Original article: Effectiveness between supervised clinical exercise with Maitland manual therapy and Home exercise program in treating osteoarthritis of knee: Comparative study 1Dr.Mrs. Swati Sandeep Kadu, 2 Dr Subhash Khatri, 3 Dr Tejas Suryavanshi, 4 Dr Abhijit Diwate 1Assistant Professor,PDVVPF S College Of Physiotherapy, Ahmednagar, Maharashtra, India 2Principal, College Of Physiotherapy, Pravara Institute Of Medical Sciences,Loni, Maharashtra,India 3Assistant Professor, PDVVPF S College Of Physiotherapy, Ahmednagar, Maharashtra,India 4Associate Professor,PDVVPF S College Of Physiotherapy, Ahmednagar, Maharashtra,India Corresponding author: Dr. Swati S. Kadu Abstract: Introduction: The present study was planned to determine effectiveness between supervised Clinical Exercise with Maitland mobilization and an home exercise program in treating osteoarthritis of knee in Indian set up. Materials & Methods: Subjects in clinic treatment group received supervised exercise, individualized manual therapy, and a home exercise program over a 4-week period. Subjects in home exercise group received same home exercise program initially, reinforce.the measured outcomes were distance walked in 6 minutes and Western Ontario McMaster Universities Osteoarthritis Index (WOMAC). Results & Conclusion: Both groups showed clinically and statistically significant improvements in the 6-minute walk distances and WOMAC scores at 4 weeks By 4 weeks, WOMAC scores had improved by 52% in clinic treatment group and by 26% in home exercise group. Average 6-minute walk distances had improved about 10% in both groups. Subjects in clinic treatment group were less likely to be taking medications for their arthritis and were more satisfied with treatment compared with subjects in home exercise group. key words: Osteoarthritis, Maitland Manual therapy Introduction: Supervised Clinical Exercise and Maitland Manual Therapy achieved greater improvements than Home Exercise in functional outcome, range of motion and mini squats repetition in management of osteoarthritis. However there are quite conflict which therapy will be better at home based long term follow-up and rehabilitation of patients of osteoarthritis. 1 The present study was planned to determine effectiveness between supervised Clinical Exercise with Maitland mobilization and an home exercise program in treating osteoarthritis of knee in Indian set up. Methodology: The present interventional study was conducted at Physiotherapy Department, MGM Hospital, Aurangabad, Maharashtra, India. Subjects in clinic treatment group received supervised exercise, individualized manual therapy, and a home exercise program over a 4-week period. Subjects in home exercise group received same home exercise program initially, reinforce.the measured outcomes were distance walked in 6 minutes and Western Ontario 105
McMaster Universities Osteoarthritis Index (WOMAC). 2 Procedure: Informed written consent was obtained after screening for inclusion and exclusion criteria. Subjects in both groups provided descriptive data for age, sex, height, weight, duration of symptoms, presence of symptoms in one or both knees, previous surgery, medication.all enrollment, data collection, and clinic treatment sessions were conducted in physiotherapy department at MGM Hospital, CIDCO, Aurnagabad, Maharashtra The primary outcome measure in this study was the WOMAC. A secondary outcome measure was a timed 6 minute walk test. The WOMAC consists of 24 questions, each corresponding to a visual analog scale, designed to measure patients' perceptions of pain, stiffness, and dysfunction. High WOMAC scores reflect high self-perceptions across he 3 domains measured by scale. WOMAC, which was specifically designed to evaluate patients with OA of hip or knee, has been shown to be a highly responsive, multidimensional outcome measure that yields moderately reliable and valid scores. Time 6- minute walk test measures distance a person walks in 6 minutes and has been demonstrated to yield reliable measurements of functional exercise capacity. it is frequently used in OA-related trials. 2 Following pretreatment measurements, subjects received a standardized clinical examination lumbar Simple functional tests (eg, squatting, step-ups) that limited or reproduced symptoms were used to obtain daily baseline measurements to help assess effect of manual intervention. For eg, if the examination revealed that a subject was limited in ability to perform a full squat or if subject experienced pain with that activity, squatting would be reassessed after manual techniques intended to improve knee flexion. If symptoms associated with squatting were subsequently decreased or range of squatting motion improved, that technique was considered to have a positive effect and would be continued at subsequent sessionssubjects interventional group received daily treatment for six weeks except on holidays. This included HF TENS for 20 minutes, hot pack for 20 minutes and Manual therapy and supervised exercises for 20 minutes. The manual therapy techniques, consisting of passive physiological and accessory movements, muscle stretching, and soft tissue mobilization, were applied by the investigator primarily to knee and surrounding structures as per Maitland s mobilization described in Mobilization of peripheral joints text book. In addition to receiving manual therapy treatments, subjects in interventional group performed a standardized and supervised knee exercise program at each treatment session. This program consisted of active ROM exercises, muscle strengthening, muscle stretching, and riding a stationary bicycle. The number of strengthening exercise bouts and stationary bicycle riding time were increased or decreased by the investigator based on subject response. The exercise program was based on best available evidence for most efficient methods of producing desired effects of increasing strength, flexibility, and ROM at initiation of this study. Subjects were examined for adverse signs and symptoms such as increased pain, joint effusion, and increased skin temperature over knee joints at each clinic visit. 106
Home exercise group received detailed verbal and hands-on instruction in a home-based program of same exercises as clinical treatment group. Similar to subjects who received clinical treatment, subjects in home exercise group were instructed that pain should be avoided in all exercises except in t case that pain or stiffness decreased with each repetition. Each subject received a detailed supporting handout containing instructions and photographs of the exercises. Subjects in home exercise group were allowed to ride a stationary bicycle if they stated that riding a bicycle was currently part of their exercise routine or if they could not walk for safety reasonsa follow-up examination was performed for t home exercise group 2 weeks after the initial visit. Investigator checked for adverse signs and symptoms such as increased pain, joint effusion, and increased skin temperature over knee joints. Exercise log was reviewed, subjects were again supervised performing home-based program, and observed performance deficiencies were corrected. Exercises were progressed only if the symptoms and signs of osteoarthritis were stable or decreasing. After 6 weeks, subjects from both groups returned to the clinic for another blinded assessment of WOMAC scores and 6-minute walk test measurements. Subjects in both groups were instructed to refrain from their home exercises and their daily walk on the day of the second assessment. Assessments were performed at the same time of day as the pretest to help control for daily cycles in pain and stiffness. Data thus obtained was used for statistical analysis DATA ANAYSIS Mean and SD data were calculated for all tested variables. Paired t test was used to test different between the pre and post treatment scores in the same group and unpaired t test was used to test the difference between the post treatment scores between two groups. Variables calculated were Womac score, mini squats repetition, AROM, PROM of flexion and extension right and left. After analyzing the data, the results can be interpreted as follows : Using a unpaired t text in the data, there was highly significant difference between mean average changes from 0 week to 8 week in group I for the total Womac score i.e. Using a unpaired t text in the data, there was highly significant differences between mean average changes from 0 week to 8 week in group I & II for the mini squats repetition per minute i.e. Using a unpaired t test in the data (n = 30, df = 58), there was highly significant difference between mean average changes at 0, 4 th, 6 th & 8 th week in group I & II and significant difference at 2 nd week in flexion AROM of right side. Using a unpaired t test in the data (n = 30 df = 58), there was highly significant difference between mean average changes at 0, 4 th,6 th,& 8 th week in group I & II and significant difference at 2 nd week in extension AROM of right side. Indian Journal of Basic & Applied Medical Research Is Now with IC Value 5.09 107
Table 1 : Comparison of the mean s at 0 week & 8 week interval in WOMAC scores of Group 1 and Group II. Time interval Group I Group II t p Result 0 wk 55.6 ± 0.55 53.96 ± 0.55 12.55 2 wk 53.38 ± 0.55 51.25 ± 0.5 12.27 4 wk 51.04 ± 0.53 48.82 ± 0.52 13.71 6 wk 48.06 ± 0.55 47.90 ± 0.57 8.32 8 wk 44.90 ± 0.57 46.20 ± 0.53 7.51 Table no. 2 : Comparison of the mean s at 0 week & 8 week intervals in Mini Squats repetition per minute of Group I and Group II. Time interval Group I Group II t p Result 0 wk 21.1 ± 0.55 21.83 ± 0.53 3.15 2 wk 23.6 ± 0.52 23.56 ± 0.41 3.44 4 wk 26.16 ± 0.48 25.4 ± 0.48 4.08 6 wk 28.7 ± 0.47 27.26 ± 0.55 4.5 8 wk 31.86 ± 0.51 29.1 ± 0.54 5.22 S. 108
Table no. 3 : Comparison of the mean s at 0 week & 8 week intervals in Flexion AROM Right side of Group I and Group II. Time Group I Group II T p Result interval 0 wk 31.8 to 127.36 32.12 to 126.86 (± 2.67 (± 0.56, 0.30) 0.34, 0.69) 3.52 2 wk 29.7 to 127.6 30.76 to 126.4 2.08 ( ± 0.45, 0.30) ( ± 0.31, 0.21) 1.99 4 wk 27.2 to 128 29.43 to 129.40 4.71 ( ± 0.42, 0.26) ( ± 0.29, 0.19) 3.34 6 wk 26.2 to 128 28.93 to 130.46 8.1 ( ± 0.40, 0.22) ( ± 0.31, 0.19) 3.87 8 wk 23.5 to 130 26.6 to 130.4 8.93 ( ± 0.45, 0.22) ( ± 0.26, 0.19) 4.18 Indian Journal of Basic & Applied Medical Research Is now officially listed in CABI, UK 109
Table no.4 : Comparison of the mean s at 0 week & 8 week intervals in Extension AROM Right side of Group I & Group II Time interval Group I Group II T p Result 0 wk 126.36 to 31.8 126.86 to 32.13 3.61 (± 0.29, 0.54) (± 0.68, 0.32) 2.72 2 wk 127.6 to 29.7 127.4 to 30.76 2.06 p < 0.05 ( ± 0.30, 0.45) ( ± 0.20, 0.30) 2.01 p < 0.05 4 wk 127 to 25.2 128.4 to 30.43 3.32 ( ± 0.26, 0.40) ( ± 0.19, 0.29) 4.5 6 wk 128.1 to 22.5 130.4 to 28.9 3.81 ( ± 0.21, 0.40) ( ± 0.19, 0.31) 6.96 8 wk 132 to 19 131.4 to 27.6 4.34 ( ± 0.23, 0.37) ( ± 0.19, 0.27) 7.22 DISCUSSION The present study was undertaken to determine effectiveness of Maitland Manual Therapy with Supervised Clinical Exercise and Home Exercise alone on functional outcome measures with osteoarthritis of knee. Data collected highly significant improvements on WOMAC score in patients with primary osteoarthritis of knee. Thus it can be concluded that Maitland Manual Therapy with Supervised Clinical Exercise as well as Home Exercise are beneficial in functional activities in primary osteoarthritis of patients. 3,4 According to Deyel et al Physical Therapy treatment effectiveness for osteoarthritis of knee. 5 Supervised Clinical Exercise and Maitland Manual Therapy achieved greater improvements than Home Exercise in functional outcome, range of motion and mini squats repetition.group I patients were treated with Maitland Manual Therapy combined with Supervised Clinical Exercise. The results of the present study indicate that there was highly significant () decrease in pain, stiffness and physical function. 110
There was highly significant () increase in Mini Squate repetition and improvement in range of motion.group II patients were treated with only Home Exercise the results of the present study indicate that there was highly significant (p <0.01) decrease in WOMAC. There was also increases in no of repetition of Mini Squats and range of motion.both treatments groups obtained successful outcomes as measured by significant reduction in WOMAC scores and improvements in range of motion, Mini Squats over 4 week period As cited by previous study by Deyle et al Womac scores exceeded the 20 to 25% levels suggested as minimally meaningful by Barr et al. The post treatment Womac scores in the group who received treatments in Group I were, markedly better than the Group II. Deyel et al. 5 The exercise was simple but it adequately addressed the lower limb physical findings, that are common in patients with osteoarthritis of knee. Yetterberg et all 1997 Stressed importance of targeting the clinical treatment and appropriately closing exercises to improve joint motion, muscular strength for the patients with osteoarthritis of knee.home exercise did show improvements in Mini Squats repetition (0wk 20.83 ± 0.53 to 8wk 28.1 ± 0.51 highly significant). Activities that maintain flexibility, muscle strength and co-ordination help to maintain joint function in the joints that have been affected with osteoarthritis. Thompson et al 1998. 6 Both the groups in current study improved their mini squats repetition presumably due to daily program. Group receiving Maitland Manual Therapy in their Womac Score as stated above at end of 8 wk. There was a significant improvement in stiffness and ADL Group also showed improvement in the range of motion both active, passive flexion extension of both the knees at 8 week (flexion rt/1t, extension rt/1t, active, passive 19 to 132 ± 0.37, 0.23; 19 to 132 ± 0.37, 0.23; 18.3 to 132 ± 0.30, 0.17; 18.3 to 132.1 ± 0.30, 0.17 respectively highly significant). Active range and passive range for flexion and extension has improved for both the sides due to application of grade III and IV. Home exercise group did show improvements in their ranges for both the sides. The only difference being that the terminal ranges of extension of the Home group is less than that the group received passive mobilization. Nicholsan et al 1985 also found that all ranges improved significantly when treated with passive joint mobilization. According to Carolyn Wadsworth et al passive exercises have multiple effects and benefits this study supports a passive exercise program along with therapeutic activities as a mean for the improvements of functional hand to back shoulder. 7 Conclusion This study has shown that Maitlands Mobilization with Supervised Clinical Exercise it is possible to improve functional capacity and increase range of motion with Osteoarthritis of knee.the results indicate that Maitland Mobilization with Supervised Clinical Exercise has better influence on the functional capacity of the patients. Especially Mini Squats Repetition and Range of Motion when compared with that of Home Exercise Program.The study also shows that Maitland Mobilization technique is safe, effective and well tolerated by patients with OA knee. 111
References: 1. Felson DT, Zhang Y, Hannan MT, et al. Risk factors for incident radiographic knee osteoarthritis in the elderly: the Framingham Study. Arthritis Rheum. 1997; 40:728 733. 2. Lachance L, Sowers MF, Jamadar D, Hochberg M. The natural history of emergent osteoarthritis of the knee in women. Osteoarthritis Cartilage. 2002; 10: 849 854. 3. Messier SP, Losser RF, Mitchell MN, et al. Exercise and weight loss in obese older adults with knee osteoarthritis : a preliminary study. J Am Geriatr Soc 2000; 48: 1062 1072. 4. Christensen R, Astrup A, Bliddal H. Weight loss : the treatment of choice for knee osteoarthritis? A randomized trial. Osteoarthritis Cartilage. 2005; 13:20-27. 5. Deal CL, Schnitzer TJ, Lipstein E, et al. Treatment of arthritis with topical capsaicin: a double-blind trial. Clin Ther. 1991; 13: 383-393. 6. Moseley JB, O Malley K, Peterson NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002; 347:81-88. 7. Kellgren J. Lawrence J. Radiological assessment of osteoarthrosis. Ann Rheum Dis 1957; 16:494-501. Date of submission: 23 Aug 2013 Date of Provisional acceptance: 29 September 2013 Date of Final acceptance: 20 October 2013 Date of Publication: 04 December 2013 Source of support: Nil; Conflict of Interest: Nil 112