
Everyone has made really good points so far. It’s hard to think that our go-to interventions may not actually be making much of a difference for these patients.
As Taylor mentioned, I think the authorized did not emphasize the effect of PT interaction/belief in interventions enough. It would be interesting to know how much of an effect there was just by going to the appointments and interacting with a caring therapist. They almost need a 3rd group that did literally nothing, or just something at home.
As Taylor, Anna, and Lauren were commenting on: I wondering how much effect the severity of the arthritis has on the treatment. I think we discussed last weekend that we are most effective with low to moderate arthritis so maybe the impairments in the included group were more severe than that? Also, I agree with Lauren that the exclusion criteria were quite limiting (no exercise more than 1x/week, limited walking) so it’d be interesting to see the same study done in a more active group.
I’ll continue to treat these individuals with manual therapy and exercise, but also put more on an emphasis on education and activity modifications (assistive device) when indicated. As Eric as mentioned before – just because it’s not supported in the literature doesn’t mean we should completely change our practice pattern. Just good to know what the research is saying on things we assume.
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I think that in general it can be easy to take studies (no matter how well done) and find something that you see as a flaw in clinical applicability and remain closed minded on changing practice patterns, which could for sure lead to inefficiency in patient care. Not being open minded or efficient enough in clinical reasoning to change your plan of care if you aren’t getting the results you expected is something that I find myself doing too much. This study is a good one to challenge practice patterns in this population, but also make me think more about other areas where I might be trying to force what I think is the right treatment but need to do more research.
In particular have been struggling with a few patients with knee OA and have been doing some more digging. Anybody have any good articles for treatment in this population they can send my way?
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