Downloaded from http://bjsm.bmj.com/ on September 17, 2016 - Published by group.bmj.

com

Review

Effects of exercise and manual therapy on pain

associated with hip osteoarthritis: a systematic
review and meta-analysis
Lucy Beumer,1 Jennie Wong,1 Stuart J Warden,2 Joanne L Kemp,3 Paul Foster,1
Kay M Crossley1,4
Additional material is
published online only. To view
please visit the journal online
(http://dx.doi.org/10.1136/
bjsports-2015-095255).
1

School of Health and

Rehabilitation Sciences,
The University of Queensland,
Brisbane, Queensland,
Australia
2
School of Health and
Rehabilitation Sciences,
Indiana University,
Indianapolis, Indiana, USA
3
Australian Centre for Research
into Injury and Sport and its
Prevention (ACRISP),
Federation University Australia,
Ballarat, Victoria, Australia
4
School of Allied Health,
College of Science, Health and
Engineering, La Trobe
University, Bundoora, Victoria,
Australia
Correspondence to
Professor Kay M Crossley,
BAppSc (Physio), PhD, School
of Allied Health, College of
Science, Health and
Engineering, La Trobe
University, Bundoora
VIC 3086, Australia;
k.crossley@latrobe.edu.au
Accepted 1 November 2015
Published Online First
26 November 2015

ABSTRACT
Aim To explore the effects of exercise (water-based or
land-based) and/or manual therapies on pain in adults
with clinically and/or radiographically diagnosed hip
osteoarthritis (OA).
Methods A systematic review and meta-analysis was
performed, with patient reported pain assessed using a
visual analogue scale (VAS) or the Western Ontario and
McMaster Universities Arthritis Index (WOMAC) pain
subscale. Data were grouped by follow-up time
(03 months=short term; 412 months=medium term
and; >12 months=long term), and standardised mean
differences (SMD) with 95% CIs were used to establish
intervention effect sizes. Study quality was assessed
using modied PEDro scores.
Results 19 trials were included. Four studies showed
short-term benets favouring water-based exercise over
minimal control using the WOMAC pain subscale (SMD
0.53, 95% CI 0.96 to 0.10). Six studies supported
a short-term benet of land-based exercise compared to
minimal control on VAS assessed pain (SMD 0.49,
95% CI 0.70 to 0.29). There were no medium (SMD
0.23, 95% CI 0.48 to 0.03) or long (SMD 0.22,
95% CI 0.51 to 0.06) term benets of exercise
therapy, or benet of combining exercise therapy with
manual therapy (SMD 0.38, 95% CI 0.88 to 0.13)
when compared to minimal control.
Conclusions Best available evidence indicates that
exercise therapy (whether land-based or water-based) is
more effective than minimal control in managing pain
associated with hip OA in the short term. Larger highquality RCTs are needed to establish the effectiveness
of exercise and manual therapies in the medium and
long term.

INTRODUCTION

To cite: Beumer L, Wong J,

Warden SJ, et al. Br J Sports
Med 2016;50:458463.

Hip osteoarthritis (OA) is characterised by structural and functional failure of the femoroacetabular
joint. Radiologically, hip OA is evident by joint
space narrowing, bony sclerosis, osteophyte formation and deformity of the femoral head and acetabulum.1 Clinically, hip OA results in pain, globally
reduced hip range of motion, altered gait,
decreased lower limb proprioception and balance
and weakness of the surrounding musculature.2
These physical impairments contribute to reduced
productivity through increased rates of absenteeism, poor physical function and fatigue secondary
to sleep disturbance.3
International guidelines recommend that nonpharmacological treatments be included as a rstline strategy for the initial management of hip OA.4

In particular, exercise and manual therapies are frequently introduced to manage the pain associated
with hip OA.5 6 Previous systematic reviews have
synthesised available evidence to explore the efcacy of manual7 8 and exercise8 9 therapies in reducing pain in populations with hip OA. However,
these reviews were hampered by a limited number
of hip OA specic randomised clinical trials (RCTs)
available for analysis at the time. Since a number of
RCTs investigating the effects of manual and exercise therapies for hip OA have been recently published, it is timely to conduct an updated
high-quality systematic review. The aim of this systematic review was to examine the short-term,
medium-term and long-term efcacy of land-based
and water-based exercise therapies and manual
therapies in the reduction of pain in patients with
hip OA.

METHOD
Identication and selection of studies
The systematic review protocol was developed and
executed according to the guidelines supplied by
the PRISMA (Preferred Reporting Items for
Systematic Reviews and Meta-analyses) statement.10
The
following
databases
were
searched:
MEDLINE, EMBASE, CINAHL, PEDro, SCOPUS
and the full Cochrane Library. Search terms
included those related to the hip, arthritis, rehabilitation and randomised controlled trial. The full
details of the search strategy used for MEDLINE,
and adapted for all other databases, are included in
online supplement 1. Publications from the earliest
record until July 2014 were considered for inclusion. The database searches were conducted independently by two investigators (LB and KMC),
who also retrieved article abstracts. A grey literature
search was also conducted of: Google Search
Engine; Clinical Trial registers in the USA, UK,
Australia and the Netherlands; and online-rst journals. Reference lists of published systematic reviews
were searched to conrm the retrieval of appropriate studies.
Title and abstracts were screened for eligibility by
at least two investigators (from JW, PF, SJW and
KMC), with full texts obtained if necessary. Any
discrepancies were resolved during a consensus
meeting with a third reviewer. The criteria for
inclusion of studies are presented in box 1. Studies
may have compared exercise therapy and/or
manual therapy with a control intervention, or
compared between manual therapy and exercise
therapy, or compared different types of manual

Beumer L, et al. Br J Sports Med 2016;50:458463. doi:10.1136/bjsports-2015-095255

1 of 7

Downloaded from http://bjsm.bmj.com/ on September 17, 2016 - Published by group.bmj.com

Review
Box 1 Inclusion criteria
Design
Randomised trial
Published in English
Participants
Adults with clinically and/or radiographically diagnosed hip OA
Intervention
Exercise (water-based or land-based) and/or manual therapies
Outcome measures
Patient-reported pain scores on a visual analogue scale (VAS),
numerical rating scale (NRS) or the Western Ontario and
McMaster Universities Arthritis Index (WOMAC) pain subscale

therapies or exercise therapies. Studies were excluded if they

only investigated postarthroplasty care or presented combined
hip and knee OA data where data for the hip OA group could
not be extracted or obtained. Studies were also excluded if they:
(1) presented results that duplicated those reported previously;
(2) did not report pain on one of the outcome measures presented in box 1, or; (3) had a high risk of bias (see next
section).

Assessment of characteristics of studies

A modied PEDro rating scale with 15 criteria was used to rate
the methodological quality of included studies (see online supplement 2). The modied scale has previously been used with
high inter-rater reliability in systematic reviews.11 12 Two investigators (from JW, JLK and PF) independently evaluated included
studies on the 15 criteria, with any discrepancies resolved by a
third independent reviewer (KMC). Once consensus was
reached, a nal rating out of 14 was calculated by summing the
criteria with a positive score. The maximum score was 14 as criterion 1 (specication of eligibility criteria) was not counted as
it inuences trial external validity, but not internal or statistical
validity.
The six PEDro rating criteria that satisfy the requirements of
the PRISMA statement13 were used to determine the risk of
bias. These criteria were: (1) adequacy of randomisation (criterion 4); (2) allocation concealment (criterion 5); (3)
between-group baseline comparability (criterion 6); (4) blinding
of outcome assessors (criterion 9); (5) adequate follow-up
(>85%) (criterion 11) and; (6) intention-to-treat analysis (criterion 12). The criterion related to lack of participant or therapist
blinding were not considered to be a high source of bias due to
the difculties inherent in blinding for physical interventions
such as exercise therapy and manual therapy. Studies scoring
positively on 5 of the 6 criteria were classied as having a low
risk of bias, while those scoring 34 were classied as having a
moderate risk. Studies scoring 2 were considered to have a
high risk of bias and were excluded from the review.

13 weeks=short term, 412 months=medium term and >12

months=long term), with some studies providing data at multiple follow-up times. Data at the latest time point was used for
studies reporting multiple follow-up times within an individual
time point window.
Review Manager (RevMan) 5.314 was used to compute standardised mean differences (SMD), and their 95% CIs, to indicate intervention effect sizes on pain. The SMD was calculated
using follow-up scores and SDs if baseline data was comparable.
Email was used to contact authors for additional data, or means
and SDs were obtained from published meta-analyses, when not
provided in the original publication. Effect sizes were considered to be being nearly perfect (SMD <4), very large (4 to
2), large (2 to 1.2), moderate (1.2 to 0.6), small (0.6
to 0.2) and trivial (0.2 to 0),15 with negative values favouring
the intervention of interest. Signicance was set at p<0.05.
Study data were pooled using a random effects model when
interventions and comparative groups were deemed similar and
used the same patient-reported outcome measure (VAS or
WOMAC) and follow-up time (short, medium or long term).
Heterogeneity was conrmed by calculating 2 (>0.05) and I2
(<50%) scores. To determine if studies investigating exercise
therapy prior to total hip arthroplasty affected the pooled
results, a sensitivity analysis was performed excluding presurgical studies.

RESULTS
Flow of studies through the review
The search identied 7016 papers of which 68 were retrieved in
full-text (gure 1). Forty-ve full-text papers were excluded
based on the exclusion criteria, with six of these excluded
because data from individuals with hip OA could not be separated from those with knee OA (see online supplement 3 for the
excluded papers). Twenty-three papers were rated on the PEDro
scale for risk of bias, with four excluded due to a high risk of
bias (see online supplement 4 for ratings for PEDro scores for
the papers with high risk of bias). No papers were excluded for
not reporting pain on the VAS, NRS or WOMAC pain subscale.
Inter-rater agreement on overall modied PEDro score was very

Data analysis
Inter-rater reliability of modied PEDro ratings for both overall
agreement and each criterion was evaluated by calculating
percent of initial agreement and kappa () coefcients. Patient
reported pain scores were converted to a 100-point scale.
Convention for the WOMAC is to assign 0 points to the worst
score and 100 points to a perfect score. The scale was reversed
in this review to provide directional consistency with VAS and
NRS data. Data were grouped by follow-up time (3 months or
2 of 7

Figure 1

Flow of studies through the review.

Beumer L, et al. Br J Sports Med 2016;50:458463. doi:10.1136/bjsports-2015-095255

Downloaded from http://bjsm.bmj.com/ on September 17, 2016 - Published by group.bmj.com

Review
high (=0.90; 95% agreement) and inter-rater reliability for
individual items ranged from very high agreement (=0.74) for
criterion 9 to perfect agreement (=1.00) for criteria 1 and
4. Consensus was reached on all criteria after initial discussion.

Characteristics of included studies

The overall modied PEDro score and characteristics of the 19
included studies are shown in online supplements 5 and
6. Thirteen studies compared exercise therapy +/ education to
a minimal control,13 1627 four compared different types of
exercise therapy,16 18 28 29 three compared manual therapy and
exercise therapy to exercise therapy alone,20 22 30 four
compared manual and exercise therapy to a minimal
control,20 22 30 31 two compared manual therapy to exercise
therapy,20 32 and one compared different types of manual
therapy.33 The mean age of participants in included studies
ranged from 52 to 77 years, mean body mass index ranged from
21.7 to 33.8 kg/m2, and hip OA mean symptom duration
ranged from 24 months to 102 months.

Effect of exercise therapy on pain in patients with hip OA

There was mixed evidence from the different time points
regarding the role of exercise therapy compared to minimal
control in the management of hip OA pain (see online supplement 5). At the short-term time point (3 months or 13 weeks),
Hinman et al17 reported no signicant benet for water-based
exercise compared to control when using the VAS to assess pain
(SMD 0.13, 95% CI 1.18 to 0.93). In contrast, pooled data
from four studies1619 involving 92 participants showed signicant benets favouring water-based exercise over minimal
control when pain outcomes were assessed using the WOMAC

pain subscale (SMD 0.53, 95% CI 0.96 to 0.10; I2=0%,

2=0.38; p=0.94; gure 2A). No studies examined the
medium-term or long-term benets of water-based exercise.
Pooling data from six studies2123 2527 involving 379 participants demonstrated a benet of land-based exercise compared to
minimal control in the short-term (3 months or 13 weeks)
when pain outcomes were assessed using the VAS (SMD 0.49,
95% CI 0.70 to 0.29; I2=0%, 2=2.99; p=0.70; gure 2B).
The additional study using the VAS that could not be pooled did
not support an exercise therapy benet.24 Since two studies in
the pooled analysis included participants who were on waiting
lists for total hip arthroplasty,21 27 a sensitivity analysis was conducted to determine their impact. The pooled data from the four
remaining studies22 23 25 26 supported a similar positive benet
of land-based exercise (SMD 0.47, 95% CI 0.69 to 0.25;
I2=0%, 2=2.37; p=0.50). Four studies16 18 21 24 involving 179
participants showed no benet of land-based exercise compared
to minimal control in the short term when pain outcomes were
assessed using the WOMAC pain subscale (SMD 0.40, 95% CI
1.06 to 0.25; I2=65%, 2=8.52; p=0.04; gure 2C).
At the medium-term time point (412 months), pooled data
from three studies13 20 22 involving 237 participants revealed no
signicant benet for exercise therapy compared with control
when pain outcomes were assessed using the WOMAC pain
subscale (SMD 0.23, 95% CI 0.48 to 0.03; I2=0%,
2=0.85; p=0.65; gure 3A). Similarly, pooled data from two
studies13 24 involving 191 participants and long-term follow-ups
(>12 months) reported no benets of exercise when pain outcomes were assessed using the WOMAC pain subscale (SMD
0.22, 95% CI 0.51 to 0.06; I2=0%, 2=0.21; p=0.65;
gure 3B).

Figure 2 Forest plots of the short-term (<3 months or 13 weeks) effects of exercise therapy on pain associated with hip OA. (A) Effect of
water-based exercise compared to minimal control when pain outcomes were assessed using the WOMAC pain subscale. (B) Effect of land-based
exercise compared to minimal control when pain outcomes were assessed using the VAS. (C) Effect of land-based exercise compared to minimal
control when pain outcomes were assessed using the WOMAC pain subscale. Data are presented as standardised mean difference, with differences
<0 favouring exercise therapy. OA, osteoarthritis; VAS, visual analogue scale; WOMAC, Western Ontario and McMaster Universities Arthritis Index.
Beumer L, et al. Br J Sports Med 2016;50:458463. doi:10.1136/bjsports-2015-095255

3 of 7

Downloaded from http://bjsm.bmj.com/ on September 17, 2016 - Published by group.bmj.com

Review

Figure 3 Forest plots of the: (A) medium-term (412 months) and (B) long-term (>12 months) effects of land-based exercise therapy compared to
minimal control on pain associated with hip OA when pain outcomes were assessed using the WOMAC pain subscale. Data are presented as
standardised mean difference, with differences <0 favouring exercise therapy. OA, WOMAC, Western Ontario and McMaster Universities Arthritis Index.
Four studies16 18 28 29 compared different types of exercise
therapies (see online supplement 5). Pisters et al29 compared a
12-week behavioural graded activity approach focusing on individually tailored exercises aimed at a patients functional complaints to usual exercise therapy. They reported small and
moderate effect sizes at 3 and 9 months in favour of behavioural
graded activity when pain outcomes were assessed using the
WOMAC pain subscale, respectively; however, benets were not
maintained at the long-term (5 year) follow-up. Fukumoto
et al28 compared high and low velocity home-based resistance
training nding no signicant group difference in VAS-assessed
pain after 8-weeks. Similarly, Foley et al16 and Fransen et al18
found no differences between water-based and land-based exercises when pain outcomes were assessed in the short term using
the WOMAC pain subscale.

Effect of manual therapy with or without exercise on pain

in patients with hip OA
Individual studies provided some evidence regarding the role of
manual therapy in the management of hip OA pain (see online
supplement 6). However, pooled evidence from three
studies22 30 31 (248 participants) found no signicant effect of
combined manual and exercise therapy over minimal control in
the short term (3 months or 13 weeks) when pain outcomes
were assessed using the VAS (SMD 0.38, 95% CI 0.88 to
0.13; I2=74%, 2=7.76; p=0.02; gure 4A). Similarly, pooled
evidence from two studies30 31 reported no medium-term (4
12 months) benet of combined manual and exercise therapy
over minimal control when pain outcomes were assessed using
the VAS (SMD 0.07, 95% CI 0.50 to 0.36; I2=42%,
2=1.74; p=0.19; gure 4B).
Comparing manual therapy against exercise therapy revealed
no benets. Pooled data from two studies (158 participants)
found no short-term effect of combined manual and exercise
therapy compared to exercise therapy alone when pain outcomes were assessed using the VAS (SMD 0.48, 95% CI:
1.55 to 0.59; I2=91%, 2=10.74; p=0.001; gure 4C).22 30
Likewise, individual data from two studies20 32 comparing
manual therapy with exercise therapy reported no group differences. Only one study compared two types of manual therapy
techniques, reporting no additional short-term benet of chiropractic lower limb full kinetic chain (including lumbar spine and
lower limb) manipulation compared with targeted hip
manipulation.33
4 of 7

DISCUSSION
Our systematic review identied 19 RCTs evaluating the efcacy
of exercise and manual therapies on pain associated with hip
OA. Meta-analyses indicate that both land-based and
water-based exercise programmes were superior to a control
intervention in the short term; however, no benets of landbased exercise therapy were seen at a medium-term or longterm follow-up. There were no benets of manual therapy when
either combined with exercise or introduced in isolation.

Exercise therapy
Current clinical guidelines recommend exercise therapy in the
management of hip OA.4 Exercise therapy, including group
exercise, aquatic exercise and home exercise programmes, is
commonly utilised by physiotherapists.5 6 For land-based exercise, our results are consistent with the recent Cochrane review
of land-based exercise for hip OA by Fransen et al.9 Our nding
of a similar effect for water-based exercise therapy suggest that
exercise therapy may benet people with hip OA in the shortterm irrespective of delivery mode. The majority of exercise
therapy interventions in our review included some form of education. Education is an essential component of physiotherapy
management, and aims to promote a greater understanding of
OA and promote self-management strategies for this degenerative disease. In the current review, the isolated effects of education were not evaluated and education may have contributed to
some of the observed benets of exercise.
Our pooled results for water-based exercise therapy revealed
a small effect size for decreasing pain in patients with hip OA in
the short term compared to minimal intervention control.
Water-based exercise therapy enables buoyancy forces to reduce
weight bearing in the lower limbs, thus unloading arthritic
joints to provide pain relief. The warmth of the water may also
provide pain relief by improving circulation and reducing
muscle spasm. The best effects were observed by Rooks et al,19
where exercise programmes were performed three times a week.
Treatment frequency may be an important factor when considering exercise for pain relief.
Pooled data for land-based exercise therapy revealed a small
signicant effect for decreasing pain in the short-term. Two of
the pooled studies targeted preoperative improvements in
pain,21 27 while four investigated a non-surgical
group.22 23 25 26 The effect of exercise therapy on pain reduction was not limited by the inclusion of the preoperative studies,
Beumer L, et al. Br J Sports Med 2016;50:458463. doi:10.1136/bjsports-2015-095255

Downloaded from http://bjsm.bmj.com/ on September 17, 2016 - Published by group.bmj.com

Review

Figure 4 Forest plots of the: (A) short-term (3 months or 13 weeks) and (B) medium-term (412 months) effects of combined manual and
exercise therapy over minimal control, and (C) short-term (3 months or 13 weeks) of combined manual and exercise therapy over exercise therapy
alone when pain outcomes were assessed using the VAS. Data are presented as standardised mean difference, with differences <0 favouring
exercise therapy. VAS, visual analogue scale.

where less improvement may be expected, since removal of

these studies did not appreciably change the pooled results. The
exercise therapy elements of all studies were similar; incorporating hip stretches, strengthening exercises and balance tasks. The
additional study that could not be pooled, did not support exercise therapy, which may reect their use of group therapy rather
than individualised treatment.24 In contrast, the RCTs with the
best individual results were French et al22 and van Baar et al.25
French22 included a 30 min individually supervised session once
a week for 8 weeks and a home programme, where patients
were encouraged to do 30 min of aerobic exercise 5 days a
week. These recommendations are in line with the Australian
and WHO recommendations for exercise in older adults.3436
van Baar et al25 showed a moderate effect using an individualised exercise programme including muscle strengthening and
stretching exercises, ADL modication and a home programme
performed one-to-three times a week.
The medium-term and long-term exercise therapy effects
were less encouraging. Pooled data from three studies suggest a
non-signicant tendency ( p=0.08) towards positive exercise
therapy effects on pain in the medium-term, while long-term
exercise therapy effects were not observed in two pooled studies
( p=0.13). Adherence to exercise programmes in the mediumterm and long-term usually decreases37 and this factor would
inuence the effectiveness of exercise beyond the short term.
Additionally, OA is a progressive, degenerative disease that may
naturally worsen over time regardless of intervention. While the
best available evidence appears to favour exercise therapy for
short-term pain relief, more RCTs are needed to conrm the
effect size. Furthermore, the tendency towards a positive
medium-term exercise effect could be conrmed with more
studies incorporating a longer follow-up. It is also possible that
exercise therapies with longer duration, top-up sessions or with
adherence strategies may facilitate better effects.
Four studies compared different types of exercise therapies.
The study by Pisters et al,29 suggests that a behavioural graded
activity approach in an initial 12-week programme plus a series
Beumer L, et al. Br J Sports Med 2016;50:458463. doi:10.1136/bjsports-2015-095255

of booster sessions, is effective with small and moderate effect

sizes at 3-month and 9-month follow-ups, respectively. The
focus on education and behaviour modication, with reminder
sessions may have assisted long-term change and adherence to
the exercise programme; however, the isolated effect of behavioural graded activity versus booster sessions was not explored
and warrants further study. In contrast, Fukumoto et al,28 compared high velocity with low velocity training as part of a hip
strengthening home exercise programme and found no signicant difference in pain outcomes after 8 weeks. This suggests
strengthening exercises are more important than speed of performance. The studies by Foley et al16 and Fransen et al18
found no differences between water-based and land-based exercises; however, a lack of statistical power due small sample sizes
(6 subjects per comparative group) may have contributed to
the absence of statistical ndings. Ultimately, more studies are
required to conrm any superior effects of one type of exercise
therapy, or whether individual participant characteristics may
predict better outcomes with different types of exercise therapy.
In summary, the best available evidence indicates that alternate forms of exercise therapy delivery, water-based or landbased, appear to result in positive, but small effects. More RCTs
are needed to conrm these short-term effects. There is a clear
need to evaluate longer term exercise therapy treatments, and
those that include individualised exercise therapy and increasing
physical activity.

Manual therapy
Physiotherapy is recommended for management of hip OA4 and
manual therapy is a common component of contemporary
physiotherapy.5 6 Our current review located ve studies investigating manual therapy for hip OA and failed to identify a positive benet of manual therapy (with or without exercise) when
compared to either exercise therapy alone or a minimal control.
Our pooled data indicate that manual therapy when combined with exercise is not an effective intervention for pain
from hip OA in the short term. However, there was
5 of 7

Downloaded from http://bjsm.bmj.com/ on September 17, 2016 - Published by group.bmj.com

Review
considerable statistical (I2=74%) and methodological heterogeneity. Hence, more studies are required to have condence in the
pooled results. Manual therapy was not superior to exercise
therapy in two studies.20 32 Similarly, combined manual and
exercise therapy was not superior to exercise therapy alone
from three studies.20 22 32 The only study to compare different
manual therapy techniques found no additional benet of applying chiropractic techniques to the lumbar spine and lower limb
compared to treating the hip alone.33
The best available evidence for short-term effects on hip OA
pain does not support manual therapy. However, more RCTs
are needed to conrm these effects and there is a need to evaluate treatments that extend beyond 3 months.

Strengths and limitations

This study has a number of strengths. Our review investigated a
large number of studies (n=19) from an extensive literature
search and excluded studies with high risk of bias. We evaluated
land-based and water-based exercise therapy separately, as well
as manual therapy (although many of the studies did introduce
multiple interventions in combination). Importantly, 10 out of
the 19 included studies investigated interventions that were
designed specically for people with hip OA, and not a combined hip/knee OA treatment approach. This increases the
clarity regarding the specicity of treatment for hip OA;
however, there remains a need for additional studies of interventions targeted solely towards hip OA.
Despite the strengths of our study, there are some limitations
that should be acknowledged. We did not explore exercise or
manual therapy effects on function and only included RCTs in

What are the ndings?

English language, which may have excluded potentially eligible

studies with relevant ndings. Also, it is recognised that we
cannot account for publication bias where non-signicant results
were not published. The heterogeneity between study populations and interventions may also limit our results. Future studies
must be high-quality RCTs fullling the criteria for low risk of
bias. Also, the studies should include greater participant
numbers. A number of studies in this review had <15 subjects
per group, making it difcult to establish treatment effects.

CONCLUSION
In conclusion, this systematic review identied a number of
RCTs that evaluated the efcacy of exercise and manual therapies on pain associated with hip OA. From the available data,
there is evidence that exercise therapy (whether land-based or
water-based) is more effective than minimal intervention control
in the short term. No signicant benets of land-based exercise
were observed at medium-term or long-term follow-up time
points. Similarly, there were no signicant benets for manual
therapy at any time point. Ultimately, larger, high-quality RCTs
are needed to better elicit the effectiveness of exercise and
manual therapies for hip OA.
Twitter Follow Joanne Kemp at @JoanneLKemp
Acknowledgements Dr Andrew Claus is thanked for his contribution in
identifying potentially eligible studies from retrieved titles and abstracts.
Contributors LB and KMC performed database searches. JW, PF, SJW and KMC
screened articles for eligibility. JW, JLK, PF rated article characteristics. SJW and KMC
carried out the statistical analyses and drafted the manuscript. All authors were
involved in the analysis and interpretation of the data. All authors were involved in
study conception and design. All authors provided critical revision of the manuscript,
and read and approved the nal manuscript. SJW and KMC are the guarantors, and
had full access to all of the data and take responsibility for its integrity and
accuracy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.

Pooled data demonstrated short term (03 months) benets

of water-based or land-based exercise over minimal control
when assessed using the Western Ontario and McMaster
Universities Arthritis Index pain subscale and visual
analogue scale assessed pain, respectively.
There were no benets of exercise therapy when assessed at
either a medium-term (412 months) or long-term
(>12 months) follow-ups.
There were no benets of manual therapy when either
combined with exercise or introduced in isolation.

REFERENCES
1
2
3
4

5
6

How might it impact on clinical practice in the future?

Our search indicated a general lack of well-designed clinical
trials exploring the benets of exercise and/or manual
therapies specically targeting individuals with hip
osteoarthritis (OA).
Despite the limited number of trials, clinicians can prescribe
water-based and land-based exercises to individuals with hip
OA with the expectation that short-term benets should be
obtained.
With the execution and publication of further clinical trials,
clinicians will be provided with a rmer evidence base as to
the short and long-term benets of exercise and/or manual
therapies in individuals with hip OA.
6 of 7

7
8

9
10

11

12

13

Altman RD, Gold GE. Atlas of individual radiographic features in osteoarthritis,

revised. Osteoarthritis Cartilage 2007;15(Suppl A):A156.
Abhishek A, Doherty M. Diagnosis and clinical presentation of osteoarthritis. Rheum
Dis Clin North Am 2013;39:4566.
Hunter DJ, Schoeld D, Callander E. The individual and socioeconomic impact of
osteoarthritis. Nat Rev Rheumatol 2014;10:43741.
Nelson AE, Allen KD, Golightly YM, et al. A systematic review of recommendations
and guidelines for the management of osteoarthritis: the chronic osteoarthritis
management initiative of the U.S. bone and joint initiative. Semin Arthritis Rheum
2014;43:70112.
Cowan S, Blackburn M, McMahon K, et al. Current Australian physiotherapy
management of hip osteoarthritis. Physiotherapy 2010;96:28995.
French H. Physiotherapy management of osteoarthritis of the hip: a survey of
current practice in acute hospitals and private practice in the Republic of Ireland.
Physiotherapy 2007;93:25360.
French HP, Brennan A, White B, et al. Manual therapy for osteoarthritis of the hip
or kneea systematic review. Man Ther 2011;16:10917.
Romeo A, Parazza S, Boschi M, et al. Manual therapy and therapeutic exercise in
the treatment of osteoarthritis of the hip: a systematic review. Reumatismo
2013;65:6374.
Fransen M, McConnell S, Molina-Hernandez G, et al. Exercise for osteoarthritis of
the hip. Cochrane Database Syst Rev 2014;4:CD007912.
Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting
systematic reviews and meta-analyses of studies that evaluate healthcare
interventions: explanation and elaboration. BMJ 2009;339:b2700.
Bisset L, Paungmali A, Vicenzino B, et al. A systematic review and meta-analysis of
clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med
2005;39:41122.
Collins NJ, Bissett LM, Crossley KM, et al. Efcacy of nonsurgical interventions for
anterior knee pain systematic review and meta-analysis of randomized trials. Sports
Med 2012;42:3149.
Fernandes L, Storheim K, Sandvik L, et al. Efcacy of patient education and
supervised exercise versus patient education alone in patients with hip

Beumer L, et al. Br J Sports Med 2016;50:458463. doi:10.1136/bjsports-2015-095255

Downloaded from http://bjsm.bmj.com/ on September 17, 2016 - Published by group.bmj.com

Review

14
15
16

17

18

19

20

21

22

23

24

25

osteoarthritis: a single blind randomized clinical trial. Osteoarthritis Cartilage

2010;18:123743.
Review Manager (RevMan) [ program]. Version 5.3 for Windows version.
Copenhagen: The Nordic Cochrane Centre: The Cochrane Collaboration, 2014.
Hopkins W. Linear models and effect magnitudes for research, clinical and practical
applications. Sportscience 2010;14:4958.
Foley A, Halbert J, Hewitt T, 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;62:11627.
Hinman RS, Heywood SE, Day AR. Aquatic physical therapy for hip and knee
osteoarthritis: results of a single-blind randomized controlled trial. Phys Ther
2007;87:3243.
Fransen M, Nairn L, Winstanley J, et al. Physical activity for osteoarthritis
management: a randomized controlled clinical trial evaluating hydrotherapy or Tai
Chi classes. Arthritis Care Res 2007;57:40714.
Rooks DS, Huang J, Bierbaum BE, et al. Effect of preoperative exercise on measures
of functional status in men and women undergoing total hip and knee arthroplasty.
Arthritis Care Res 2006;55:7008.
Abbott JH, Robertson MC, Chapple C, et al. Manual therapy, exercise therapy, or
both, in addition to usual care, for osteoarthritis of the hip or knee: a randomized
controlled trial. 1: clinical effectiveness. Osteoarthritis Cartilage 2013;21:52534.
Ferrara PE, Rabini A, Maggi L, et al. Effect of pre-operative physiotherapy in
patients with end-stage osteoarthritis undergoing hip arthroplasty. Clin Rehabil
2008;22:97786.
French HP, Cusack T, Brennan MA, et al. Exercise and Manual Therapy Arthritis
Research Trial (EMPART) for osteoarthritis of the hip: a multicentre randomised
controlled trial. Arch Phys Med Rehabil 2013;94:30214.
Hopman-Rock M, Westhoff MH. The effects of a health educational and exercise
program for older adults with osteoarthritis for the hip or knee. J Rheumatol
2000;27:194754.
Juhakoski R, Tenhonen S, Malmivaara A, et al. A pragmatic randomized controlled
study of the effectiveness and cost consequences of exercise therapy in hip
osteoarthritis. Clin Rehabil 2011;25:37083.
van Baar ME, Dekker J, Oostendorp RA, et al. The effectiveness of exercise therapy
in patients with osteoarthritis of the hip or knee: a randomized clinical trial.
J Rheumatol 1998;25:24329.

Beumer L, et al. Br J Sports Med 2016;50:458463. doi:10.1136/bjsports-2015-095255

26
27

28

29

30

31

32

33

34

35

36
37

Tak E, Staats P, Van Hespen A, et al. The effects of an exercise program for older
adults with osteoarthritis of the hip. J Rheumatol 2005;32:110613.
Hoogeboom TJ, Dronkers JJ, van den Ende CH, et al. Preoperative therapeutic
exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
Clin Rehabil 2010;24:90110.
Fukumoto Y, Tateuchi H, Ikezoe T, et al. Effects of high-velocity resistance training
on muscle function, muscle properties, and physical performance in individuals with
hip osteoarthritis: a randomized controlled trial. Clin Rehabil 2014;28:4858.
Pisters MF, Veenhof C, Schellevis FG, et al. Long-term effectiveness of exercise
therapy in patients with osteoarthritis of the hip or knee: a randomized controlled
trial comparing two different physical therapy interventions. Osteoarthritis Cartilage
2010;18:101926.
Poulsen E, Hartvigsen J, Christensen HW, et al. Patient education with or without
manual therapy compared to a control group in patients with osteoarthritis of the
hip. A proof-of-principle three-arm parallel group randomized clinical trial.
Osteoarthritis Cartilage 2013;21:1494503.
Bennell KL, Egerton T, Martin J, et al. Effect of physical therapy on pain and
function in patients with hip osteoarthritis: a randomized clinical trial. JAMA
2014;311:198797.
Hoeksma HL, Dekker J, Ronday HK, et al. Comparison of manual therapy and
exercise therapy in osteoarthritis of the hip: a randomized clinical trial. Arthritis Care
Res 2004;51:7229.
Brantingham JW, Parkin-Smith G, Cassa TK, et al. Full kinetic chain manual and
manipulative therapy plus exercise compared with targeted manual and
manipulative therapy plus exercise for symptomatic osteoarthritis of the hip: a
randomized controlled trial. Arch Phys Med Rehabil 2012;93:25967.
Brown W, Moorheard G, Marshall A. Choose health: be active. A physical activity
guide for older Australians. Canberra, Australia: Commonwealth of Australia and
the Repatriation Commission, 2005:127.
Nelson ME, Rejeski WJ, Balir SN, et al. Physical activity and public health in older
adults: recommendation from the American College of Sports Medicine and the
American Heart Association. Med Sci Sports Exerc 2007;39:143545.
World Health Organisation. Global recommendations on physical activity for health.
Switzerland: World Health Organization, 2010:160.
Petursdottir U, Arnadottir SA, Halldorsdottir S. Facilitators and barriers to exercising
among people with osteoarthritis: a phenomenolgical study. Phys Ther
2010;90:101425.

7 of 7

Downloaded from http://bjsm.bmj.com/ on September 17, 2016 - Published by group.bmj.com

Effects of exercise and manual therapy on

pain associated with hip osteoarthritis: a
systematic review and meta-analysis
Lucy Beumer, Jennie Wong, Stuart J Warden, Joanne L Kemp, Paul
Foster and Kay M Crossley
Br J Sports Med 2016 50: 458-463 originally published online November
26, 2015

doi: 10.1136/bjsports-2015-095255
Updated information and services can be found at:
http://bjsm.bmj.com/content/50/8/458

These include:

Supplementary Supplementary material can be found at:

Material http://bjsm.bmj.com/content/suppl/2015/11/26/bjsports-2015-095255.
DC1.html

References
Email alerting
service

Topic
Collections

This article cites 34 articles, 10 of which you can access for free at:
http://bjsm.bmj.com/content/50/8/458#BIBL
Receive free email alerts when new articles cite this article. Sign up in the
box at the top right corner of the online article.

Articles on similar topics can be found in the following collections

BJSM Reviews with MCQs (173)
Physiotherapy (234)
Degenerative joint disease (236)
Musculoskeletal syndromes (427)
Osteoarthritis (115)

Notes

To request permissions go to:

http://group.bmj.com/group/rights-licensing/permissions
To order reprints go to:
http://journals.bmj.com/cgi/reprintform
To subscribe to BMJ go to:
http://group.bmj.com/subscribe/