Deyle and colleagues (2000)

suggested that periarticular and muscular connective tissue could be implicated as symptom sources in patients with osteoarthritis of the knee. One (pilot) study analysed the effect of knee joint mobilisation on osteoarthritic hyperalgesia and found favourable effects on pain (Moss et al 2006). In our opinion, additional manual mobilisation is an effective adjunct to exercise in physiotherapy for patients with pain from osteoarthritis of the knee. The exercise protocols used http://www.selleckchem.com/products/Bosutinib.html in the studies included in the present review recommended manual mobilisations for patients with a lot of pain and with restricted range of motion (Fransen et al 2001, van Baar et al 1998). In the study by Deyle and colleagues (2000), the treatment group received manual physical therapy based on the results of the examination. We hypothesise that larger effects of manual mobilisations can be expected specifically in subgroups of patients with more pain, greater loss of mobility, or both. Neither of the two studies categorised as examining physio/manual therapy described

how often additional passive manual mobilisations were delivered. A cohort study that measured the process of care in physiotherapy treatment according to the Dutch guidelines on osteoarthritis of the hip and knee found that the proportion of passive manual mobilisations in physiotherapy treatment was Vorinostat 18% (Jansen et al 2010). Higher effects on pain tend to be paired with higher scores on physical function because the relationship between the effects for pain and physical function was fairly strong (r = 0.78). Similarly, in a cross-sectional survey it was found that in men

and women with knee osteoarthritis pain intensity during the last eight days was significantly associated with WOMAC physical function (Perrot et al 2009). In a 3-year cohort study, increased pain was found to be associated with worsening of limitations in activities in patients with osteoarthritis of the hip or knee (van Dijk et al 2006). So, for many patients with osteoarthritis of the knee it Adenosine is suggested that pain relief is accompanied by improvements in functioning. In conclusion, exercise therapy plus manual mobilisation showed a moderate effect size on pain (0.69) compared to the small effect sizes for strength training (0.38) or exercise therapy alone (0.34). Supervised exercise treatment in physiotherapy and manual therapy should in our opinion include at least an active exercise program involving strength training, aerobic activity exercises, and active range of motion exercises. To achieve better pain relief in patients with knee osteoarthritis, physiotherapists or manual therapists might consider adding manual mobilisation to optimise supervised active exercise programs. More evidence is needed to examine the short-and long-term effects of adding passive manual mobilisation specifically in subgroups of patients with more pain, greater loss of mobility, or both. eAddenda: Available at JoP.