Articular mobilizations for knee OA, to do or not to do – Narrative Review

Volume 1 | Issue 1 | March-June 2017 | Page 7-9 | Ajit S Dabholkar, Tejashree A Dabholkar

Authors : Ajit S Dabholkar [1], Tejashree A Dabholkar [1]

[1] School of Physiotherapy, DY Patil University, Nerul, Navi Mumbai-400706

Address of Correspondence
Dr. Ajit Dabholkar
School of Physiotherapy, DY Patil University, Nerul, Navi Mumbai-400706


Background: Osteoarthritis (OA) is a common progressive joint disease, involving not only the joint lining but also cartilage, ligaments, and bone. Knee osteoarthritis is a highly prevalent condition with a significant socioeconomic burden to society. It is known to affect sufferers through pain, loss of function and changes in health related quality of life. Management typically involves pharmacologic and/or exercise based therapy approaches to reduce pain. Previous studies have shown multimodal treatment approaches incorporating manual therapy to be efficacious.
Objectives: To appraise the literature by summarizing the findings of current evidence in manual therapy for knee osteoarthritis.
Methodology: Relevant full text articles focusing on joint mobilization of knee osteoarthritis were searched by using Boolean operator “and” using the terms ‘knee’, ‘osteoarthritis’ and ‘manual/ manipulative therapy and knee mobilization’ limited to humans. Databases like PubMed, Cochrane and Google scholar were reviewed for references. Articles included were current clinical practice guidelines, Systematic Reviews, Randomised controlled trials, Case Series and Literature review. In addition, the reviewers manually checked for any articles in peer reviewed journals.
Results: The studies revealed that Manual therapy in osteoarthritis knee have favourable response and can be administered as a sole treatment or as an adjunctive treatment for effective patient care.
Conclusions: The current evidence base is encouraging of the notion that manipulation/manual therapy is effective in treatment of knee osteoarthritis patients.
Key words: Osteoarthritis, knee pain, manual therapy, mobilization, manipulation.


Musculoskeletal conditions are the most common cause of chronic disability around the world. The importance of musculoskeletal conditions as a cause of mortality and morbidity has been recognized by the designation of 2000–10 as the Bone and Joint Decade by the United Nations [1], World Health Organization (WHO), and more than 60 countries around the world. WHO (2003,2004)[2,3] has highlighted the burden of musculoskeletal conditions. Estimates of the global burden of these conditions have increased 25% over the past decade (WHO 2000) [4]
Osteoarthritis is increasing among the world’s aging populations and is the sixth leading cause of years lost because of disability globally. It accounts for nearly 3% of the total global years lost to disability, and 10 % of men and 18% of women over the age of 60 have OA.
Osteoarthritis is the most common form of arthritis and one of the leading causes of pain and disability worldwide (NICE, 2008; Reginster, 2002) [5,6]. It is characterised by a progressive loss of articular cartilage, joint space narrowing, sclerosis of subchondral bone and osteophyte formation. Soft tissues such as the capsule can undergo soft tissue contracture and fibrosis [7]. These changes can result in pain, impaired mobility, reduced muscle strength, limitation in activities of daily living [8,9] and reduced quality of life [10] with the knee and hip joints most commonly affected
Restricted joint mobility, especially in terms of knee flexion, appears to be an important determinant of disability in patients with osteoarthritis [8, 11].
Manual therapy is a physical treatment used by physiotherapists, chiropractors, osteopaths and other practitioners to treat musculoskeletal pain and disability, and includes massage therapy, joint mobilisation and manipulation.
Recently published clinical guidelines on the management of OA recommended manual therapy as an adjunctive therapy to exercise for OA. (NICE, 2008 [5]; RACGP, 2009 [12]. A requirement also exists for simple and inexpensive treatment protocols to fill the void between medication, exercise and surgery. Thus, this narrative review gives a comprehensive review on current evidence in joint mobilization in OA knee

Searches and selection : Peer reviewed journal articles that predominantly focussed on joint mobilization in knee OA were included in this review. The articles were identified via a search of PubMed, Cochrane library and Google Scholar. All types of articles, including primary research and review reports were included. Reference lists from identified articles and additional citations of interest located manually were also searched. The articles selected should be available in full text and only Human studies were selected.
The comprehensive details of the related articles on articular mobilizations in osteoarthritis of knee are included in table 1 [13 -23]

Discussion and Conclusion

The small number of included studies indicates the limited research to date. All studies were heterogeneous regarding the types of manual therapy and comparison interventions used. Findings suggest that manual therapy may have a beneficial short-term effect in reducing pain and improving physical function for patients with knee OA compared with no intervention. A recent systematic review and meta-analysis revealed that the findings in the present meta-analytical review support the use of manual therapy versus a number of different comparators for improvement in self-reported knee function. Lesser support is present for pain reduction, and no endorsement of functional performance can be made at this time [23].
Although, a systematic review revealed that there is less convincing evidence from three studies included in this review on manual therapy on OA knee with a high risk of bias that manual therapy has favourable outcome. The knee OA studies had variable results: one study showed no group differences for pain and function; one showed larger effects for the manual therapy group for both pain and function and the third favoured manual therapy for function but no group differences for pain [24].
In view of clinical practice guidelines/ Literature????
A systematic review of recommendations and guidelines for the management of osteoarthritis highlighted that Exercise in combination of Manual therapy is effective in treatment of OA knees [25]. Also, the literature review suggests that manual therapy of the knee and full kinetic chain (SI or foot) can be combined with multimodal/exercise therapy [26].

Effect on Knee cartilage:
An interesting study of Du N et al highlighted manipulation is effective in treatment of knee osteoarthritis by decreasing the maximum defect diameter and increasing the volume of knee cartilage [27].

Role of Multimodal treatments:
Patients with knee osteoarthritis may improve their pain, stiffness and physical function with sustained physical exercise, manual therapy or both, according to new research findings. This study showed that benefits imparted by a comprehensive program of exercise therapy or manual therapy, provided by Physical Therapists; remain significant to at least two years follow-up [28]. Jansen et al [29] recommended 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 2011, Meta-analysis Knee OA; 12 studies, Meta-regression suggests manual therapy and exercise (ES=0.69) may have a larger effect in relieving pain than strengthening (ES=0.38) or exercise alone (ES=0.34) in the short-term; however, confidence intervals were wide and overlapped. American college of Rheumatology (2012) recommends Manual therapy in combination with exercise supervised by physiotherapist [30]. A regimen consisted of manual therapy together with resistive exercises appears to be more effective at improving muscle strength, proprioception and functional performance than resistive exercise alone [31].
Thus, we conclude that manual therapy can be effective in the management of patients with OA knee. The extent, to which these treatments are effective in managing symptoms and slowing disease progression, remains to be proven.
A limitation of the current review may be that only few databases were searched. Other databases could have been searched in order to broaden the review and not to overlook other guidelines and/or references for manual therapy in the treatment of knee osteoarthritis.
Lapane et al’s conclusion is quite appropriate for this review as a whole. The current evidence base is encouraging of the notion that manipulation/manual therapy is helpful in osteoarthritis patients. It is also encouraging to see new and more sophisticated studies being planned in the protocols cited above. Hopefully, this will lead to greater acceptance and utilization of this form of therapy in osteoarthritis patients.


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How to Cite this Article: Dabholkar AS & Dabholkar TA. Articular mobilizations for knee OA, to do or not to do – Narrative Review. J Evidence-Based Physio Research March -June 2017; 1(1): 7-9.

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