The Benefits of Adding Manual Therapy to Exercise Therapy for Improving Pain and Function in Patients With Knee or Hip Osteoarthritis: A Systematic Review With Meta-analysis.

For people with knee or hip osteoarthritis, exercise therapy is a well-established treatment, but clinicians often add manual therapy, hands-on techniques like joint mobilization, hoping to boost results. This review pooled 19 randomized controlled trials comparing exercise plus manual therapy against matched exercise programs alone, to see whether the addition actually helps. The picture that emerged was mixed and time-dependent. In the short term, there was some evidence, ranging from very low to moderate certainty, that adding manual therapy helped with pain and with a combined pain-function-stiffness score, but not with function assessed on its own.

In the medium term, evidence pointed to possible benefit for function but not pain, again at low certainty. Over the long term, however, high-certainty evidence showed no added benefit at all. The authors' main point is that whatever early benefit might exist does not appear to persist, and much of the earlier evidence carries considerable uncertainty.

If you have knee or hip osteoarthritis, you may have been offered exercise therapy along with manual therapy, where a physiotherapist uses hands-on techniques like joint mobilization alongside your exercises. This review looked at 19 trials to see whether adding manual therapy actually makes exercise therapy work better for pain and movement. The findings were mixed.

In the short term, there was some evidence, though of quite variable and often low quality, that adding manual therapy helped with pain and with a combined score covering pain, function, and stiffness, but not with function measured by itself. A bit further out, there were hints of benefit for function but not for pain.

Looking at the long term, though, the evidence was much stronger and showed no extra benefit from adding manual therapy at all. In short, if there is any advantage to adding manual therapy, it seems to fade over time, and the early findings themselves are not very certain.

This is a summary of research, not medical advice. Talk to your own healthcare provider about anything affecting your care.

This review addresses whether adding manual therapy to exercise therapy improves pain and function outcomes in knee or hip osteoarthritis beyond exercise alone, drawing on 19 randomized controlled trials comparing matched exercise programs with and without manual therapy. Short-term findings (very low to moderate certainty) favored the combined approach for pain and the composite WOMAC pain-function-stiffness score, but not for function alone.

Medium-term evidence (low to very low certainty) suggested possible benefit for performance-based function but not pain. Long-term evidence was high certainty and showed no added benefit for either pain or function. For clinical reasoning, this sharpens expectations: any added value of manual therapy as an adjunct appears time-limited and is supported mainly by low-certainty short- and medium-term data, while the long-term null finding rests on stronger evidence.

The main limitation is the wide range in certainty across timepoints and outcomes, meaning the short-term benefits in particular could reflect chance findings or bias rather than a reliable effect, and the review does not establish whether differences in attention or contact time between arms contributed to short-term results.