Original article
Exercise and Manual Physiotherapy Arthritis Research Trial (EMPART) for Osteoarthritis of the Hip: A Multicenter Randomized Controlled Trial

https://doi.org/10.1016/j.apmr.2012.09.030Get rights and content

Abstract

Objectives

To determine the effectiveness of exercise therapy (ET) compared with ET with adjunctive manual therapy (MT) for people with hip osteoarthritis (OA); and to identify if immediate commencement of treatment (ET or ET+MT) was more beneficial than a 9-week waiting period for either intervention.

Design

Assessor-blind randomized controlled trial with a 9-week and 18-week follow-up.

Setting

Four academic teaching hospitals in Dublin, Ireland.

Participants

Patients (N=131) with hip OA recruited from general practitioners, rheumatologists, orthopedic surgeons, and other hospital consultants were randomized to 1 of 3 groups: ET (n=45), ET+MT (n=43), and waitlist controls (n=43).

Interventions

Participants in both the ET and ET+MT groups received up to 8 treatments over 8 weeks. Control group participants were rerandomized into either ET or ET+MT groups after 9 week follow-up. Their data were pooled with original treatment group data: ET (n=66) and ET+MT (n=65).

Main Outcome Measures

The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical function (PF) subscale. Secondary outcomes included physical performance, pain severity, hip range of motion (ROM), anxiety/depression, quality of life, medication usage, patient-perceived change, and patient satisfaction.

Results

There was no significant difference in WOMAC PF between the ET (n=66) and ET+MT (n=65) groups at 9 weeks (mean difference, .09; 95% confidence interval [CI] −2.93 to 3.11) or 18 weeks (mean difference, .42; 95% CI, −4.41 to 5.25), or between other outcomes, except patient satisfaction with outcomes, which was higher in the ET+MT group (P=.02). Improvements in WOMAC, hip ROM, and patient-perceived change occurred in both treatment groups compared with the control group.

Conclusions

Self-reported function, hip ROM, and patient-perceived improvement occurred after an 8-week program of ET for patients with OA of the hip. MT as an adjunct to exercise provided no further benefit, except for higher patient satisfaction with outcome.

Section snippets

Design

The Exercise and Manual Physiotherapy Arthritis Research Trial (EMPART) multicenter RCT was conducted in 4 academic teaching hospitals in an urban area in Ireland.

The study was approved by each of the hospital's research committees. An initial 3 group parallel arm trial (allocation ratio 1:1:1) was used, with a modified cross-over design, whereby control group participants were crossed over to 1 of 2 intervention arms after a 9-week period, thereby ensuring sufficient power to test the primary

Participants

One hundred and thirty-one patients were recruited across the 4 sites between May 2008 and February 2010. In the initial 3 group allocation, 43 patients were randomized each to the ET+MT and control groups, and 45 were randomized to the ET group. Figure 1 shows participant flow through the trial. Eight patients (6.1%) withdrew from the trial at 9 weeks: 4 declined continuation, 1 had hip surgery, 1 developed cardiac symptoms, 1 could not be contacted by the researcher, and 1 withdrew for family

Primary research aim

This assessor-blinded multicenter RCT assessed the effectiveness of the addition of MT to an 8-week ET program for the treatment of hip OA. There was no significant difference between the ET and ET+MT groups in the majority of outcomes at 9 or 18 weeks, except patient satisfaction with outcome. Because of the number of outcomes assessed in this study, this significant finding of satisfaction may have occurred by chance. Patients reported higher satisfaction with outcome for the ET+MT group, as

Conclusions

This RCT demonstrated that an 8-week program of ET, with and without adjunctive MT, for people with hip OA, showed similar improvements in self-report function, ROM, and PGA at 9 weeks, which were maintained at 18 weeks. However, the clinical meaningfulness of these changes is questionable. Patient satisfaction was higher for those who received adjunctive MT. These findings highlight the benefit of physiotherapy-based exercise for those with hip OA, but no additive benefit from the use of

Supplier

  • a.

    Statacorp, 4905 Lakeway Dr, College Station, TX 77845.

Acknowledgments

We thank the treating physiotherapists in this trial: Claire Gilsenan, MSc, Aisling Brennan, MSc, Vanessa Cuddy, BSc, Breon White, MSc, Martina Fitzpatrick, MSc, Aoife Caffrey, MSc, Jennifer Eadie, MSc, Fiona Lenehan, MSc, Rachel Egginton, BSc, Fiachra McLeid, MPhySt, Donal Scanlon, MManTher, Yvette Harte, BSc, Maire-Brid Casey, MManTher, Maura O'Rahilly, BSc, Ruth McCollum, BSc, Mary Cassells, MPhysio, Grainne Quinn, BSc, Fiona Cahill, BSc, Sarah O'Driscoll, MSc, Sheila McDermott, MManTher,

References (51)

  • L. Fernandes et al.

    Efficacy of patient education and supervised exercise vs patient education alone in patients with hip osteoarthritis: a single blind randomized clinical trial

    Osteoarthritis Cartilage

    (2010)
  • E. Parent et al.

    Comparative responsiveness of locomotor tests and questionnaires used to follow early recovery after total knee arthroplasty

    Arch Phys Med Rehabil

    (2002)
  • I. Boutron et al.

    Blinding was judged more difficult to achieve and maintain in nonpharmacologic than pharmacologic trials

    J Clin Epidemiol

    (2004)
  • K.L. Dominick et al.

    Health-related quality of life and health service use among older adults with osteoarthritis

    Arthritis Rheum

    (2004)
  • N. Bellamy et al.

    Recommendations for a core set of outcome measures for future phase III clinical trials in knee, hip, and hand osteoarthritis. Consensus development at OMERACT III

    J Rheumatol

    (1997)
  • M. Fransen et al.

    Exercise for osteoarthritis of the hip

    Cochrane Database Syst Rev

    (2009)
  • G. Hernández-Molina et al.

    Effect of therapeutic exercise for hip osteoarthritis pain: results of a meta-analysis

    Arthritis Care Res

    (2008)
  • M.E. van Baar et al.

    The effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a randomized clinical trial

    J Rheumatol

    (1998)
  • C. Veenhof et al.

    Effectiveness of behavioral graded activity in patients with osteoarthritis of the hip and/or knee: a randomized clinical trial

    Arthritis Rheum

    (2006)
  • A. Foley et al.

    Does hydrotherapy improve strength and physical function in patients with osteoarthritis–a randomised controlled trial comparing a gym based and a hydrotherapy based strengthening programme

    Ann Rheum Dis

    (2003)
  • E. Tak et al.

    The effects of an exercise program for older adults with osteoarthritis of the hip

    J Rheumatol

    (2005)
  • M.E. van Baar et al.

    Effectiveness of exercise in patients with osteoarthritis of hip or knee: nine months' follow up

    Ann Rheum Dis

    (2001)
  • S.L. Hughes et al.

    Long-term impact of Fit and Strong! on older adults with osteoarthritis

    Gerontologist

    (2006)
  • M. Hopman-Rock et al.

    The effects of a health educational and exercise program for older adults with osteoarthritis for the hip or knee

    J Rheumatol

    (2000)
  • G.D. Deyle et al.

    Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial

    Ann Intern Med

    (2000)
  • Cited by (83)

    • Exercise before and after orthopedic surgery

      2022, Exercise to Prevent and Manage Chronic Disease Across the Lifespan
    View all citing articles on Scopus

    Supported by a Fellowship for the Therapy Professions from the Health Research Board, Ireland (grant no. CTPF-06-12).

    No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

    Clinical Trials Registration No.: NCT007096566

    View full text