Background: Knee osteoarthritis (KOA) is the most common form of arthritis, leading to pain
disability in seniors and increased health care utilization. Manual therapy is one widely used
physical treatment for KOA.
Objective: To evaluate the effectiveness and adverse events (AEs) of manual therapy compared
to other treatments for relieving pain, stiffness, and physical dysfunction in patients with KOA.
Study Design: A systematic review and meta-analysis of manual therapy for KOA.
Methods: We searched PubMed, EMBASE, the Cochrane Library, and Chinese databases for
relevant randomized controlled trials (RCTs) of manual therapy for patients with KOA from the
inception to October 2015 without language restrictions. RCTs compared manual therapy to
the placebo or other interventional control with an appropriate description of randomization.
Two reviewers independently conducted the search results identification, data extraction, and
methodological quality assessment. The methodological quality was assessed by PEDro scale.
Pooled data was expressed as standard mean difference (SMD), with 95% confident intervals (CIs)
in a random effects model. The meta-analysis of manual therapy for KOA on pain, stiffness, and
physical function were conducted.
Results: Fourteen studies involving 841 KOA participants compared to other treatments were
included. The methodological quality of most included RCTs was poor. The mean PEDro scale
score was 6.6. The meta-analyses results showed that manual therapy had statistically significant
effects on relieving pain (standardized mean difference, SMD = -0.61, 95% CI -0.95 to -0.28, P
= 76%), stiffness (SMD = -0.58, 95% CI -0.95 to -0.21, P = 81%), improving physical function
(SMD = -0.49, 95% CI -0.76 to -0.22, P = 65%), and total score (SMD = -0.56, 95% CI -0.78 to
-0.35, P = 50%). But in the subgroups, manual therapy did not show significant improvements on
stiffness and physical function when treatment duration was less than 4 weeks. And the long-term
information for manual therapy was insufficient.
Limitations: The limitations of this systematic review include the paucity of literature and
inevitable heterogeneity between included studies.
Conclusion: The preliminary evidence from our study suggests that manual therapy might be
effective and safe for improving pain, stiffness, and physical function in KOA patients and could
be treated as complementary and alternative options. However, the evidence may be limited by
potential bias and poor methodological quality of included studies. High-quality RCTs with longterm follow-up are warranted to confirm our findings.
Key words: Knee osteoarthritis, manual therapy, systematic review
Efficacy of low frequency pulsed subsensory threshold electrical stimulation vs placebo on pain and physical function in people with knee osteoarthritis: systematic review with meta-analysis
