Abstract

Background

The knowledge and utilization of manual therapy in treating knee osteoarthritis (OA) may help explain the effective utilization of manual therapy for managing knee OA. Little is known about the knowledge and utilization of manual therapy in the management of knee OA by physical therapists (PTs) in Saudi Arabia. The present study aimed to evaluate the knowledge and utilization of manual therapy by PTs in Saudi Arabia via a survey method.

Methods

A cross-sectional study design was used. PTs working in various hospitals in Saudi Arabia participated. A 29-item questionnaire was developed based on previous studies. One hundred ninety-seven participants returned the completed questionnaire (response rate, 78.8%). Descriptive statistics were utilized to summarize and present the study participants鈥� characteristics and responses.

Results

Approximately one-third (35.2%) of the participants did not receive any formal manual therapy training, whereas the others received formal manual therapy training in undergraduate (23.8%) or postgraduate (40.9%) studies. Only approximately one-third of the participants (29.9%) were qualified as certified manual therapy practitioners. Most participants (57%) reported using manual therapy according to the patient鈥檚 condition. Most of the participants cited several treatment goals for manual therapy, including pain reduction (84.8%), improved range of motion (77.2%), increased mobility (58.2%), and improved function (55.4%).

Conclusions

PTs in Saudi Arabia showed a positive attitude toward using manual therapy for treating knee OA. However, they suggested combining exercise and manual therapy as the best treatment option for knee OA.

Trial registration

Not applicable.

Introduction

Knee osteoarthritis (OA) is a major musculoskeletal problem affecting 630听million people globally [1]. Given the aging population and the increasing trend of obesity globally, the prevalence of knee OA will increase substantially in the future [1]. Although the prevalence of knee OA in Chinese men is comparable to that in Caucasian men, Chinese women have a significantly greater incidence of knee OA than Caucasian women do [2, 3]. In Saudi Arabia, the prevalence of knee OA has notably increased over the past decades, currently affecting approximately 30鈥�40% of adults aged 50 years and above, with women being more frequently affected than men [4,5,6,7,8]. The increasing prevalence in Saudi Arabia is linked to factors such as an aging population, elevated obesity rates, and sedentary lifestyles, which are key risk factors for the onset of knee OA [6,7,8].

OA often affects weight-bearing joints such as the knee joint [9], resulting in significant mobility restrictions [10] and a substantial financial burden [11, 12]. The risk of disability resulting from knee OA is equal to that of cardiac disorders and greater than that of any other medical problem in the older population [13, 14]. Common clinical manifestations of knee OA include pain, stiffness, joint enlargement, crepitus, muscle weakness, deformity, impaired proprioception, reduced joint motion, and disability [15].

Physiological impairments, such as reduced joint motion, muscle weakness, impaired balance, and proprioception, can be improved by regular exercise [16,17,18]. Previous studies reported improved functional outcomes after therapeutic exercise in people with knee OA [19, 20]. A systematic review indicated improved outcomes in terms of pain and function following physical therapy interventions in patients with knee OA [21]. A recent Cochrane review revealed high-quality evidence of land-based therapeutic exercise in reducing knee pain and moderate-quality evidence for improving functional outcomes in patients with knee OA [22].

Manual therapy is a therapeutic technique used by physical therapists (PTs) to reduce pain and improve mobility and function [23]. Manual therapy includes mobilization/manipulation consisting of a series of skilled passive movements to any joints [24]. Several studies have recommended active and passive mobilization for better and long-lasting outcomes [25,26,27,28,29,30]. Deyle et al. [25] reported clinically better results after the combined intervention of manual therapy, strengthening, range of motion, and stretching exercises than did a placebo control group. In another study, Deyle et al. [26] reported better symptomatic relief after manual therapy and a supervised exercise program than after a home exercise program. Fish et al. [27] reported better outcomes following knee joint mobilization than did the placebo for managing knee OA. Furthermore, Moss et al. [28] reported an immediate local and more generalized hypoalgesic effect of accessory mobilization to the knee joint in patients with knee OA. Jansen et al. [29] suggested the inclusion of manual mobilization to improve supervised active exercise programs. Moreover, a review study indicated that manual therapy could be included along with a multimodal exercise program [30].

Knee OA in Saudi Arabia presents considerable challenges to the healthcare system, leading to a decline in the quality of life for patients and a rise in healthcare expenses [31]. Understanding how manual therapy is used in treating knee OA may shed light on its effectiveness in managing this condition. However, there is limited information on the awareness and implementation of manual therapy by PTs in Saudi Arabia for treating knee OA. Consequently, this study was conducted to assess the knowledge and utilization of manual therapy among PTs in Saudi Arabia through a survey method.

Materials and methods

Study design and procedure

This study was conducted with a cross-sectional design. A 29-item questionnaire was developed on the basis of previous studies [14,15,16, 32] to explore several domains, including demographic and professional characteristics (items 1鈥�11), training in manual therapy (items 12鈥�16), the utilization of manual therapy in managing knee osteoarthritis (items 17鈥�22), and participants鈥� perceived knowledge, importance, and confidence concerning manual therapy outcomes (items 23鈥�28). The final item (29) asked participants to rate manual therapy as a treatment option for knee OA on a 10-point scale, divided into four categories: <3 (average), 3鈥�5 (good), 6鈥�8 (very good), and >鈥�8 (excellent). A panel of fifteen senior physical therapists specializing in musculoskeletal physical therapy, all of whom are registered with the Saudi Physical Therapy Association (SPTA) and certified as manual therapists with over five years of consultant-level experience, conducted a peer review of the questionnaire to assess its clarity and comprehensibility. Following three rounds of revisions, the questionnaire was finalized and deemed ready for data collection from the intended audience.

The questionnaire was designed to be completed within 3鈥�5听min. A summary of the questionnaire is provided in Supplementary Table S1. The survey was conducted via Google Forms鈥攁n online platform鈥攁nd the questionnaire link was distributed through email to 250 physical therapists employed in various hospitals across different regions of Saudi Arabia, including the central (Riyadh), western (Jeddah), northern (Hail), southern (Najran), and eastern (Dammam) regions. An assistant physical therapist was responsible for sending emails, receiving the participants鈥� queries and responses and further reporting to the senior physical therapist. In the initial section of the Google form, the study title was presented in the title case. Below the title, participants were required to acknowledge a statement confirming that their participation in the study was voluntary and that confidentiality would be maintained. The participants were then prompted to provide their email addresses, which served as their consent to participate in the study. Following this, they were prompted to complete the questionnaire. In response to item 17 of the questionnaire, if participants selected the option 鈥渘ever,鈥� the Google form was programmed to automatically end the session and submit their responses. Conversely, if they chose any other option, the form allowed them to proceed and complete the remaining sections of the questionnaire. Reminder emails were sent to the participants at two-week intervals. The survey was conducted between July 2018 and October 2018.

The participants who completed all the items of the Google Forms questionnaire were included in the study. Those who did not provide their email address, failed to complete any item of the form, or selected 鈥渘ever鈥� for item 17 were excluded from the study. The number of participants who submitted responses was visible on the Google Forms dashboard. Once the target number of responses was achieved, the data were prepared for analysis.

Ethics approval and consent to participate

The present study was approved by the Ethics Subcommittee of King Saud University (ID: RRC-2018-008 dated: 18 July 2018). All methods were performed in accordance with the relevant guidelines and regulations. Informed consent was obtained from all the study participants, and all the participants voluntarily completed the questionnaire.

Statistical analysis

Descriptive statistics were utilized to summarize and present the characteristics of the study participants and their responses. Measures of central tendency (mean) and dispersion (standard deviation) were calculated for continuous variables to provide insight into the average values and variability within the dataset. Categorical variables were summarized via frequency counts and percentages to illustrate the distribution of responses across the different categories. In certain sections of the questionnaire, participants had the option to provide more than one response, which resulted in cumulative response percentages exceeding 100%. This allowed us to capture the complexity and variability of participant perspectives on specific questions. For such multi-response items, the analysis considers each selected response as an independent occurrence to ensure accurate representation of the data. All the statistical analyses were performed via software (IBM SPSS, version 24.0) [33].

Results

A total of 197 participants completed the questionnaire (response rate, 78.8%). Table听1 shows the participants鈥� characteristics. More than half (53.3%) of the participants were male. Approximately half of the participants (49.7%) had a postgraduate qualification. Approximately one-third of the participants (29.4%) had 4 to 7 years of clinical experience. Nearly half of the participants (49.5%) worked in a private setting. Most of the participants were located in the Dammam region (44.7%), followed by the Riyadh region (30.5%). Half of the participants specialized in general practice, while approximately one-third (30.1%) specialized in musculoskeletal/orthopedic conditions. More than half (58.5%) of the participants were not registered with the Saudi Physical Therapy Association.

Table 1 Participants鈥� characteristics

The participants鈥� responses to the questions related to manual therapy training are presented in Table听2. Approximately one-third (35.2%) of the participants did not receive any formal manual therapy training, whereas the others received formal manual therapy training in undergraduate (23.8%) or postgraduate (40.9%) studies. More than half (69.4%) of the participants participated in any manual therapy workshops. Most of the participants (41.1%) attended a total duration of 1鈥�2 days of workshops, followed by 3鈥�5 days of workshops (26.5%). Most of the participants (52%) attended a workshop on the Mulligan mobilization technique followed by the Maitland mobilization technique (33.7%). Only approximately one-third of the participants (29.9%) were qualified as certified manual therapy practitioners.

Table 2 Participants鈥� responses to the questions related to manual therapy training

The responses of the participants to questions related to the utilization of manual therapy in the treatment of knee OA are given in Table听3. Most of the participants (57%) responded that they used manual therapy according to the patient鈥檚 condition. Most of the participants reported that they commonly see 0鈥�2 patients with knee OA daily. Most of the participants (66.1%) responded that their patients were in the 50鈥�70 years age group. The sex of the patients was evenly distributed [male (40.6%) versus female (39.6%)], as reported by the participants. Most of the participants (31.9%) responded that they often prescribe 7鈥�8 treatment sessions. Most of the participants (39.5%) responded that they often provide a total duration of 30鈥�45听min in each treatment session. Most participants (42.6%) responded that they often use a combination of manual therapy techniques followed by the Mulligan mobilization technique (40.3%). Most of the participants cited several treatment objectives for using manual therapy techniques, including pain reduction (84.8%), improvement in range of motion (77.2%), increased mobility (58.2%), and improvement in function (55.4%). Most of the participants (76%) reported that they used manual therapy to treat OA of the patellofemoral and tibiofemoral knee joints. Most of the participants (85.3%) reported that the combination of exercise therapy and manual therapy was the best treatment option for the treatment of knee OA. Most of the participants responded that they used the VAS (64.4%) and the Goniometer (53.9%) to determine patient improvement and treatment success after manual therapy. Most of the participants (65.6%) reported that manual therapy was an important treatment option in the treatment of knee OA. The majority of the participants gave a rating of 6鈥�8 on a 10-point scale for manual therapy as a treatment option for knee OA.

Table 3 The participants responded to questions related to the utilization of manual therapy in treating knee osteoarthritis (OA)

Discussion

The results of the current cross-sectional study indicated that most PTs working in Saudi Arabia had received formal manual therapy training in undergraduate or postgraduate studies. However, only a few were qualified as certified manual therapy practitioners. Most of the PTs working in Saudi Arabia completed a short-term course of Mulligan and Maitland mobilization techniques and supported the utilization of manual therapy in treating knee OA on the basis of the patient鈥檚 condition. Previous studies have supported the use of manual therapy in the form of active and passive mobilization for improved outcomes [24,25,26,27,28,29,30]. Walsh and Hurley reported that approximately 64% of their participants utilized manual therapy for the management of knee OA [34].

Manual therapy techniques, including Mulligan mobilization, therapeutic massage, and Maitland mobilization, were popular among respondents. A recent study investigated the acute effects of Mulligan mobilization and tapping on pain and function in patients with knee OA [35]. They concluded that Mulligan mobilization and tapping improved pain and performance during functional tasks. Another study recommended the use of Mulligan mobilization in the early management of knee OA [36]. A previous study demonstrated the safety, feasibility, and effectiveness of therapeutic massage in the management of knee OA [37]. Another study reported improved quality of life, relaxation effects, and symptomatic relief following therapeutic massage in patients with knee OA [38].

The participants cited several treatments aimed at manual therapy techniques, including pain relief, increasing range of motion, increasing mobility, and improving function. In a previous study, physiotherapy鈥檚 (including manual therapy) main goals were to improve self-management capacity, patient knowledge, and pain relief [34]. Past studies have shown that manual therapy has a positive effect on treating musculoskeletal pain [38,39,40,41]. A systematic review indicated moderate evidence for the effect of manual therapy in increasing pressure pain thresholds in patients with musculoskeletal pain [42].

Most of the participants suggested that the combination of exercise therapy and manual therapy is the best treatment option for the management of knee OA. Another study reported significant improvements in knee pain and function following a combination of exercise and individualized manual therapy in patients with knee OA [24]. Furthermore, Deyle et al. [25, 26] reported that the inclusion of manual therapy and supervised exercise provides greater improvements in patients with knee OA.

The current study has potential limitations. Using a self-report questionnaire could lead respondents to overestimate their responses, and it is difficult to validate the accuracy of the information from respondents. However, since participation was voluntary and identification data were anonymous, there were fewer chances of incorrect information regarding patient management. The questionnaire used in this study was adapted from a previous study [14,15,16, 32], but its psychometric properties were not evaluated, which may have affected the quality of the data. Furthermore, data specific to the widely practiced McKenzie method of manual therapy were not collected separately, limiting the study鈥檚 ability to draw critical insights regarding this technique. Future research should aim to address these limitations to offer more comprehensive and valuable information for interested readers.

Conclusions

Physical therapists in Saudi Arabia are equipped with formal training in manual therapy, both at the undergraduate and postgraduate levels. They demonstrate a strong, positive attitude toward integrating manual therapy into the treatment of knee osteoarthritis (OA). However, their insights highlight that the optimal approach for managing knee OA lies not in manual therapy alone but in a strategic combination of manual therapy techniques and targeted exercise therapy. This combined approach provides a deeper understanding of the multifaceted needs of knee OA patients and underscores a commitment to delivering comprehensive, evidence-based care.