0008-3194/2008/229242/$2.

00/JCCA 2008

The effect of a manual therapy knee protocol

on osteoarthritic knee pain:
a randomised controlled trial
Henry Pollard, BSc, Grad Dip Chiro, Grad Dip AppSc, MSportSc, PhD1*
Graham Ward, BSc, BE (Sc) MSc (hons) Mass, PhD2
Wayne Hoskins, B Chiro Sc1
Katie Hardy, BAppSci (Ex&SpSci)1

Background: Knee osteoarthritis is a highly prevalent

condition with a significant socioeconomic burden to
society. It is known to effect sufferers through pain, loss
of function and changes in health related quality of life.
Management typically involves pharmacologic and/or
exercise based therapy approaches to reduce pain.
Previous studies have shown multimodal treatment
approaches incorporating manual therapy to be
efficacious. The aim of this study is to determine if a
manual therapy technique knee protocol can alter the self
reported pain experienced by a group of chronic knee
osteoarthritis sufferers in a randomised controlled trial.
Methods: 43 participants with a chronic, nonprogressive history of osteoarthritic knee pain, aged
between 47 and 70 years were randomly allocated
following a screening procedure to an intervention group
(n=26; 18 men and 8 women, mean age 56.5 years) or a
control group (n=17; 11 men and 6 women, mean age
54.6 years). Participants were matched for present knee
pain intensity measured on a visual analogue scale.
The intervention consisted of the Macquarie Injury
Management Group Knee Protocol whilst the control
involved a non-forceful manual contact to the knee
followed by interferential therapy set at zero.
Participants received three treatments per week for two
consecutive weeks with a follow up immediately after the
final treatment. Post-treatment Participants completed
11 questions including present knee pain intensity and
feedback regarding their response to treatment utilizing

Antcdents : Arthrose du genou ou gonarthrose est

une condition trs prsente, ce qui constitue un poids
socio-conomique important pour la socit. On sait
quelle affecte les personnes qui en souffrent, en leur
infligeant des douleurs, des pertes de motricit et des
atteintes leur sant, en plus de sattaquer leur qualit
de vie. La gestion du cas fait dhabitude appel la
pharmacologie et/ou lexercice, fonde sur des
approches thrapeutiques pour attnuer la douleur. Des
tudes antrieures ont dmontr quune mthode de
traitement combine, y compris une thrapie manuelle,
savrait efficace. Lobjectif de la prsente tude consiste
vrifier, dans un essai clinique comparatif randomis,
si une technique de thrapie manuelle, applique au
protocole de traitement du genou, peut attnuer la
douleur dont fait tat un groupe de patients souffrant de
gonarthrose chronique.
Mthode : 43 participants, gs de 47 70 ans et
ayant un historique chronique mais non progressif de
gonarthrose, ont t choisis au hasard la suite dune
procdure de slection ; ils ont t rpartis entre un
groupe dintervention (n=26 ; 18 hommes et 8 femmes,
dont la moyenne dge est de 56,5 ans) et un groupe
tmoin (n=17 ; 11 hommes et 6 femmes, dont la moyenne
dge tait 54,6 ans). Les participants ont t regroups
en fonction de lintensit de la douleur mesure par
lchelle visuelle analogue.Lintervention a consist
appliquer le Macquarie Injury Management Group
Knee Protocol alors que le groupe de contrle

1 Macquarie Injury Management Group, Department of Health and Chiropractic, Macquarie University, NSW 2109, Australia.
2 Faculty of Health & Behavioural Sciences, Wollongong University, NSW 2522, Australia.
* Please address all correspondence to: Dr Henry Pollard, Macquarie Injury Management Group, c/o PO Box 448, Cronulla NSW, 2230 Australia.
Email addresses: HP: hpollard@optushome.com.au GW: graham_ward@uow.edu.au WH: waynehoskins@optusnet.com.au
KH: katie.hardy@optusnet.com.au
JCCA 2008.
J Can Chiropr Assoc 2008; 52(4)

229

The effect of a manual therapy knee protocol on osteoarthritic knee pain: a randomised controlled trial

a visual analogue scale. Results were analysed using

descriptive statistics.
Results: Prior to the intervention, there was no
significant differences in age or present knee pain
intensity. Following treatment, the intervention group
reported a significant decrease in the present pain
severity (mean 1.9) when compared to the control group
(mean 3.1). Response to treatment questions indicated
that compared to the control group, the intervention
group felt the intervention had helped them (intervention
mean 7.0; control mean 3.4), felt it decreased their knee
symptoms such as crepitus (intervention mean 6.0;
control mean 3.4) and improved their knee mobility
(intervention mean 6.4; control mean 3.4) and their
ability to perform general activities (intervention mean
6.5; control mean 3.8). Importantly the MIMG Knee
Protocol intervention group reported no adverse
reactions during treatment.
Conclusions: A short-term manual therapy knee
protocol significantly reduced pain suffered by
participants with osteoarthritic knee pain and resulted in
improvements in self-reported knee function immediately
after the end of the 2 week treatment period.
(JCCA 2008; 52(4):229242)

consistait en un contact manuel non nergique au genou,

suivi par une thrapie interfrentielle tablie zro. Les
participants ont reu trois traitements par semaine
pendant deux semaines conscutives, puis un suivi tout de
suite aprs la fin du traitement. Aprs le traitement, les
participants ont rempli un formulaire comptant 11
questions, dont une sur lintensit de la douleur quils
ressentaient au moment de fournir leurs rponses et leurs
commentaires sur leur raction au traitement faisant
appel lchelle visuelle analogue. Les rsultats ont t
analyss en utilisant la grille de statistiques descriptives.
Rsultats : Avant lintervention, il ny avait pas de
diffrence entre les ges et lintensit de la douleur aux
genoux. Aprs le traitement, le groupe dintervention a
rapport une rduction importante de lintensit de la
douleur (moyenne de 1,9) par comparaison au groupe
tmoin (moyenne de 3,1). Les rponses aux questions sur
le traitement indiquent que, par comparaison au groupe
de contrle, le groupe dintervention a senti que le
traitement avait fait du bien (moyenne du groupe
dintervention 7,0 ; groupe de contrle, 3.4),a peru une
rduction des symptmes aux genoux, la crpitation
articulaire, (moyenne du groupe dintervention 6,0;
moyenne du groupe de contrle 3,4) et a amlior la
motricit de leurs genoux (moyenne dintervention 6,4;
groupe de contrle 3,4) et leur capacit deffectuer des
activits gnrales (moyenne du groupe dintervention
6,5; groupe de contrle 3,8). Il est important de
souligner que le Groupe dintervention du protocole du
genou MIMG a rapport quaucune raction indsirable
ne stait manifeste aprs le traitement.
Conclusions : Un protocole de thrapie manuelle du
genou a permis de rduire de manire importante la
douleur pour les participants souffrant de gonarthrose et
sest traduit par lamlioration de la motricit des
genoux chez les participants, immdiatement la fin des
deux semaines de traitement.
(JACC 2008; 52(4):229242)

k e y wo r d s : chiropractic, musculoskeletal
manipulation, manual therapy, knee, pain, osteoarthritis,
clinical trial

m o t s c l s : chiropratique, manipulation musculosquelettique, thrapie manuelle, genou, douleur, arthrose,

essai clinique

230

J Can Chiropr Assoc 2008; 52(4)

H Pollard, G Ward, W Hoskins, K Hardy

Background
Osteoarthritis (OA) is one of the most prevalent articular
disorders affecting humankind and a major cause of disability and socioeconomic burden.1,2 The increasing impact
of such disorders on patients and healthcare systems has
seen the designation of the Decade of Bone and Joint from
2000 to 2010.3 OA is a chronic degenerative disorder of
multifactorial aetiology, including acute and/or chronic
insults from normal wear and tear, age, obesity, and joint
injury.4,5 The true pathogenesis remains poorly understood.1 OA is characterized by degradation of the articular
cartilage, resulting in an alteration of its biomechanical
properties.6 This contributes to a focal loss of articular
cartilage, loss of joint space, osteophyte formation, focal
areas of synovitis, periarticular bone remodelling and
subchondral cysts.7 Evidence of knee osteoarthritic
change on radiographs increases with age8 and has been
found in 72.1% of symptomatic participants and 41.6% of
asymptomatic participants aged 40 or older.9 However,
there is a low level of agreement between examiners in determining the degree of knee osteoarthritic change on
radiographs10 and considerable variability in determining
the progression of OA radiographically.11 Furthermore,
evidence of radiological OA is not an accurate predictor of
pain or disability.12,13 Radiological evaluation of knee osteoarthritis is of limited ability as a guide for management
in most cases and it falls to more subjective measures of
pain and disability to guide clinical practice.
At the knee joint, soft tissue changes can include decreases in the strength of the quadriceps and sagittal
range of motion, as well as increased soft tissue contracture.14 Collectively these changes produce the typical
clinical picture of joint pain; worsening symptoms with
activity and weight bearing, and stiffness developing at
rest. These facilitate the decline in physical function and
progression of disability.7 If advanced, OA may ultimately require total knee arthroplasty, a management option
that is under scrutiny to evaluate its cost-effectiveness,
particularly considering the revision rate15 and the substantial costs involved.16
The knee joint, along with other major weight bearing
joints including joints of the spine and hip, are commonly
subject to degenerative changes17. There is a higher prevalence of OA with advanced age18 and in females.18,19 In
fact, most knee pain in the elderly is due to OA.20 Knee osteoarthritis produces significant changes in health-related
J Can Chiropr Assoc 2008; 52(4)

quality of life, particularly physical, mental and social

components of health.21,22 Determining accurate prevalence and incidence rates of knee osteoarthritis is difficult
due to the lack of homogeneity in published studies.18 Figures regarding prevalence of symptomatic knee osteoarthritis in the general population vary, with estimates of
7.2% in those aged 40 or older,9 12.5% in those aged over
4523 and 14.8% in those aged 50 or older.24 OA in young
adults is most commonly a result of a specific injury to the
knee, particularly intra-articular injury involving the anterior cruciate ligament (ACL).25 Ten years after ACL injury approximately half of all patients display clinical signs
of knee osteoarthritis and extrapolating these results indicates that nearly all patients will have OA after 1520
years.26 These figures appear regardless of whether reconstructive surgery is performed.27 Former Finnish world
class athletes were found to have an increased prevalence
of musculoskeletal disorders than the normal population.28 Swedish soccer and ice hockey players reported a
significant relationship with the presence of osteoarthritis,
but only with previous knee injurues.29 However in Australia, a significantly greater prevalence and severity of
knee osteoarthritis, producing a twofold increased risk of
knee replacement, was found in Australian Rules Football
players.30 Occupational stresses including prolonged
kneeling and/or squatting and lifting may also increase the
risk of knee osteoarthritis31.
The treatment of knee osteoarthritis is currently limited to the management of symptoms rather than reducing
disease progression.1 An evidence based approach to
management should include patient education about OA
and its management, including pain management, options
to improve function, decrease disability, and prevent or
retard progression of the disease.32 Common current
treatment strategies involve pharmacological treatments,
non-pharmacological treatments and surgical interventions. Analgesic and anti-inflammatory drugs are widely
used in management,33 despite known serious adverse effects associated with long term NSAID use34 and doubts
about their efficacy.35 Paracetamol is the primary oral analgesic and, if successful, the preferred long term analgesic.32 NSAIDs are considered in patients unresponsive to
paracetamol.32 Current best evidence suggests NSAIDs
may be beneficial in the reduction of pain in the short
term, but there is no support for their long term use.36
Intra-articular corticosteroids are an option for inflam231

The effect of a manual therapy knee protocol on osteoarthritic knee pain: a randomised controlled trial

mation and pain relief, however the short term pain reduction provides relatively short lived benefits, and no
difference in knee function is evident long-term.37 Intraarticular corticosteroids are indicated for flare up of knee
pain, especially if accompanied with effusion.32 Recent
times has seen the advancement of alternative so-called
natural pharmaceutical options such as glucosamine
and chondroitin.38 Supplementation use is supported by a
growing, but heterogeneous research base of mixed methodological quality than other pharmaceutical interventions.32 It has been demonstrated that these products have
a slower onset of action but their symptomatic effects
tend to be more long lasting after the end of treatment.39
Invasive interventions may include arthroscopy and joint
replacement surgery that are considered when other treatment modalities have failed and for patients who generally have more severe pain and disability with radiographic
evidence of OA.32 In a randomised placebo-controlled
trial the outcomes after arthroscopic lavage or arthroscopic debridement were no better than those after a placebo procedure and at no point did either of the
intervention groups report less pain or better function
than the placebo group.40 Alternatively, replacement surgery is considered an effective procedure in improving
knee function, decreased pain, and may provide the opportunity to resume a more active lifestyle.41
Whilst these forms of therapy help to deal with symptoms, osteoarthritis is often viewed as a problem of biomechanical function. In order to treat the large and growing
number of sufferers, various treatment approaches outside
the use of drugs are utilised. Thus, many sufferers visit
practitioners who provide therapy intended to improve
their function. To address the concerns of lost function, including the ability to ambulate, several forms of physical
therapy have been advocated, with various strength-based
and exercise programs the cornerstone of treatment. Prescription of an aerobic walking and quadriceps strengthening exercise program had been used successfully,
producing a reduction in both pain and disability.42 The
implementation of laterally wedged shoe orthotics has
also been shown to provide symptomatic relief.43 Such interventions are typically used in combination with pharmaceutical interventions.
A requirement also exists for simple and inexpensive
treatment protocols to fill the void between medication,
exercise and surgery. Multimodal approaches utilizing a
232

combination of exercises and individualized manual therapy (received twice weekly for 4 weeks) has resulted in
significant improvements in knee pain and function when
compared to a placebo therapy of sub-therapeutic ultrasound in both the short term and long term follow up.44
Another trial compared clinic based treatment incorporating supervised exercise, individualized manual therapy
and a home exercise program over a four week period to
a home exercise program.45 The results indicated that in
both groups knee pain decreased and function improved
in the short and long term. Another randomised controlled trial investigated high velocity thrust techniques (received 8 times over 3 weeks) to the knee compared with
NSAIDs. They found no objective or subjective differences between the groups; both were equally effective.46
Therefore, use of manual therapy should be offered as an
alternative to pharmaceutical administrations.
Recently, there has been interest in research of the
clinical efficacy of chiropractic manual therapy techniques for spinal structures.47 Whilst this interest is both
appropriate and desirable, much less attention has been
focused upon chiropractic interventions directed towards
peripheral joints. The application of chiropractic knee
techniques has been previously documented in the literature.46,48 Furthermore, little research has been directed
into chiropractic interventions for the aging population.
The aim of this investigation was to determine if a/the
Macquarie Injury Management Group (MIMG) knee protocol can alter the self reported pain experienced by a
group of chronic knee osteoarthritis sufferers compared
to a control group in a randomised trial.
Methods
This study sought and received approval from the Macquarie University and the University of Wollongong
Human Ethics Committees. Participants gave written informed consent prior to participation in the study. A CONSORT diagram is provided for your reference (Figure 1).
Participants
Fifty-seven people responded to a print media advertising
campaign. After identification of the appearance of OA in
one or both knees on radiographs and meeting the inclusion criteria for the study (Table 1), 43 participants were
included in the study. Nine participants were excluded as
they could not meet the required dosage, 3 participants
J Can Chiropr Assoc 2008; 52(4)

H Pollard, G Ward, W Hoskins, K Hardy

Figure 1

Modified Consolidated Standard for Reporting Clinical Trials (CONSORT) diagram

Respondents to print
media n=57
Excluded (n= 14)
Eligible participants
n=43
Randomisation

Allocated to MIMG treatment

Group n=26

Allocated to Control Group

n=17
Baseline Measures

Lost n=0

Lost n=0

Dose: 3 treatments per week for 4 weeks

Post-treatment measures

Analysed
(n= 26)

were excluded as they experienced significant concurrent

pain in the lower limb, 1 participant was excluded as they
demonstrated significant varus deformity and one participants was excluded as they suffered a concurrent golden
staff infection in the lower limb. It was not investigated
whether participants were currently undertaking concurrent treatment or supplementation. Participants then completed a knee pain questionnaire representing the present
pain intensity on a graduated 10 centimetre rule, or visual
analogue scale (VAS). The participants then drew a card
J Can Chiropr Assoc 2008; 52(4)

Analysed
(n=17 )

from a sealed container. The container held 2 identical

cards, with either Card 1 or Card 2 typed on the inside
of them. The participants gave the card to a research assistant who wrote down the allocation to intervention
group (card 1) or control group (card 2). The card was then
replaced into the container, and shuffled before the next
participant drew from the container. Participants were randomly allocated to an intervention group (n=26) or a control group (n=17). The non-homogenous division between
groups was due to the random nature of group allocation.
233

The effect of a manual therapy knee protocol on osteoarthritic knee pain: a randomised controlled trial

Figure 2

234

Macquarie Injury Management Group Knee Protocol Part One: Myofascial Mobilisation Technique

J Can Chiropr Assoc 2008; 52(4)

H Pollard, G Ward, W Hoskins, K Hardy

Figure 3 Macquarie Injury Management Group Knee Protocol Part Two: Myofascial Manipulation

Table 1

Inclusion criteria

Inclusion Criteria
Participants must be aged between 45 and 70 years and must suffer the following:
A prior medical diagnosis of osteoarthritis in the knee(s) as per Forman et al (1983)
Self reported mild to moderate knee pain of at least one year duration
Self reported knee crepitus
Self reported restricted range of motion and/or joint deformity of the knee
No history of joint replacement therapy
No recent history of meniscal or other knee surgery (less than 6 months)
J Can Chiropr Assoc 2008; 52(4)

235

The effect of a manual therapy knee protocol on osteoarthritic knee pain: a randomised controlled trial

Table 2

Change in 11 post study questions utilizing the visual analog scale

Visual Analogue Scale

Control
mean

Treatment
mean

Difference (CI)

p value

How would you rate your pain?

3.1

1.9

1.1 (0.1, 2.2)

0.042*

Do you feel the treatment has helped you?

4.1

2.9 (4.8, 1.1)

0.002*

Has the pain / discomfort inside your knee improved?

3.5

6.7

3.1 (4.9, 1.4)

0.001*

Has the mobility in your knee improved?

3.9

6.4

2.5 (4.2, 0.7)

0.007*

The treatment was painful to receive

0.5

0.6

0.1 (1.2, 1.0)

0.874

Compared with other treatment (analgesic / antiinflammatory medication ),

I feel this treatment to be effective

4.2

7.4

3.2 (5.1, 1.2)

0.002*

I can perform general activities better than before the

treatment

3.8

6.5

2.7 (4.8, 0.6)

0.013*

The clicking and grinding sensations in my knee

have improved

3.4

2.6 (4.7, 0.5)

0.017*

The changes occurring in my knee have changed the

mobility in my hip

2.5

2.8

0.2 (2.3, 1.8)

0.815

10

I feel that this type of treatment should be used in the

management of my knee pain

4.1

1.8

2.3 (0.8, 3.8)

0.004*

11

How would you rate this treatment program in terms

of the effectiveness on decreased pain and increased
function

4.7

7.8

3.1 (5.0, 1.3)

0.002*

Intervention Group
The intervention group received a MIMG chiropractic
knee protocol, explained in Figures 2 and 3. It consists of
a non-invasive myofascial mobilisation procedure and an
impulse thrust procedure performed on the symptomatic
knee of participants. It cases were OA was bilateral; mobilisation was perform on both knees. The mobilisation
procedure directed a small, sustained load and specific
force to the patellofemoral articulation in a pre-determined direction of movement. This load was achieved
through the active extension and flexion of the knee in
the range starting from 90 of knee flexion to available
full extension. During this movement, the patella is actively mobilised in a supero-inferior direction in a plane
directed tangentially to the patella. In this position, minimal compressive load is placed upon the patellofemoral
articulation, as this movement is usually perceived as
236

painful in osteoarthritic patients. This allows the subject

to actively articulate through knee flexion and not excessively tighten the quadriceps to cause a vector that compresses the patella onto the femur. A positive orthopaedic
test finding is pain reproduction upon compressing patellofemoral structures. The mobilization procedure stretches the joint capsule in the sagittal plane, gently mobilises
any restriction to normal movement within the limits of
patient tolerance and likely loosens adhesions of the patellofemoral articulation. In addition, it may be used on
anterior thigh musculature to effectively mobilise tight
myofascial thigh structures.
Control Group
The control intervention consisted of a palmar contact to
the knee without the application of force followed by interferential set at zero. The control group were told that
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H Pollard, G Ward, W Hoskins, K Hardy

Table 3

Changes in group pain scores between the control and treatment groups

VAS

Pre-Test Mean (CI)

Post-Test Mean (CI)

p value

Control Group

17

3.5 (2.2, 4.7)

3.1 (2.1, 4.1)

0.602

Treatment Group

26

3.3 (2.6, 4.0)

1.9 (1.3, 2.6)

0.004*

Table 4
VAS

Changes between control group and treatment in pain scores

Difference (CI)

p value

Pre-Test

0.2 (1.1, 1.5)

0.771

Post-Test

1.1 (0.1, 2.2)

0.042*

the procedure was a micro current application that they

should not be able to feel. The experimental protocol was
performed so that participants were not aware to which
group they were assigned. The participants were informed that one treatment might be more effective than
another. The treatment regime consisted of 3 treatments
per week for 2 consecutive weeks with a follow-up assessment after the final treatment.
Immediately following their involvement in the 2
week trial, participants completed 11 post treatment
questions including present knee pain intensity and questions regarding feedback on their response to treatment
utilising a VAS. This scale was utilised as per previous
researchers.49 The 11 short questions required a response
of between 0 and 10 on a 10 centimetre rule, and can be
seen in Table 2. The minimum or zero point response on
the VAS represented the response: none (Question 1), no
effect (Questions 2, 10), no improvement (Questions 3, 4,
8), not painful (Question 5), not effective (Question 6,
11), and no change (Questions 7, 9). The 10 or maximum
response on the VAS represented the following responses: unbearable (Questions 1,5), very effective (Questions
2, 6, 11), excellent improvement (Questions 3, 4, 8),
much better (Questions 7, 9), and strongly disagree
(Question 10). Gallagher reports a 13 mm difference on
the VAS represents the smallest measurable change in
pain severity that is clinically important.50
A post-intervention session was held after all the results had been collected and the results tabulated. Participants in the control group were offered the treatment
program, of which all participants accepted but one.
J Can Chiropr Assoc 2008; 52(4)

Statistical Analysis
Statistical data was entered into power Macintosh computer, and utilised via a database soft ware package. Statistical analysis utilised Minitab v8.2. Repeated ANOVA
calculations were made to describe differences between
the groups. The p value used for all analyses was p>0.05.
Results were found to be statistically significant at the
5% level.
Results
Participants were randomly assigned to the intervention
group (mean age 56.5 years) or a control group (mean
age 54.6 years). Prior to the intervention no significant
difference in present intensity knee pain between the intervention and control groups was evident (Table 3). It
was a requirement that the participants had mild to moderate knee pain (as determined by a the McGill Pain
Questionnaire). Following treatment the intervention
group rated their pain less (1.9) while no change was noted in the control group (3.1) (Table 4). This change in
pain in the intervention group was statistically significant
when compared with the control (Table 3).
The results to the remaining 10 questions can be found
in Table 2. When the participants were asked if the treatment helped them, the intervention group indicated a positive response (7.0), which was significant when
compared with the control group (4.1). Furthermore,
when participants were asked if pain within the knee had
improved, the intervention group (3.5) had significantly
improved when compared with the control group (6.7).
The participants were asked if a general improvement in
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The effect of a manual therapy knee protocol on osteoarthritic knee pain: a randomised controlled trial

knee mobility was noted since the treatment had begun

(Question 4). The responses indicate a significant improvement in the intervention group (6.4) greater than the
control group (3.9). When asked if the clicking and
grinding sensations (crepitus) in the knee had changed
(Question 8), the intervention group (6.0) indicated a significant improvement when compared with the control
group (3.4). The intervention group (6.5) also indicated a
significantly improved ability to perform general activities (Question 7) when compared to the control group
(3.8). When asked to comment on whether their hip
movement had been improved by the knee treatment
(Question 4), the results indicated significantly improved
mobility in the intervention group (6.4) when compared
to the control group (3.9).
Following these questions several other questions were
asked regarding the type of treatment that the participant
received. When asked if the treatment was painful to receive (Question 5) the participants responses indicated
that little discomfort was experienced with the treatment;
the results were similar for both the intervention group
(0.6) and the control group (0.5). When asked to compare
the short-term effect of their treatment to previous pharmacologic based prescriptions they had received (including analgesics and anti-inflammatory medication)
(Question 6), the results demonstrated a significant subjective feeling of effectiveness for the intervention group
(7.4) when compared to the control group (4.2). When
asked if the treatment that they received should be included into the management protocol of their knee pain
(Question 10), the results demonstrated a significant difference between groups. Those in the intervention group
(1.8) felt strongly that the management that they had
received should be included in the management of arthritis, but the control group (4.1) were somewhat unequivocal. Finally, the participants were asked to rate the
treatment they received in terms of the effectiveness on
decreased pain and increased function (Question 11).
Again, the intervention group (7.8) rated the treatment as
being more effective when compared to the equivocal result of the control group (4.6).
Discussion
The results indicated that a MIMG knee protocol was
successful in reducing self reported present intensity osteoarthritic knee pain in the short-term and that this
238

change was statistically significant when compared with

a control group. It is unlikely that the results for the intervention group can be explained in terms of a spontaneous
remission or through natural resolution, as it was a requirement of the study for the knee pain to have been a
chronic stable condition.
Research into arthritis and particularly OA has largely
investigated medical interventions and physical therapy
modalities including exercise. Much less emphasis has
been placed on other manual therapy approaches. Several
studies have investigated manual therapy for OA of the
knee.44,45 employing protocols that included other forms
of therapy in a multi-modal approach. Our particular
study employed one manual therapy discipline for effective pain reduction in osteoarthritic knee patients.
An important consideration revealed in the post treatment questionnaire was the issue of pain and discomfort
created by the treatment. Whilst concern may surround
the use of manual therapy in the elderly,51 or in degenerative cases, it is understood there are a range of chiropractic methods suitable for certain patients and specific
scenarios.5255 Our results indicate that the treatment
caused little or no discomfort to the patients. Such findings are valuable as participants ages ranged from 47 to
70 years old. Whilst practitioner precaution is advised in
dealing with patient conditions related to bone weakness,
ligamentous laxity, deformity and tumour, much can be
offered to the individual that has good bony and ligamentous integrity that also happens to suffer from osteoarthritis of the knee.
The MIMG protocol used for the intervention consisted
of a non-invasive myofascial mobilisation procedure and
an impulse thrust procedure specific to the patellofemoral
articulation. The patient is able to actively articulate
through knee flexion and not excessively tighten the quadriceps to cause a vector that compresses the patella onto
the femur. The mobilization procedure stretches the joint
capsule in the sagittal plane, gently mobilises any restriction to normal movement within the limits of patient tolerance and likely loosens adhesions of the patellofemoral
articulation. In addition, it may be used on anterior thigh
musculature to effectively mobilise tight myofascial thigh
structures. Together these effects allow the knee greater
mobility with less effort, restriction and pain. An important aspect of the procedure is that participants are able to
cease participation at any point during the application of
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H Pollard, G Ward, W Hoskins, K Hardy

the procedure or at any time during the experimentation,

meaning it is performed voluntary within their tolerance
levels. This is an important first step in determining the
limit to which force is used in the application of the manual therapy. It provides direct feedback to the practitioner
about the degree of stiffness, limitation and pain present in
the afflicted knee. The MIMG technique is a potentially
useful addition to prehabilitation programs (rehabilitation
aimed at improving range of motion, strength and reducing swelling prior to surgery). Of the conditions to which
this procedure has been applied, only the leg with a
marked degree of lateral instability (genu valgus or genu
varus), or acute meniscal lesions seemed not to tolerate it.
It has become a useful addition to many techniques often
used to treat knee dysfunction.
The second part of the procedure utilises a manual
therapy procedure that is not under the voluntary control
of the patient. It involves the application of a longitudinal
traction of the tibio-femoral joint in a manner designed to
distract the knee and mobilise the joint in a near full extension position. An impulse type thrust directed in the
caudal direction is delivered to the knee of the patient.
The leg of the patient is held in a position of light traction
with the hands of the practitioner placed either side of the
knee with the thumbs contacting on the tibial tuberosity
and the fingers wrapping around the knee to the popliteal
space. In addition to the above placement, the practitioner may optionally enhance the leverage available by
placing the involved leg of the patient between the practitioners legs (at the level of the lower calf) in order to add
further traction leverage. The object of this procedure is
not to produce joint cavitation, more so to mobilise the
joint. In cases of tibial rotational restriction, the pre-manipulative set up could include a rotated tibia as a start
point. The thrust component remains the same and is directed purely caudal in direction. Done correctly, this
procedure is painless and has been used anecdotally to
treat chronic meniscal injury. However, this procedure
requires intact ligamentous and capsular structures to operate successfully. It also requires practice by the practitioner to acquire the motor skills necessary to perform the
procedure.
Of interest to clinicians and patients alike, a significant
treatment effect was found after only a short course of
treatment. The study consisted of 3 treatments per week
for 2 consecutive weeks, a total of 6 treatments that proJ Can Chiropr Assoc 2008; 52(4)

duced significant self-reported pain and dysfunction. Previous studies have attempted to estimate the relationship
between dosage and outcome parameters for low back
pain56, headache57 and fibromyalgia.58 They found between 912 chiropractic treatments were feasible for pain
relief and between 15 and 30 for quality of sleep and fatigue level. Further research should implement dosage
characteristics of treatment modalities for improvements
in valid and reliable measurement outcomes. This would
hasten the transfer of information from researcher to the
clinician.
The importance of the patellofemoral compartment in
knee dysfunction and knee osteoarthritis is well established.59,60 Disease of the patellofemoral articulation can
cause pain, and be responsible for a great deal of difficulty in the everyday activities of squatting, using steps and
stairs, kneeling, and rising up from chairs.61 Misalignment of the patella laterally has been proposed as a cause
of the much of the pain associated with many patellofemoral conditions.62 These misalignment syndromes are
often referred to as tracking problems63 and are classically managed by physiotherapists through taping based
protocols of the patella to correct the tracking problem.64
However, such protocols for knee osteoarthritis have
shown it be no more effective than placebo in a randomised, double blind, placebo controlled trial.65
Preliminary findings of this study promote future research for chiropractic protocols in the management of
OA and other similar degenerative disorders. Large Randomised clinical trials could investigate unimodal or
multimodal chiropractic protocols. Further research
should also attempt to address the dosage and duration of
treatment required to resolve or manage a condition. Future investigations should study objective measurements
of function and pain, with a medium to long term follow
up to assess the duration of treatment effect or surgical
intervention.
Limitations
A limitation of this study was that a superior objective
outcome measure for treatment was not provided. The
use of validated and reliable questionnaires such as the
Knee Injury and Osteoarthritis Outcome Score (KOOS),
the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the short form 36 Health Survey
Questionnaire and objective functional tests such as dis239

The effect of a manual therapy knee protocol on osteoarthritic knee pain: a randomised controlled trial

tance walked in 6 minutes would benefit future study.

Once known, these data may be compared with the data
gained from other approaches to the treatment of OA in
the knee, and the pain and suffering that it causes in the
older population.
Another limitation was the absence of strict exclusion
criteria based around the use of concurrent therapies or
additional supplementation. Investigation of these variables in future study can provide stronger evidence on the
effectiveness of a manual therapy intervention for OA of
the knee.
Finally, the outcomes of this study were assessed
immediately following a 2 week intervention period. It
outlines the short-term effects of this protocol on osteoarthritis, however further research is necessary to investigate long-term results of such an intervention for
osteoarthritis. The clinical relevance of a short-term treatment program for osteoarthritis, which is chronic in nature, is uncertain.
Conclusions
The MIMG manual therapy knee protocol outlined in this
research demonstrated significant short-term relief of
self-reported pain and dysfunction in participants with
knee osteoarthritis. In addition, no participants in either
group reported adverse effects/discomfort with intervention. In light of these findings, it is recommended that
further research be conducted to determine the utility of
this protocol in patients not achieving satisfactory pain
management with traditional approaches of exercises and
medication for knee osteoarthritis. Further research
should also focus on the duration of the clinical effects as
measured by the reduction of symptoms in medium and
long-term objective measures of pain and disability.
Competing interests
No funding was received in the preparation of this manuscript. The authors have no conflict of interest directly related to the content of the manuscript. The investigators
do not stand to benefit from the commercial use of the
protocol or the teaching of this protocol.
Authors contributions
HP conceived of the study, participated in its design, constructed the literature review, provided treatment to the
Participants, and helped to draft and edit the manuscript.
240

GW participated in the design and helped edit and

draft the manuscript.
WH assisted with the literature review and helped edit
and draft the manuscript.
KH assisted with the literature review and helped edit
and draft the manuscript.
All authors read and approved the manuscript.
Acknowledgements
No Source of funding was used in the preparation of this
manuscript. The authors have no conflict of interest that
is directly relevant to the content of this manuscript.
References
1 Jackson BD, Wluka AE, Teichtahl AJ et al. Reviewing
knee osteoarthritis a biomechanical perspective. J Sci
Med Sport 2004; 7(3):347357.
2 Wu CW, Kalunian KC. New developments in
osteoarthritis. Clin Geriatr Med 2005; 21(3):589601.
3 Bjorklund L. The Bone and Joint Decade 20002010.
Inaugural meeting 17 and 18 April 1998, Lund, Sweden.
Acta Orthop Scand Suppl. 1998; 281:6780.
4 Mandelbaum B, Waddell D. Etiology and pathophysiology
of osteoarthritis. Orthopedics 2005; 28(2 Suppl):s207214.
5 Cicuttini FM, Spector TD. Genetics of osteoarthritis. Ann
Rheum Dis 1996; 55(9):6567.
6 Pearle AD, Warren RF, Rodeo SA. Basic science of
articular cartilage and osteoarthritis. Clin Sports Med 2005;
4(1):112.
7 Mahajan A, Verma S, Tandon V. osteoarthritis. J Assoc
Physicians India 2005; 53:634641.
8 Felson DT, Naimark A, Anderson J et al. The prevalence
of knee osteoarthritis in the elderly. The Framingham
osteoarthritis Study. Arthritis Rheum 1987; 30(8):914918.
9 Du H, Chen SL, Bao CD, et al. Prevalence and risk factors
of knee osteoarthritis in Huang-Pu District, Shanghai,
China. Rheumatol Int 2005; 25(8):585590.
10 Vilalta C, Nunez M, Segur JM, et al. Knee osteoarthritis:
interpretation variability of radiological signs. Clin
Rheumatol 2004; 23(6):501504.
11 Ravaud P, Giraudeau B, Auleley GR, et al. Variability in
knee radiographing: implication for definition of
radiological progression in medial knee osteoarthritis. Ann
Rheum Dis 1998; 57(10):624629.
12 Odding E, Valkenburg HA, Algra D, et al. Associations of
radiological osteoarthritis of the hip and knee with
locomotor disability in the Rotterdam Study. Ann Rheum
Dis 1998; 57(4):203208.
13 Jordan J, Luta G, Renner J, et al. Knee pain and knee
osteoarthritis severity in self-reported task specific
disability: the Johnston County OA Project. J Rheumatol
1997; 24(7):13441349.
J Can Chiropr Assoc 2008; 52(4)

H Pollard, G Ward, W Hoskins, K Hardy

14 Scott WN, Insall JN, Kelly MA. Arthroscopy and

Meniscectomy: Surgical Approaches, Anatomy, and
techniques. In: Surgery of the knee. Edited by Insall JN.
New York, Churchill Livingstone 1993; 165216.
15 Best JT: Revision total hip and total knee arthroplasty.
Orthop Nurs 2005; 24(3):174179.
16 Bourne RB, Maloney WJ, Wright JG. An AOA critical
issue. The outcome of the outcomes movement. J Bone
Joint Surg Am 2004; 86-A(3):633640.
17 Altman R, Asch E, Bloch D, et al. Development of criteria
for the classification and reporting of osteoarthritis:
classification of osteoarthritis of the knee. Arthritis Rheum
1986; 29:10391049.
18 DAmbrosia RD: Epidemiology of osteoarthritis.
Orthopedics 2005; 28(2 Suppl):s201205.
19 Zhang Y, Xu L, Nevitt MC, et al. Comparison of the
prevalence of knee osteoarthritis between the elderly
Chinese population in Beijing and whites in the United
States: The Beijing OA Study. Arthritis Rheum 2001;
44(9):20652071.
20 Felson DT: Epidemiology of hip and knee OA.
Epidemiologic Reviews 1988; 10:124.
21 Salaffi F, Carotti M, Stancati A, et al. Health-related
quality of life in older adults with symptomatic hip and
knee OA: a comparison with matched healthy controls.
Aging Clin Exp Res 2005; 17(4):255263.
22 van der Waal JM, Terwee CB, van der Windt DA, et al.
The impact of non-traumatic hip and knee disorders on
health-related quality of life as measured with the SF-36 or
SF-12. A systematic review. Qual Life Res 2005;
14(4):11411155.
23 Bedson J, Jordan K, Croft P. The prevalence and history of
knee osteoarthritis in general practice: a case-control study.
Fam Pract 2005; 22(1):103108.
24 Kacar C, Gilgil E, Urhan S, et al. The prevalence of
symptomatic knee and distal interphalangeal joint
osteoarthritis in the urban population of Antalya, Turkey.
Rheumatol Int 2005; 25(3):201204.
25 Roos EM: Joint injury causes knee osteoarthritis in young
adults. Curr Opin Rheumatol 2005; 7(2):195200.
26 Myklebust G, Bahr R. Return to play guidelines after
anterior cruciate ligament surgery. Br J Sports Med. 2005;
39(3):127131.
27 Von Porat A, Roos EM, Roos H. High prevalence of
osteoarthritis 14 years after an anterior cruciate ligament
tear in male soccer players: a study of radiographic and
patient relevant outcomes. Br J Sports Med 2004; 38:263.
28 Kujala UM, Sarna S, Kaprio J, et al. Hospital care in later
life among former world-class Finnish athletes. JAMA
1996; 276(3):216220.
29 Thelin N, Holmberg S, Thelin A. Knee injuries account for
the sports-related increased risk of knee osteoarthritis.
Scand J Med Sci Sports. 2006 Oct; 16(5):329333.

J Can Chiropr Assoc 2008; 52(4)

30 Deacon A, Bennell K, Kiss ZS, et al. osteoarthritis of the

knee in retired, elite Australian Rules footballers. Med J
Aust 1997; 166(4):187190.
31 McMillan G, Nichols L. osteoarthritis and meniscus
disorders of the knee as occupational diseases of miners.
Occup Environ Med 2005; 62(8):567575.
32 Jordan KM, Arden NK, Doherty M, et al. Standing
Committee for International Clinical Studies Including
Therapeutic Trials ESCISIT: EULAR Recommendations
2003: an evidence based approach to the management of
knee osteoarthritis: Report of a Task Force of the Standing
Committee for International Clinical Studies Including
Therapeutic Trials (ESCISIT). Ann Rheum Dis 2003;
62(12):11451155.
33 McColl GJ. Pharmacological therapies for the treatment of
osteoarthritis. Med J Aust 2001; 19; 175 Suppl:S108111.
34 Pham K, Hirschberg R. Global safety of coxibs and
NSAIDs. Curr Top Med Chem 2005; 5(5):465473.
35 Dieppe PA, Frankel SJ, Toth B. Is research into the
treatment of osteoarthritis with NSAIDs misdirected?
Lancet 1992; 341:353354.
36 Bjordal JM, Ljunggren AE, Klovning A, et al. Nonsteroidal anti-inflammatory drugs, including cyclooxygenase-2 inhibitors, in osteoarthritic knee pain: metaanalysis of randomised placebo controlled trials. BMJ
2004, 329(7478):1317.
37 Bellamy N, Campbell J, Robinson V, et al. Intraarticular
corticosteroid for treatment of osteoarthritis of the knee.
Cochrane Database Syst Rev 2005; (2):CD005328.
38 Owens S, Wagner P, Vangsness CT Jr. Recent advances in
glucosamine and chondroitin supplementation. J Knee Surg
2004; 17(4):185193.
39 Morreale P, Manopulo R, Galati M, et al. Comparison of
the antiinflammatory efficacy of chondroitin sulphate and
diclofenac sodium in patients with knee osteoarthritis.
J Rheumatol 1996; 23:13851391.
40 Moseley JB, OMalley K, Petersen NJ, et al. A controlled
trial of arthroscopic surgery for osteoarthritis of the knee.
N Engl J Med 2002; 347(2):8188.
41 Kane RL, Saleh KJ, Wilt TJ, et al. The functional outcomes
of total knee arthroplasty. J Bone Joint Surg Am 2005;
87(8):17191724.
42 Roddy E, Zhang W, Doherty M. Aerobic walking or
strengthening exercise for osteoarthritis of the knee? A
systematic review. Ann Rheum Dis 2005; 64(4):544548.
43 Marks R, Penton L. Are foot orthotics efficacious for
treating painful medial compartment knee osteoarthritis?
A review of the literature. Int J Clin Pract 2004; 58(1):
4957.
44 Deyle GD, Henderson NE, Matekel RL, et al. Effectiveness
of manual physical therapy and exercise in osteoarthritis of
the knee. A randomized, controlled trial. Ann Intern Med
2000; 132(3):173181.

241

The effect of a manual therapy knee protocol on osteoarthritic knee pain: a randomised controlled trial

45 Deyle GD, Allison SC, Matekel RL, et al. Physical therapy

treatment effectiveness for osteoarthritis of the knee: A
randomized comparison of supervised clinical exercise and
manual therapy procedures versus a home exercise
program. Phys Ther 2005; 85(12):13011317.
46 Tucker M, Brantingham JW, Myburg C. Relative
effectiveness of a non-steroidal anti-inflammatory
medication (Meloxicam) versus manipulation in the
treatment of osteo-arthritis of the knee. Eur J Chiro 2003;
50:163183.
47 Nelson CF, Lawrence DJ, Triano JJ, et al. Chiropractic as
spine care: a model for the profession Chiropr Osteopat
2005; 13:9.
48 Hoskins WT, Pollard HP. Successful management of
hamstring injuries in Australian Rules footballers: two case
reports. Chiropr Osteopat 2005; 13(1):4.
49 Ogon M, Krismer M, Sollner W, et al. Chronic low back
pain measurement with visual analogue scales in different
settings. Pain 1996; 64(3):425428.
50 Gallagher EJ, Liebman M, Bijur PE: Prospective validation
of clinically important changes in pain severity measured
on a visual analog scale. Ann Emerg Med 2001,
38:633638
51 Blackman J, Prip K. Mobilisation techniques. Edinburgh,
Churchill Livingstone 1988:4554.
52 Cooperstein R, Killinger LZ. Chiropractic Techniques in
Care of the Older Patient. In: Brian Gleberzon Editor.
Chiropractic care of the older patient. Butterworth
Heineman. Oxford, UK. 2001; 359383.
53 Killinger LZ. Chiropractic Adjusting Techniques in the
Care of Aging Patients. In: Redwood D, and Cleveland CC
III, editors. Fundamentals of Chiropractic Text. Mosby
Publishers. 2003
54 Bergman TF, Larson L. Manipulative therapy and older
persons. Top Clin Chir0.1996; 3:5665.
55 Killinger LZ. Chiropractic adjusting and the aging
patient. J Amer Chiropr Assoc. Nov. 2003; 40:2628.

56 Haas M, Groupp E, Aickin M, et al. Dose response for

chiropractic care of chronic cervicogenic headache and
associated neck pain: a randomized pilot study. J
Manipulative Physiol Ther 2004; 27:547553.
57 Haas M, Groupp E, Kraemer DF. Dose-response for
chiropractic care of chronic low back pain. Spine J 2004;
4:574583.
58 Hains G, Hains F. A combined ischemic compression and
spinal manipulation in the treatment of fibromyalgia: a
preliminary estimate of dose and efficacy. J Manipulative
Physiol Ther 2000; 23:225230.
59 McAlindon TE, Snow S, Cooper C, et al. Radiographic
patterns of knee osteoarthritis in the community: the
importance of the patellofemoral joint. Ann Rheum Dis
1993; 51:844849.
60 Ledingham J, Regan M, Jones A, et al. Radiographic
patterns and associations of osteoarthritis of the knee in
patients referred to hospital. Ann Rheum Dis 1993;
52:520526.
61 Iwano T, Kurosawa H, Tokayama H, et al.
Roentgenographic and clinical findings of patellofemoral
osteoarthrosis. With special reference to its relationship to
femorotibial osteoarthrosis and etiologic factors. Clin
Orthop Rel Res 1990; 252;190197.
62 Morrissey M. Reflex inhibition of thigh muscles in knee
injury. Causes and treatment. Sports Med 1989; 7:263.
63 McConnell J. The management of chondromalacia
patellae: a long term solution. Aust J Phys Ther 1986;
32:215219.
64 McConnell J. The physical therapists approach to
patellofemoral disorders. Clin Sports Med 2002;
21(3):363387.
65 Bennell KL, Hinman RS, Metcalf BR, et al. Efficacy of
physiotherapy management of knee joint osteoarthritis: a
randomised, double blind, placebo controlled trial. Ann
Rheum Dis 2005; 64(6):906912.

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