A Comparison of Two Manual Physical Therapy Approaches and Electrotherapy Modalities for Patients with Knee Osteoarthritis: A Randomized Three Arm Clinical Trial
Ebru, K. M., Ercin, E., Ozdincler, A. R., Ones, N., (2018). Physiotherapy Theory and Practice, 34(8), 600-612.

Abstracted by: Kayla Enloe SPT, Missouri State University, Springfield, Missouri

The most common chronic, degenerative joint disorder is osteoarthritis (OA) and the treatment objectives include attempting to reduce disability and control pain. Positive findings from several studies have supported the effects of treatment using manual therapy techniques in conjunction with exercise in patients with knee OA. Mobilization with movement (MWM) and passive joint mobilization are both forms of manual therapy used during treatment of knee OA. Electrotherapy is also a common treatment option. There is little research to compare the forms of manual therapy or the use of manual therapy versus electrotherapy in the treatment outcomes of those with knee OA. Therefore, the aim of this study was to compare long-term treatment outcomes, including primary, or function-related measures, and secondary, or pain-related measures, range of motion, and muscle strength, in three different groups.

The three different treatment groups were MWM, PJM, and electrotherapy. Primary outcomes were measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Aggregated Locomotor Function (ALF) test. All measures were taken initially, at the end of intervention, and at a one year follow up. The study included 72 subjects over the age of 40 with bilateral knee OA of a severity of grade 2-3 according to the Kellgren and Lawrence scale and meeting all other inclusion criteria in a single-blind randomized clinical trial. The subjects were randomly divided into three groups (MWM, PJM, or electrotherapy) with all groups receiving the same standardized exercise program, including aerobic, active range of motion, strength, and stretching exercises, as well as the treatment variable three times a week for 50 minute sessions, totaling 12 sessions in all. Subjects were not to take analgesics or NSAIDs during the study.

The MWM group received three sets of ten repetitions of sustained manual glides of the tibia during active knee flexion and extension in the direction that provided the least pain-relief and most improved subject’s range of motion at evaluation. The rate of two-three oscillations per second for one-two minutes was used to provide the PJM group with knee distraction and dorsal glides, ventral glides, and patellar glides with gradually increasing grades of oscillation. TENS, with electrodes placed on either side of the joint, continuous mode, and biphasic waves for 20 minutes, and pulsed ultrasound, 1-MHz frequency and effective radiating area of 3.5-5 cm2 applied to the medial and lateral knee for five minutes, were used with the electrotherapy group.

Major findings include no significant difference found between groups with function, range of motion, and strength from pre- to post-treatment, however, the MWM and PJM groups had a greater increase in function, flexion and extension range of motion, and quadriceps strength at the one year follow up than the electrotherapy group. There were no differences between the MWM and PJM groups at the one year follow up in the aforementioned areas. A greater decrease in pain at rest, during activity, and at night from pre- to post-treatment and post-treatment to one year follow up was found in the MWM and PJM group compared to the electrotherapy group. There was no significant difference in mean changes of pain on the visual analog scale between the MWM and PJM groups. The findings of this study support that manual therapy techniques, either mobilization with movement or passive joint mobilization, with an exercise program are superior in benefits including pain level, functional level, range of motion, and strength of the quadriceps to electrotherapy with an exercise program in those with knee OA.

Personal Commentary: In my past clinical experience with a patient that has osteoarthritis of the knee, I have felt in a corner with my treatment options. The patient came in for therapy and stated that physical therapy was just what was happening until a total knee replacement could be done. I felt that the only option that I had was modalities with light glides and some strengthening exercises for the plan of care. Due to the nature of the clinical experience, I was only with the patient for one session and was not able to look up more specific options that would provide the most pain relief for the patient. Had I had this article and the knowledge that I now have, I would have felt much better about my treatment session and would have been more competent. This article, as well as other articles cited within the original article, support specific manual therapy techniques that provide greater pain relief than just exercise or just exercise and electrotherapy. McAlindon et. al. (2014) found that electrotherapy (EMG biofeedback) had no additive effect on pain in those with knee OA. Jansen et. al. (2011) found that manual mobilization with an exercise program had a moderate effect on pain relief compared to the smaller effect from just strength training or just an exercise program in those with knee OA.

These studies, along with the original article, support the use of manual therapy techniques in those with knee OA and I will be using this principle in my future therapy practice. A key point of the original article is the lack of difference in mobilization with movement and passive joint mobilization on pain relief. To me, this means that these manual therapy techniques are both tools to put in the toolbox when working with patients with knee OA and the tool that should be used is the one that most benefits the patient. With pain relief being one of the main treatment objectives we have as physical therapists, and the fact that reducing pain can increase the buy-in of the patient and aid in a more favorable treatment outcome, having this information at our disposal is very helpful.


  • Jansen M. J., Viechtbauer W., Lenssen A. F., Hendriks E., De Bie R. A., (2011). Strength training alone, exercise therapy alone, and exercise therapy with passive manual mobilization each reduce pain and disability in people with knee osteoarthritis: A systematic review. Journal of Physiotherapy, 57(1), 11-20. doi: 10.1016/s1836- 9553(11)70002-9.
  • McAlindon, T., Bannuru, R., Sullivan, M., Arden, N., Berenbaum, F., Bierma-Zeinstra, S., Hawker, G., Henrotin, Y., Hunter, D., Kawaguchi, H., Kwoh, K., Lohmander, S., Rannou, F., Roos, E., Underwood, M. (2014). OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis and Cartilage, 22(3), 363-388. doi: 10.1016/j.joca.2014.01.003.