Pragmatism in manual therapy trials for knee osteoarthritis: a systematic review.

The authors state explicitly that this review did not assess whether manual therapy is effective for knee OA; it only describes the design characteristics of existing trials. No pooled treatment effect is reported. Interrater reliability was fair at best (kappa 0.25 to 0.45 across RITES domains) and slight for RoB-2 scoring (kappa 0.04), meaning the ratings of individual trials carry meaningful uncertainty. Only 7 of the 34 trials had a null primary outcome, which limits the power of the association test between trial design and outcome. Only English-language trials were included, which may exclude relevant work published in other languages. The definition of manual therapy was restricted to joint mobilization or manipulation; trials of massage, dry needling, cupping, or other hands-on techniques were excluded, so the findings do not cover the full range of manual techniques a PT might use.

The authors declare no competing interests and no financial support for the study. A disclaimer notes the views do not reflect the official policy of the Uniformed Services University, U.S. Department of Defense, or the U.S. Government.

Do not read the 27 positive trials as proof that manual therapy works in your clinic. The authors state this review did not assess treatment effectiveness, and most of those trials used narrow patient selection and controlled settings that do not mirror a typical practice. The finding here is about the design of the evidence, not about the size of the treatment effect.