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Can Primary Care Physicians Treat Knee Osteoarthritis with Patellar Mobilization?

A combination of manual therapy and home-based exercise may be beneficial for patients with knee osteoarthritis.

With Regina Wing Shan Sit, MBBS, DCH, Elmer Pinzon, MD, MPH, and Jeff Chandler, MS, PT

More than any other disease, knee osteoarthritis is responsible for disabling people from carrying out their routine activities.1 Due to its high prevalence and the lack of a cure, the condition carries a substantial economic burden,and nonpharmacological interventions including exercise and manual therapy remain first-line treatments.3

Contributing to knee osteoarthritis is a muscular imbalance within the thigh, wherein the vastus medialis oblique (VMO) muscle along the thigh’s interior side is weaker than the vastus lateralis and iliotibial band found along the thigh’s exterior.4 “Usually we have a very strong lateral thigh muscle, and if we don’t have enough medial side muscle on the thigh—because both muscles attach to the patella—this can pull the patella to the lateral side,” Regina Wing Shan Sit, MBBS, clinical assistant professor at the JC School of Public Health and Primary Care in Hong Kong, China, told PPM.

The Potential of Patellar Mobilization Therapy

Dr. Sit led a team of researchers from the Chinese University of Hong Kong’s School of Public Health and Primary Care in a new study that looks at the potential of patellar mobilization therapy.5 “The initial objective was to develop a kind of maneuver that is cheap and that can be delivered by primary care physicians,” said Dr. Sit.

A combination of manual therapy and home-based exercise may be beneficial for patients with knee osteoarthritis. (Source: 123RF)

The Phase II randomized clinical trial assigned 208 patients with knee osteoarthritis to two groups: an intervention group that received patellar mobilization therapy (PMT) and a passive control group that went untreated. For patients, PMT involved two components: bimonthly visits with their physicians who mobilize their patellofemoral joints in a lateral-to-medial direction with a glide maneuver for five minutes per affected knee, and twice daily home-based exercises to strengthen their VMO muscles over the course of the 24-week study. To ensure proper execution of VMO exercises, the physicians also supervised their patients for another five minutes during each of the three visits while the patients completed the exercise.

Relying on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score as a primary measure of PMT’s efficacy, along with a host of secondary measures that included objective tests of physical function, results showed that PMT reduced pain and improved knee function.

Study Limitations

The study lacked an active control group, which would have allowed the effects of PMT to be compared to a different intervention, such as exercise alone. In addition, the sample was 80.3% female, a product of a greater willingness by Chinese women over men to participate in medical research. Moreover, the results may not be generalizable to populations in which people with knee osteoarthritis are also struggling with obesity, a condition that hinders patellar mobilization.

Elmer Pinzon, MD, MPH, medical director, owner, and president of University Spine and Sports Specialists in Knoxville, TN, and a member of PPM’s Editorial Advisory Board, advocates that future studies add a stationary or ambulatory squat to the list of objective measures. This way, he notes, “you’re not only testing the function of your quadriceps or the VMO, but also the functionality of the menisci.”

For Jeff Chandler, MS, PT, owner of Focus Physiotherapy in Knoxville, TN, only including the lateral-to-medial glide within the PMT intervention feels like a missed opportunity. “If you’re going to actually gain mobility,” he said, “an inferior glide to increase the bend of your knee is very important.”

Implementing PMT

“For feasibility, it’s an excellent treatment,” said Dr. Pinzon, adding that being able to learn how to perform PMT in just one hour—as the study notes—is incredible. However, training aside, the idea of squeezing 10 to 15 minutes of therapy and exercise supervision into an appointment may deter many doctors. “Most primary care physicians are not going to want to take the time to do manual therapy,” said Chandler.

In response to these concerns, Dr. Sit recommended that primary care physicians do what their time will allow. “If you’re too busy, just prescribe the exercise. But, if you have more time, why don’t you correct the alignment?” She emphasized that the manual therapy will improve proprioception of the knee.

In Hong Kong, Dr. Sit believes the intervention may be more readily implemented in private settings where doctors have more time, while publicly the best strategy may be to teach the technique to allied health workers instead. Either way, she believes a “train-the-trainer” approach should allow for diffuse implementation of PMT, enabling primary care physicians and other health workers to treat knee osteoarthritis patients directly. Even with time constraints, PMT may provide some benefits, and as Dr. Pinzon notes, “Some is better than none when it comes to treating people with osteoarthritis.”

Last updated on: January 16, 2019
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