Jansen et al: Exercise and manual therapy for knee osteoarthritis

Strength training alone, exercise therapy alone, and

exercise therapy with passive manual mobilisation
each reduce pain and disability in people with knee
osteoarthritis: a systematic review
Mariette J Jansen1,2, Wolfgang Viechtbauer2,3, Antoine F Lenssen4,5, Erik JM Hendriks1,2
and Rob A de Bie1,2
1
Department of Epidemiology, Maastricht University, 2CAPHRI research school, Maastricht University, 3Department of Methodology and Statistics,
Maastricht University, 4Department of Physiotherapy Maastricht University Medical Centre, 5Zuyd University, Heerlen
The Netherlands

Question: What are the effects of strength training alone, exercise therapy alone, and exercise with additional passive
manual mobilisation on pain and function in people with knee osteoarthritis compared to control? What are the effects of
these interventions relative to each other? Design: A meta-analysis of randomised controlled trials. Participants: Adults with
osteoarthritis of the knee. Intervention types: Strength training alone, exercise therapy alone (combination of strength training
with active range of motion exercises and aerobic activity), or exercise with additional passive manual mobilisation, versus
any non-exercise control. Comparisons between the three interventions were also sought. Outcome measures: The primary
outcome measures were pain and physical function. Results: 12 trials compared one of the interventions against control.
The effect size on pain was 0.38 (95% CI 0.23 to 0.54) for strength training, 0.34 (95% CI 0.19 to 0.49) for exercise, and 0.69
(95% CI 0.42 to 0.96) for exercise plus manual mobilisation. Each intervention also improved physical function significantly.
No randomised comparisons of the three interventions were identified. However, meta-regression indicated that exercise plus
manual mobilisations improved pain significantly more than exercise alone (p = 0.03). The remaining comparisons between the
three interventions for pain and physical function were not significant. Conclusion: Exercise therapy plus manual mobilisation
showed a moderate effect size on pain compared to the small effect sizes for strength training or exercise therapy alone. To
achieve better pain relief in patients with knee osteoarthritis physiotherapists or manual therapists might consider adding
manual mobilisation to optimise supervised active exercise programs. [Jansen MJ, Viechtbauer W, Lenssen AF, Hendriks
EJM, de Bie RA (2011) Strength training alone, exercise therapy alone, and exercise therapy with passive manual
mobilisation each reduce pain and disability in people with knee osteoarthritis: a systematic review. Journal of
Physiotherapy 57: 11–20]
Key words: Exercise, Physiotherapy, Manual therapy, Osteoarthritis of the knee

Introduction Exercise is a broad concept that may include strength training,

range of motion exercises, and aerobic activity. Education
Osteoarthritis of the hip or knee is the most common form and home exercises are also often part of an exercise
of arthritis and causes musculoskeletal pain and physical intervention. Fransen and McConnell (2008) analysed
dysfunction. The prevalence of knee osteoarthritis in the the effects of these various treatment methods, studying
Netherlands in 2007 was 14.3 per 1000 for men and 23.8 per subgroup effects for simple quadriceps strengthening,
1000 for women, while the prevalence of hip osteoarthritis lower limb muscle strengthening, strengthening together
was 10.2 per 1000 for men and 18.9 per 1000 for women with an aerobic component, walking program only, and
(Poos and Gommer 2009). The disease has a great impact other treatment content. However, they were unable to
on the patient’s physical function and quality of life. demonstrate any significant difference in effect size between
Exercise plays an important role in the management of this these subgroups for either pain or physical function.
chronic disabling disease (Zhang et al 2008). An overview
of systematic reviews reported that there is high-quality For the management of hip and knee osteoarthritis, referral to
evidence that exercise reduces pain and improves physical a physiotherapist is recommended for symptomatic patients
function in patients with osteoarthritis of the knee (Jamtvedt (Zhang et al 2007). In the Osteoarthritis Research Society
et al 2008). Recently, evidence for a positive effect of exercise International (OARSI) evidence-based expert consensus
therapy was provided in a systematic review (Fransen and guidelines (Zhang et al 2008), the recommendation to
McConnell 2008). The review showed beneficial effects in refer to a physiotherapist is based on the positive results
terms of both pain (standardised difference in the mean of studies that analysed the effects of physical therapy
change between the treatment and the control group 0.40, (Fransen et al 2001) and manual physical therapy (Deyle
95% CI 0.30 to 0.50) and physical function (0.37, 95% CI et al 2005, Deyle et al 2000). In these studies manual
0.25 to 0.49) in patients with osteoarthritis of the knee mobilisations were part of the treatment. Physiotherapists
and manual therapists frequently combine exercise therapy
with passive manual mobilisation to treat impairments

Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 11

Research

related to joint function. Passive manual mobilisation may Box 1. Inclusion criteria.
include soft-tissue mobilisation and oscillations with the
aim of improving joint mobility and joint stability and of Design
relieving pain. Restricted joint mobility, especially in terms • Randomised controlled trial
of knee flexion, appears to be an important determinant Participants
of disability in patients with osteoarthritis (Steultjens et al • Osteoarthritis of the knee
2000, Odding et al 1996). Intervention
It is not known whether passive manual mobilisations • Exercise, strengthening, physiotherapy, manual
provide additional benefits in terms of reduced pain or therapy in patients with osteoarthritis of the knee
increased physical function when compared to strength • Supervised land-based interventions
training or compared to exercise therapy alone. We were • Individual or group exercise
unaware of any studies that directly compared these Outcomes
intervention types. Therefore, the purpose of this study was • Measures of pain and physical function
to examine the differential effects of exercise therapy with Comparisons
additional passive manual mobilisation, strength training
alone, and exercise therapy alone (combining strength • Strengthening (Code 1) versus nothing/placebo
training with active range of motion exercises and aerobic • Exercise (Code 2) versus nothing/placebo
activity) on pain and physical function in patients with • Exercise plus manual mobilisations (Code 3) versus
osteoarthritis of the knee. The research questions this study nothing/placebo
tried to answer were: • Comparisons of three codes
1. What are the effects on pain and physical function
of strength training alone, exercise therapy alone Interventions: The studies were categorised as examining
(combining strength training with active range of one of three intervention types using codes defined by MJ
motion exercises and aerobic activity), and exercise and AFL: 1 = strength training only; 2 = exercise (strength
with additional passive manual mobilisation for training/active range of motion exercises/aerobic activity);
patients with osteoarthritis of the knee? 3 = exercise plus additive manual mobilisations (physio/
2. What are the effects of these interventions relative to manual therapy). Inconsistencies in coding were resolved
each other? by consensus.

Method Outcome measures: The primary outcomes were pain and

physical function. Typical measures of these outcomes
Identification and selection of studies include the Western Ontario McMaster Universities Index
A literature search was performed to identify all eligible (WOMAC), the Lequesne Index, and visual analogue
randomised controlled trials. Electronic searches of scales. Pain and physical function belong to the core set
MEDLINE (January 1990–December 2008), PEDro, of outcomes for phase III trials in osteoarthritis (Bellamy
and CINAHL were performed, using the keywords 1997). Short-term (post-intervention) effects were analysed.
‘osteoarthritis, knee’, ‘exercise’, ‘physical therapy
Data analysis
modalities’, ‘musculoskeletal manipulations’ and
‘randomised controlled trial’, in combination with the Outcome measures were extracted by the principal author
recommended search routine for identifying randomised (MJJ). Two reviewers (MJJ and AFL) extracted information
controlled trials (see Appendix 1 on the e-Addenda for about the different intervention components. For each study
the full search strategy). Only full reports in English, and outcome measure, effect sizes were calculated using
French, German, or Dutch were included. On the basis of the difference in the mean change within the intervention
titles and abstracts, the principal author (MJJ) selected and control group divided by the pooled baseline standard
relevant studies, after which two authors (MJJ and AFL) deviation. Positive values indicate that the intervention
independently selected randomised trials comparing group improved on average more than the control group.
exercise for people with osteoarthritis of the knee versus Effect sizes of 0.2 to 0.5 can be interpreted as small, 0.5
a non-exercise control group. The inclusion criteria are to 0.8 as moderate, and greater than 0.8 as large effects.
shown in Box 1. Because the goal was to compare only To calculate the standard error of the effect size estimates,
supervised treatments, we excluded studies that examined the pre-test post-test correlation must be known for the
home exercise programs as an intervention. Disagreements pain and function measurements within each study. Since
regarding the suitability of a study for the meta-analysis this information was not available for any of the studies,
were resolved by discussion. we assumed a correlation of 0.6. All of the analyses were
repeated using an assumed correlation of 0.4 and 0.8,
yielding essentially identical results.
Assessment of study characteristics
A meta-analysis was then conducted to obtain the average
Quality: Two reviewers (MJJ and AFL) assessed the quality effect for the different intervention types and to compare
of the studies using criteria from the Evidence Based these effects against each other. We anticipated that no
Richtlijn Ontwikkeling (EBRO) guideline-development trials might be found that directly compare any of the three
platform (AGREE Collaboration 2003, Burgers and van interventions. Therefore we pre-planned a mixed-effects
Everdingen 2004). Discrepancies between raters were meta-regression model for this purpose, using restricted
resolved by discussion. maximum likelihood estimation to estimate the amount
Participants: Studies involving adults with osteoarthritis of of (residual) heterogeneity and using appropriate dummy
the knee, as defined by the original authors, were eligible. variables for the different intervention codes. To examine
potential effect modification, we repeated this analysis

12 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011

 Jansen et al: Exercise and manual therapy for knee osteoarthritis

including the type of control group (education/usual care/

ultrasound vs none), study quality (EBRO score), treatment

(0 to 9)
Total
delivery mode (individual vs group), duration of treatment

6
5
2
7
5
5
5

4
4
3
4
4
period (in weeks), treatment frequency per week, duration
of treatment period × frequency, sex (% females), mean age

Intention-to- Co-intervention
of the sample, measurement instrument (WOMAC pain/
function vs other) and type of weight bearing exercise used

reported
(non-weight bearing, weight bearing, or both) as covariates

N
N
N

N
N
N
N
N
N
N
Y
Y
in the model. All analyses were carried out in R (version
2.10.1) using the ‘metafor’ package (Viechtbauer 2010).

Results

treat analysis
Flow of studies through the review

N
N
N
N
N
N
N
Y
Y
Y
Y

Y
Of the 153 retrieved trials identified by the literature
search, 21 were relevant. Twelve of these relevant studies
were randomised controlled trials that met the inclusion
and exclusion criteria. Figure 1 outlines the flow of studies

dropouts
< 15%
through the review. Reasons for exclusion of the studies

N
N

Y
Y

Y
Y

Y
Y

Y
Y
Y
Y
were: no non-exercise control group (Deyle et al 2005,
Diracoglu et al 2005, McCarthy et al 2004, Veenhof et al
2006); no or only light strengthening exercises used in the
intervention (Bautch et al 1997, Kovar et al 1992), and not

Assessor
possible to classify under one of the three codes. Two of

blinding
the studies that could not be classified to one of the three

N
N
N
Y
Y

Y
Y
Y
Y

Y
codes best fitted to Code 2 but aerobic activity was lacking
(Hopman-Rock and Westhoff 2000, Rogind et al 1998).
In the third trial a multimodal physiotherapy program
was studied involving taping and massage in addition to
Therapist
blinding

exercise (Bennell et al 2005). Moreover aerobic activity was

N
N
N
N
N
N
N
N

N
N
N
N
not incorporated in the exercise program. The individual
treatment arm in the study of Fransen and colleagues (2001)
was excluded because aerobic activity was not incorporated
in the exercise program and because heat, ultrasound, laser
Participant

or interferential therapy were also part of the individual

blinding

treatment. Moreover the use of manual techniques was not

N
N
N
N
N
N
N
N

N
N
N
N
Titles and abstracts screened (n = 153)
similar at
baseline
Groups

EBRO = Evidence based guideline development (AGREE Collaboration 2003)

Y
Y
Y
Y
Y
Y
Y
Y

Y
Y
Y
Y

Papers excluded after screening

titles/abstracts (n = 132)
Concealed
allocation

N
N
N

N
N

N
Y
Y
Y

Y
Y

Potentially relevant papers retrieved for

evaluation of full text (n = 21)
allocation
Random
Table 1. EBRO scores of included studies.

Papers excluded after evaluation of

Y
Y
Y
Y
Y
Y
Y
Y
Y

Y
Y
Y

full text (n = 9)
• no non-exercise control group
(n = 4)
• no strength or only light strength
Thorstensson et al (2005)

exercises (n = 2)
• intervention not fitting Code 1, 2 or
Peloquin et al (1999)
Fransen et al (2001)

Hughes et al (2006)
Ettinger et al (1997)

Schilke et al (1996)

3 (n = 3)
Maurer et al (1999)
Huang et al (2005)
Deyle et al (2000)

Topp et al (2002)
Baar et al (1998)

Hay et al (2006)

Papers included in review (n = 12)

Study

Figure 1. Outline of flow of studies through the review.

Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 13

Research

Table 2. Studies classified by the three intervention codes.

Study Treatment Strength Aer ROM Stretch Mob p Manip Educ Home
Code 1
Ettinger et al (1997) Group 3 3 3
Maurer et al (1999) Indiv 3 3
Schilke et al (1996) Indiv 3
Topp et al (2002) Group 3
Huang et al (2005) Indiv 3 3
Code 2
Fransen et al (2001)* Group 3 3 3 3 3
Hay et al (2006) Indiv 3 3 3 3 3 3
Peloquin et al (1999) Group 3 3 3
Hughes et al (2006) Group 3 3 3 3 3
Thorstensson et al (2005) Group 3 3 3
Code 3
van Baar et al (1998) Indiv 3 3 3 3 3 3 3
Deyle et al (2000) Indiv 3 3 3 3 3 3 3
Code 1 = strength exercise, Code 2 = exercise alone (strength exercise/active range of motion exercises/aerobic activity), Code 3 = physio/
manual therapy (exercise plus additional manual mobilisations). Fransen* = group therapy arm. Aer = aerobic activity, ROM = active range
of motion exercises, Mob p = passive manual mobilisations, Manip = manipulation, Educ = education, Home = home exercise program,
Indiv = individual

specified. We were unable to find any study that directly were combined and compared with the control group.
compared any of the three intervention types to each other. Six studies were group-based, while the other six used
Therefore the mixed-effects meta-regression was used to individually delivered treatment. Five studies offered
analyse the relative effects of the three interventions. additional education and seven studies incorporated a home
exercise program in the intervention. See Table 2 for an
Characteristics of studies included overview of the studies included, classified according to the
Quality: The methodological quality of the studies ranged three intervention codes. In five studies the control group
from 2 to 7 on a scale from 0 to 9 points. Four studies received no intervention, whereas in six studies the control
scored 4 points (Maurer et al 1999, Peloquin et al 1999, group was given education, and in one study therapeutic
Thorstensson et al 2005, Topp et al 2002) and four studies ultrasound (Deyle 2000). In five of the twelve studies both
scored 5 points (Deyle et al 2000, Ettinger et al 1997, weight bearing and non-weight bearing strength exercise
Fransen et al 2001, Huang et al 2005). The scores of the programs were chosen, while five studies only used non-
remaining studies were 2 (Hughes et al 2006), 3 (Schilke weight bearing and two only weight bearing strength
et al 1996), 6 (Hay et al 2006), and 7 points (van Baar et al exercises. See Table 3 for a description of the main aspects
1998). Table 1 provides an overview of the methodological of the studies.
quality of the included studies.
Outcome measures: Most studies used the WOMAC
Participants: In 8 of the 12 studies, the participants to analyse the effects on pain and function. Effect sizes
had clinical evidence of osteoarthritis according to the could not be calculated for four studies, because standard
American College of Rheumatology (ACR) criteria (Altman deviations were missing (Ettinger et al 1997, Maurer et
et al 1986). Two studies recruited patients with radiographic al 1999), total WOMAC scores (instead of the pain and
evidence of osteoarthritis. One study used volunteers with function subscale scores) were presented (Deyle et al
osteoarthritis and one study recruited adults older than 55 2000), or the results pertained to a mixed group of patients
years who had consulted their general practitioner with suffering from either hip or knee osteoarthritis (van Baar et
pain, stiffness, or both. The mean age of participants in 11 al 1998). In the review by Fransen and McConnell (2008),
of the 12 studies ranged from 65 to 70 years. In 10 of the 12 the effect sizes for these four studies were calculated with
studies the majority were female (mean 75%; range 64% to the help of externally provided data. We used these effect
85%). In one study (Thorstensson et al 2005) mean age was sizes on the assumption that these data had been correctly
56 years and 50% were female. In the study of Maurer and calculated. We could not retrieve and analyse separate
colleagues (1999) 58% of the patients were male. Duration results for patients with knee and hip osteoarthritis from one
of the disease ranged from 5 months to more than 10 years. study (Hughes et al 2006). Generally, effects for knee and
hip osteoarthritis have been found to be the same (Jansen et
Intervention type: From one study (Ettinger et al 1997) al 2010, van Baar et al 1998), so we used the results for the
we took the trial arm that examined resistance training total group, assuming comparable effect sizes. Finally, for
versus a control group. From another study we took the the study by Fransen and colleagues (2001), we assumed
trial arm that examined isokinetic exercise (group I) versus that the change between baseline and Week 8 was the same
control (Huang et al 2005), and in one study (Fransen et for the two intervention groups. The 16-week results could
al 2001) we classified the ‘group therapy’ as Code 2. One not be used, since these include control participants that
study examined two different strength training programs were randomised to the two intervention groups after Week 8.
(Topp et al 2002). The mean effects of these programs

14 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011

 Jansen et al: Exercise and manual therapy for knee osteoarthritis

Table 3. Summary of included studies (n = 12).

Study Design Participants Intervention Outcome measures
Ettinger et al RCT n = 247 Exp = progressive resistance training • Knee pain scale
(1997) Age = 69 yr (SD 6) (WB/NWB)/home program • Self-reported disability
Gender = 30% male 60 min x 3/wk x 12 wk • Follow-up = 3, 9, 18 months
Group
Con = education
Maurer et al RCT n = 98 Exp = quadriceps isokinetic strength • WOMAC pain
(1999) Age = 65 yr (SD 9) training dynamometer (NWB) • WOMAC function
Gender = 58% male ? min x 3/wk x 8 wk • Follow-up = 8, 12 wk
Individual
Con = education
Schilke et al RCT n = 20 Exp = isokinetic muscle-strength training • AIMS
(1996) Age = 66 yr program (NWB) • Follow-up = 8 wk
Gender = 15% male ? min x 3/wk x 8 wk
Individual
Con = none
Topp et al RCT n = 67 Exp = I: progressive dynamic resistance • WOMAC pain
(2002) Age = 63 yr training (NWB). II: progressive isometric • WOMAC function
resistance training (NWB)
Gender = 26% male • Follow up = 16 wk
50 min 1/wk x 16 wk
Group 1/wk, 2/wk exercise at home
Con = none
Huang et al RCT n = 62 Exp = strength training (isokinetic) (NWB). • VAS pain
(2005) Age = 65 yr (SD 6) Home exercise program • Lequesne index
Gender = 20% male ? min x 3/wk x 8 wk Follow-up = 8 wk, 12 months
Individual
Con = none
Fransen et al RCT n = 81 Exp = strength training (WB/NWB) / 20 • WOMAC pain
(2001)* Age = 65 yr (SD 7) min stationary bicycle / home program • WOMAC function
3x/wk (stretches followed by 20 min of
Gender = 22% male continuous outdoor walking or indoor Follow-up = 8 wk, 16 wk
stationary bicycle)
60 min x 2/wk x 8 wk
Group
Con = none
Peloquin et al RCT n = 124 Exp = progressive aerobic, strengthening • AIMS2
(1999) Age = 66 yr (WB/NWB) and stretching exercises. Follow-up = 12 wk
Aerobic: bicycle progressive to 17 min
Gender = 30% male
60 min x 2/wk x 12 wk
Group
Con = education
Hay et al RCT n = 182 Exp = strength (NWB)/ aerobic / ROM / • WOMAC pain
(2006) Age = 68 yr stretch • WOMAC function
Gender = 35% male 20 min x 3–6 over a 10-week period
Group
Con = education
Hughes et al RCT n = 138 Exp = strength (WB/NWB) / aerobic fitness • WOMAC pain
(2006) Age = 73 yr (SD 7) walking progressive to 30 min / flexibility / • WOMAC function
education (behaviour change)
Gender = 16% male Follow-up = 8 wk, 6 months, 12
90 min x 3/wk x 8 wk months
Group
Con = arthritis self-help book
Thorstensson RCT n = 61 Exp = high intensity strength training (WB) • KOOS pain
et al Age = 56 yr (SD 6) / endurance / balance / ergometer cycling • KOOS ADL
(2005) 10 min/ home exercise program
Gender = 49% male Follow-up = 6 wk, 6 months
45 min x 2/wk x 6 wk
Group
Con = none

Table 3 continued on next page

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Research

Table 3. Summary of included studies (n = 12) – continued

Study Design Participants Intervention Outcome measures

Baar et al RCT n = 113 Exp = physiotherapy: strength (WB/NWB)/ • VAS pain
(1998) Age = 68 yr stretch / aerobic / ROM / co-ordination / • Self-observed disability
manual mobilisations / home exercises /
Gender = 22% male education Follow-up = 12 wk, 24 wk,
36 wk
30 min x 1–3/wk x 12 wk
Individual
Con = usual care by GP (education plus
medication)
Deyle et al RCT n = 69 Exp = physio/manual therapy: strength • WOMAC
(2000) Age = 61 yr (WB) / stationary bike, 5 min increasing Follow-up = 4 wk, 8 wk,
to tolerated time / ROM / stretch / manual 12 months
Gender = 43% male mobilisations / home exercises
30 min x 2/wk x 4 wk
Individual
Con = US
Exp = experimental; Con = control; WB = weight bearing; NWB= non-weight bearing; * = group therapy arm

Effect of intervention types Physical function: The effect size on physical function was
Pain: Figure 2 presents the results for pain. The effect 0.41 (95% CI 0.17 to 0.66) for strength training, 0.25 (95%
size on pain was 0.38 (95% CI 0.23 to 0.54) for strength CI 0.03 to 0.48) for exercise and 0.43 (95% CI 0.05 to 0.81)
training, 0.34 (95% CI 0.19 to 0.49) for exercise therapy, for exercise therapy with additional manual mobilisations
and 0.69 (95% CI 0.42 to 0.96) for exercise therapy plus (see Figure 3). With meta-regression, no significant
manual mobilisation. On the meta-regression, only the differences were found between the effect sizes of the
difference between exercise therapy and exercise therapy different interventions with respect to physical functioning.
with additional manual mobilisation was significant (p = Generally, the effect sizes for function tended to be smaller
0.03), although the difference between strength training and than those for pain (see Figure 4). Nevertheless, a positive
exercise therapy with additional manual mobilisation was significant correlation was found between the effects for
close to being significant (p = 0.06). pain and function, (r = 0.78, p = 0.003).

Study Intervention code Effect size (95% CI)

Schilke (1996) 1 1.06 (0.18 to 1.94)

Ettinger (1997) 1 0.36 (0.13 to 0.59)
Maurer (1999) 1 0.19 (–0.18 to 0.56)
Topp (2002) 1 0.48 (0.10 to 0.86)
Huang (2005) 1 0.44 (–0.03 to 0.91)
Peloquin (1999) 2 0.40 (0.07 to 0.73)
Fransen (2001a) 2 0.67 (0.25 to 1.09)
Thorstensson (2005) 2 0.11 (–0.38 to 0.60)
Hay (2006) 2 0.32 (0.05 to 0.59)
Hughes (2006) 2 0.22 (–0.10 to 0.54)
Baar (1998) 3 0.55 (0.20 to 0.90)
Deyle (2000) 3 0.93 (0.47 to 1.39)

Intervention code 1 0.38 (0.22 to 0.54)

Intervention code 2 0.34 (0.19 to 0.49)
Intervention code 3 0.69 (0.41 to 0.97)

–1 0 1 2
Effect size

Figure 2. Effect sizes (95% CI) of the three intervention codes on pain compared with control.

16 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011

 Jansen et al: Exercise and manual therapy for knee osteoarthritis

Study Intervention code Effect size (95% CI)

Schilke (1996) 1 0.91 (–0.25 to 2.07)

Ettinger (1997) 1 0.33 (0.01 to 0.65)
Maurer (1999) 1 0.05 (–0.46 to 0.56)
Topp (2002) 1 0.39 (–0.14 to 0.92)
Huang (2005) 1 0.87 (0.21 to 1.53)
Peloquin (1999) 2 0.38 (–0.08 to 0.84)
Fransen (2001a) 2 0.41 (–0.16 to 0.98)
Thorstensson (2005) 2 0.13 (–0.55 to 0.81)
Hay (2006) 2 0.28 (–0.10 to 0.66)
Hughes (2006) 2 0.05 (–0.39 to 0.49)
Baar (1998) 3 0.14 (–0.34 to 0.62)
Deyle (2000) 3 0.82 (0.20 to 1.44)

Intervention code 1 0.37 (0.15 to 0.59)

Intervention code 2 0.25 (0.04 to 0.46)
Intervention code 3 0.39 (0.01 to 0.77)

–1 0 1 2
Effect size

Figure 3. Effect sizes of the three intervention codes on physical function compared with control.
1.2
1.0
0.8
Effect size for function

0.6
0.4
0.2
0.0

0.0 0.2 0.4 0.6 0.8 1.0 1.2

Effect size for pain

Figure 4. Effect sizes for pain and function (points drawn proportional to the sample size of the studies).

Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011 17

Research

The test for residual heterogeneity was not significant for or booster sessions (Pisters et al 2007) may help patients
pain (QE(df = 9) = 9.93, p = 0.36), but it was for function keep up exercising and remain active. We agree with the
(QE(df = 9) = 18.22, p = 0.03). Moderator analyses showed recommendation that patients with osteoarthritis of the
that none of the potential covariates (control group, study knee should be encouraged to undertake and continue to
quality, treatment delivery mode, duration of treatment undertake regular aerobic, muscle strengthening, and range
period, treatment frequency, duration of treatment period of motion exercises (Zhang et al 2008).
× frequency, sex, age, measurement instrument, and type of
weight bearing exercise) had a significant influence on the The effect size of exercise with additional manual
size of the effects for pain or function. mobilisation on pain was significantly higher than that of
exercise therapy alone. Since our review provides only an
Discussion indirect comparison between the different treatment types,
it is not possible to conclude with certainty which treatment
All three intervention types were effective at relieving pain program is superior. We were unable to find any study that
and improving physical function. The effect size of exercise directly compared these intervention types. There has been
with additional manual mobilisation on pain (0.69) could be one trial that compared a home exercise program with
considered of moderate size, while the effect sizes of strength exercise plus additional manual mobilisation (Deyle et al
training (0.38) and exercise therapy alone (0.34) could be 2005) and concluded that manual therapy combined with
considered small. The effects on physical function tended supervised exercise offers greater symptomatic relief. For
to be smaller than those on pain, and would be considered osteoarthritis of the hip, it was found that manual therapy
moderate or small. Compared to the review by Fransen and (focusing on traction, or manipulation, and stretching)
McConnell (2008), our calculated effect sizes are somewhat resulted in greater improvement in terms of pain and
lower, both for strength training and for exercise therapy physical function than exercise (which focused on exercise
(strength training in combination with active range of strength and range of motion) (Hoeksma et al 2004).
motion and aerobic exercises). This may be related to the Two new trials are currently planning to investigate the
fact that we used a different classification procedure and effectiveness of physiotherapy programs that incorporate
did not incorporate home exercise programs. Nevertheless, exercise and manual therapy for the management of pain
confidence intervals in our study were relatively narrow, and disability in adults with osteoarthritis of the hip or knee
especially for pain, suggesting sufficiently reliable effect (Abbott et al 2009, French et al 2009).
sizes. For exercise with additional manual mobilisation only
Despite the limitations of the review, it suggests that
two studies were included, resulting in larger confidence
additional manual mobilisations may have significantly
intervals and less reliable effect sizes.
better effects compared to exercise alone in terms of pain
The treatments categorised to one of the three intervention relief. The manual mobilisation techniques used in two
types may differ in the regimen in which they were applied. studies (Deyle et al 2000, van Baar et al 1998) involved
None of the variables we examined, such as duration of muscle stretching exercises (Evjenth and Hamberg 1988)
treatment period and frequency, had a significant influence and passive physiologic and accessory joint movements
on the size of the effect. Also, whether the exercise is weight and soft tissue mobilisation (Maitland 1991, Mink et al
bearing was not an influencing factor, confirmed by equally 1983) to diminish pain and improve range of motion. From
significant improvements after weight bearing exercise a biomedical perspective, it seems reasonable that manual
and non-weight bearing exercise (Jan et al 2009). But the techniques could be useful especially for pain because the
results may be influenced by other factors, such as kind of oscillations (eg, in traction degrees I and II) are intended to
progression, therapy loyalty, or type of aerobic exercise. In induce pain inhibition. Furthermore, the purpose of manual
most of the studies stationary bike was part of the treatment mobilisation techniques is to restore damaged periarticular
and in one study aerobic fitness walking (in two studies the and intra-articular connective tissue. Deyle and colleagues
type of aerobic exercise was not specified). It is not known (2000) suggested that periarticular and muscular connective
if these aerobic exercises have different effects for pain tissue could be implicated as symptom sources in patients
or physical function. Another possible influencing factor with osteoarthritis of the knee. One (pilot) study analysed
is additional co-ordination and postural control exercise the effect of knee joint mobilisation on osteoarthritic
that was applied in two studies, one categorised to exercise hyperalgesia and found favourable effects on pain (Moss et
(Thorstensson et al 2005) and one to physio/manual therapy al 2006). In our opinion, additional manual mobilisation is
(van Baar et al 1998). One study investigated this topic and an effective adjunct to exercise in physiotherapy for patients
found significant better effects of strength training with with pain from osteoarthritis of the knee.
additional kinesthesia and balance exercises compared
to strength training alone for the functional capacities of The exercise protocols used in the studies included in the
patients, but not for pain (Diracoglu et al 2005). present review recommended manual mobilisations for
patients with a lot of pain and with restricted range of
The results of this review are limited to short-term effects. motion (Fransen et al 2001, van Baar et al 1998). In the
Only five of the studies we included also assessed long- study by Deyle and colleagues (2000), the treatment group
term effects (after 6 months or one year) (Deyle et al 2000, received manual physical therapy based on the results of the
Ettinger et al 1997, Huang et al 2005, Hughes et al 2006, examination. We hypothesise that larger effects of manual
van Baar et al 1998). Four of these studies found effects mobilisations can be expected specifically in subgroups of
fading to some extent in the long term, while one study patients with more pain, greater loss of mobility, or both.
(Huang et al 2005) found results persisting to the end of Neither of the two studies categorised as examining physio/
the one-year follow-up period. It is always a challenge manual therapy described how often additional passive
to maintain effects in the long term, but we do not know manual mobilisations were delivered. A cohort study that
which treatment method offers the most sustainable measured the process of care in physiotherapy treatment
results. Well-designed self-management programs and/ according to the Dutch guidelines on osteoarthritis of the

18 Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011

 Jansen et al: Exercise and manual therapy for knee osteoarthritis

hip and knee found that the proportion of passive manual Burgers JS, van Everdingen JJ (2004) [Evidence–based
mobilisations in physiotherapy treatment was 18% (Jansen guideline development in the Netherlands: the EBRO
et al 2010). platform]. Nederlands Tijdschrift voor Geneeskunde 148:
2057–2059.
Higher effects on pain tend to be paired with higher scores Deyle GD, Allison SC, Matekel RL, Ryder MG, Stang JM,
on physical function because the relationship between the Gohdes DD, et al (2005) Physical therapy treatment
effects for pain and physical function was fairly strong (r = effectiveness for osteoarthritis of the knee: a randomized
comparison of supervised clinical exercise and manual
0.78). Similarly, in a cross-sectional survey it was found that
therapy procedures versus a home exercise program.
in men and women with knee osteoarthritis pain intensity Physical Therapy 85: 1301–1317.
during the last eight days was significantly associated with
Deyle GD, Henderson NE, Matekel RL, Ryder MG, Garber MB,
WOMAC physical function (Perrot et al 2009). In a 3-year
Allison SC (2000) Effectiveness of manual physical therapy
cohort study, increased pain was found to be associated and exercise in osteoarthritis of the knee. A randomized,
with worsening of limitations in activities in patients with controlled trial. Annals of Internal Medicine 132: 173–181.
osteoarthritis of the hip or knee (van Dijk et al 2006). Diracoglu D, Aydin R, Baskent A, Celik A (2005) Effects of
So, for many patients with osteoarthritis of the knee it is kinesthesia and balance exercises in knee osteoarthritis.
suggested that pain relief is accompanied by improvements Journal of Clinical Rheumatology 11: 303–310.
in functioning. Ettinger WH, Jr., Burns R, Messier SP, Applegate W, Rejeski
WJ, Morgan T, et al (1997) A randomized trial comparing
In conclusion, exercise therapy plus manual mobilisation aerobic exercise and resistance exercise with a health
showed a moderate effect size on pain (0.69) compared to education program in older adults with knee osteoarthritis.
the small effect sizes for strength training (0.38) or exercise The Fitness Arthritis and Seniors Trial (FAST). Journal of the
therapy alone (0.34). Supervised exercise treatment in American Association 277: 25–31.
physiotherapy and manual therapy should in our opinion Evjenth O, Hamberg J (1988) Muscle stretching in Manual
include at least an active exercise program involving Therapy. Alfta Rehabilitation, Sweden.
strength training, aerobic activity exercises, and active Fransen M, Crosbie J, Edmonds J (2001) Physical therapy
range of motion exercises. To achieve better pain relief in is effective for patients with osteoarthritis of the knee: a
patients with knee osteoarthritis, physiotherapists or manual randomized controlled clinical trial. Journal of Rheumatology
therapists might consider adding manual mobilisation 28: 156–164.
to optimise supervised active exercise programs. More Fransen M, McConnell S (2008) Exercise for osteoarthritis
evidence is needed to examine the short- and long-term of the knee. Cochrane Database of Systematic Reviews:
effects of adding passive manual mobilisation specifically CD004376.
in subgroups of patients with more pain, greater loss of French HP, Cusack T, Brennan A, White B, Gilsenan C,
mobility, or both. n Fitzpatrick M, et al (2009) Exercise and manual physiotherapy
arthritis research trial (EMPART): a multicentre randomised
eAddenda: Available at JoP.physiotherapy.asn.au controlled trial. BMC Musculoskeletal Disorders 10: 9.
Appendix 1 Hay EM, Foster NE, Thomas E, Peat G, Phelan M, Yates HE,
et al (2006) Effectiveness of community physiotherapy and
Competing interests: None declared. enhanced pharmacy review for knee pain in people aged
over 55 presenting to primary care: pragmatic randomised
Correspondence: Dr Mariëtte Jansen, Department of trial. BMJ 333: 995.
Epidemiology, Maastricht University, The Netherlands.
Hoeksma HL, Dekker J, Ronday HK, Heering A, van der Lubbe
Email: mj.jansen@maastrichtuniversity.nl N, Vel C, et al (2004) Comparison of manual therapy and
exercise therapy in osteoarthritis of the hip: a randomized
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