title: Manual physical therapy and perturbation exercises in knee osteoarthritis.
abstract: OBJECTIVE
  Knee osteoarthritis (OA) causes disability among the elderly and is often associated with impaired balance and proprioception. Perturbation exercises may help improve these impairments. Although manual physical therapy is generally a well-tolerated treatment for knee OA, perturbation exercises have not been evaluated when used with a manual physical therapy approach. The purpose of this study was to observe tolerance to perturbation exercises and the effect of a manual physical therapy approach with perturbation exercises on patients with knee OA.
  
  
  METHODS
  This was a prospective observational cohort study of 15 patients with knee OA. The Western Ontario and McMaster Universities Arthritis Index (WOMAC), global rating of change (GROC), and 72-hour post-treatment tolerance were primary outcome measures. Patients received perturbation balance exercises along with a manual physical therapy approach, twice weekly for 4 weeks. Follow-up evaluation was done at 1, 3, and 6 months after beginning the program.
  
  
  RESULTS
  Mean total WOMAC score significantly improved (P = 0.001) after the 4-week program (total WOMAC: initial, 105; 4 weeks, 56; 3 months, 54; 6 months, 57). Mean improvements were similar to previously published trials of manual physical therapy without perturbation exercises. The GROC score showed a minimal clinically important difference (MCID)≥+3 in 13 patients (87%) at 4 weeks, 12 patients (80%) at 3 months, and 9 patients (60%) at 6 months. No patients reported exacerbation of symptoms within 72 hours following each treatment session.
  
  
  CONCLUSIONS
  A manual physical therapy approach that also included perturbation exercises was well tolerated and resulted in improved outcome scores in patients with knee OA.
authors.affiliation: Madigan Army Medical Center, Department of Physical Medicine, Tacoma, WA, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Rhon
authors.affiliation: Brooke Army Medical Center, San Antonio, TX, USA.
authors.forename: Gail
authors.initials: G
authors.lastname: Deyle
authors.affiliation: Brooke Army Medical Center, San Antonio, TX, USA.
authors.forename: Norman
authors.initials: N
authors.lastname: Gill
authors.affiliation: Occupational and Physical Therapy Service, Warrior Transition Brigade, Fort Hood, TX, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Rendeiro
keywords: Knee osteoarthritis; Manual therapy; Perturbation exercises; Physical therapy