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Presented by:Marilyn Abel, Alyssa Hamm, Yves Leduc, Silas Wiefelspuett, Pantea Zarrinkamar
Supervisor: Dr. Donna MacIntyre
INTRODUCTION PFPS Overview PFPS Theory Systematic Review Purpose
METHODS Search Strategy Screening Strategy Quality Assessment Data Analysis
RESULTS Search Strategy Quality Assessment Data Extraction Outcomes
DISCUSSION CONCLUSION
No universally accepted definition
Retropatellar or peripatellar pain of insidious onset in the absence of other diagnosed pathological conditions
Describes a spectrum of orthopedic abnormalities
Most common diagnosis of knee pain in active adults and adolescents
1 in 4 of total population; females > men
Exacerbated by prolonged sitting & repetitive weight-bearing activities
↓ Quality Of Life ↓ Participation in exercises or sports
↑ Economic burden (medical cost, days off work, etc)
Difficult to determine
Considered multi-factorial
Main Current Theory: Patellar maltracking within femoral trochlear notch
caused by abnormal muscular and biomechanical forces
Contributing Factors:
↑ Q angle Hypermobile patella Patella alta Pes planus Weak quads
↓ Flexibility of: Quadriceps Hamstrings Gastrocnemius Iliotibial band (ITB)
Potential mechanisms of patellar maltracking:
1. VL tends to be stronger and/or activates prior to the VMO Patella tracks laterally in the trochlear groove of the femur
2. Weak hip abductors Excessive femoral internal rotation and adduction under patella Relative lateral distraction of patella Increase patellofemoral joint stress
Wear on articular cartilage and altered lower extremity kinematics
Prins & Wurff, 2009 Females with patellofemoral pain syndrome have weak
hip muscles: a systematic review
Review of 5 studies that measured hip strength in females with PFPS
Concluded that females with PFPS show decreased strength in hip abduction, external rotation and extension when compared to healthy controls
2. Femoral Internal Rotation/Adduction
3. Relative Lateral Patellar Movement
1. Weak Hip Musculature
4. Knee Pain
Increased femoral internal rotation in PFPS with functional movements
Increased hip adduction angle in a prolonged run
Current rehabilitation of PFPS focuses mainly on knee musculature
Use of hip abductor strengthening as a treatment option needs to be investigated
INTRODUCTION PFPS Overview PFPS Theory Systematic Review Purpose
METHODS Search Strategy Screening Strategy Quality Assessment Data Analysis
RESULTS Search Strategy Quality Assessment Data Extraction Outcomes
DISCUSSION CONCLUSION
Patellofemoral Pain Syndrome: anterior or retropatellar pain not associated with other identifiable pathological conditions
MEDLINE search1. Patellofemoral Pain Syndrome/2. patellofemoral pain.ti,ab.3. knee pain.mp.4. runner's knee.mp.5. pfps.mp. 6. anterior knee pain.mp7. peripatellar pain.mp8. retropatellar pain.mp. 9. chondromalacia patella.mp10. patellofemoral.mp11. patellofemoral arthralgia.mp. 12. patellar pain.mp13. patellar pain syndrome.mp14. patellofemoral syndrome.mp15. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or
9 or 10 or 11 or 12 or 13 or 1416. physical therapy.mp17. Rehabilitation/
18. rehabilitation.mp. 19. physiotherapy.mp.20. exp Exercise Therapy/ or exp
Exercise/21. Muscle Strength/22. strength*.mp23. resistance training.mp24. "Physical Therapy (Specialty)"/ or
exp Physical Therapy Modalities/25. exp weight lifting/26. 16 or 17 or 18 or 19 or 20 or 21 or
22 or 23 or 24 or 2527. hip abduct*.mp.28. hip muscle*.mp29. 27 or 2830. Hip Joint/31. Hip/32. 30 or 3133. 26 and 29 and 3234. 15 and 33
Additional databases searched: CINAHL, EMBASE, PEDro, SPORTDiscus
Grey literature searched Google, Google Scholar, Papers First, ProQuest
Dissertation and Thesis
References of selected articles were scanned
Authors in the field were contacted for additional information on unpublished data and studies
Articles were screened by 2 reviewers
In the case of a disagreement, consensus was met through a meeting of the reviewers
Third party mediation was not needed
Screening Strategy
Hip abductor strength as a component of Patellofemoral Pain Syndrome treatment
Article Screening Form (Adapted from Westby, MD) RefWorks ID: _________________ Screening date: ________________ Reviewer: AH, YL Citation:_______________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________
Level of Review:Title - Appropriate? YES _____ NO _____ (reason) __________________Abstract - Appropriate? YES _____ NO _____ (reason) __________________Included for full text review? YES _____ NO _____ (reason) __________________ Full TextArticle Review:Study Design: RCT _____ CCT or Quasi-RCT _____ Crossover _____ Review _____
Case-Control _____ Cohort _____ Case Series _____Single Subject_____ Pre-Post (no control) ____
Selection Criteria: (all 6 of the selection criteria must be met for inclusion to the systematic review) 1. Subjects clinically diagnosed with Patellofemoral Pain Syndrome _____2. Intervention includes specific hip abductor strengthening _____3. Intervention is at least 4wks in duration, minimum 2-3 days/wk _____4. Comparisons are able to be drawn regarding the use of hip abductor strengthening as an effective component of treatment_____5. Study uses pain and hip abductor strength as a primary outcome _____6. Study is published in English, French, or German _____
Subjects clinically diagnosed with PFPS
Specific hip abductor strengthening as part or whole of intervention
Intervention duration minimum 4wks, 2-3 days/wk
Uses pain and hip abductor strength as outcome measures
Comparisons are able to be drawn regarding the use of hip abductor strengthening as an effective component of treatment
Studies published in English, French or German
PEDro Scale was used to assess quality of included studies
Process similar to that of Screening process
Data extraction tool used to collate relevant data
Independently extracted by 2 reviewers and compared for consistency
It was not necessary to contact authors for missing data
INTRODUCTION PFPS Overview PFPS Theory Systematic Review Purpose
METHODS Search Strategy Screening Strategy Quality Assessment Data Analysis
RESULTS Search Strategy Quality Assessment Data Extraction Outcomes
DISCUSSION CONCLUSION
Search Strategy Of 182 articles screened, 3 were eligible
Articles were excluded based on: Lack of intervention Type of intervention Focus on other knee pathologies (i.e. ITBS, OA, TKA, etc)
Auto alerts set up in MEDLINE, SPORTDiscus, Embase, and CINAHL 1 article was retrieved from Embase went to full text
included in the review
Mascal et al. 2003, Management of Patellofemoral Pain Targeting Hip, Pelvis and Trunk Muscle Function: 2 Case Reports
Tyler et al. 2006, The Role of Hip Muscle Function in the Treatment of Patellofemoral Pain Syndrome
Nakagawa et al. 2008, The Effect of Additional Strengthening of Hip Abductor and Lateral Rotator Muscles in Patellofemoral Pain Syndrome: a Randomized Controlled Pilot Study
First study to assess the role of hip musculature in PFPS treatment
Progressive hip muscle strengthening (glut max and med, hip abd, and ER): Pain relief and improved biomechanical kinematics in a
step-down exercise (decreased hip adduction and femoral internal rotation)
Strengthened hip flexors, abductors, adductors & stretched hip flexors and ITB
↑ Hip abductor strength: not significant for pain relief
Combined iliopsoas strengthening & lengthening with ITB lengthening
Quad strengthening with hip abductor and external rotation strengthening (intervention group): ↓ Pain during functional activities Did not identify which muscle group had greater
contribution
↑ hip eccentric ER and hip abd torque: not statistically significant but clinically significant Small n & short Tx time → statistically insignificant
↑ Hip motor control → clinically significant
Common PEDro trends amongst 3 included studies:
Similar baseline groups
Measured at least one key outcome in >85% of the subjects
Provided either treatment or control condition to all of their subjects
None of the three studies blinded their therapists providing the treatment
Studies were not similar enough to compare quantitatively
Data from studies was extracted and qualitatively compared based on PICO headings (Population, Intervention, Comparison, Outcomes)
Study Participants Intervention Comparison Outcomes
Mascal et al. (2003)
2 ♀ 14 wksClinic: 1-2/wk & HEP: 2/day- Glut max/med, ext rotators, core, pelvic floor
Pre/Post measures, no control group
Muscle strength, Pain, Fxn’l status, P-F jt exam, Dynamic Ax, Biomech Ax
Tyler et al. (2006)
29 ♀ 6 ♂(8 bilat, total 43 knees)
6 wksClinic: ~2/wk & HEP: 1/day - Hip flexors, abductors, adductors
Pre/Post measures, no control group
Muscle strength, Pain,Flexibility, Physical Exam
Nakagawa et al. (2008)
10 ♀ 4 ♂
6 wksClinic: 1/wk and HEP: 4/wk - All: quads- Intervention group: TA, hip abductors, ext rotators
Control group vs. Intervention group
Muscle strength, Pain,EMG
All 3 studies used the Visual Analog Scale (VAS): Nakagawa et al. (2008): squatting and prolonged sitting Mascal et al. (2003): walking Tyler et al. (2006): ADLs and exercise
All 3 looked at the presence of pain with completion of stairs Tyler et al. (2006): climbing stairs (Y/N questionnaire) Nakagawa et al. (2008): ascending & descending stairs (VAS) Mascal et al. (2003): stairs in general (VAS)
Large ↓ in pain in participants in the Mascal et al. and Nakagawa et al. studies
Tyler et al. had a ↓ in their participant’s pain but at a smaller reduction
INTRODUCTION PFPS Overview PFPS Theory Systematic Review Purpose
METHODS Search Strategy Screening Strategy Quality Assessment Data Analysis
RESULTS Search Strategy Quality Assessment Data Extraction Outcomes
DISCUSSION CONCLUSION
Aim: investigate whether patients with PFPS could benefit from hip abductor strengthening to reduce their symptoms
Conclusion: limited amount of clinical research supporting this theory presently Further research required to clarify role of hip muscle
strengthening for certain PFPS patients
Similar PFPS theoretical framework: Lack of hip control and/or weak hip musculature
Excessive femoral internal rotation and adduction under patella
Relative lateral distraction of patella Increase patellofemoral joint stress
Wear on articular cartilage and altered lower extremity kinematics
Treatment Approach: focus on hip musculature control of femoral movement
Chronological progressive improvement in quality of study design
1. Mascal et al. (2003) – case study2. Tyler et al. (2006) – cohort study3. Nakagawa et al. (2008) – RCT
Hip abductor strength ↑ as a result of each treatment protocol
Mascal et al. & Nakagawa et al. Combination of ↑ hip muscle strength (abd & ER) &
motor control → improvement of L.E. kinematics
Tyler et al. Hip abductor strengthening not clinically significant Suggests other hip musculature reduces femoral internal
rotation
Mascal et al. & Nakagawa et al. Hip abductor & external rotator strength improvements
explain change in hip kinematics recorded pain reduction
Tyler et al. Implicates different sets of musculature changes
responsible for arriving at the same conclusion of pain reduction
These variables were not specifically evaluated and tabulated in any of the included articles
Possible increases in core and hip motor control may contribute to the decrease of PFPS symptoms
Small number of studies available
Total of 51 participants were studied: → limits the conclusions that can be made from the
resulting data
Heterogeneity between the included articles: → analysis and comparison more difficult → may result in themes being overlooked and not identified for discussion
RCTs
Increase sample size
Longitudinal studies with short, medium and long-term follow-up periods
Exercise protocols with core strengthening and hip motor control exercise
Differentiation for hip external rotation, extension and abduction musculature
INTRODUCTION PFPS Overview PFPS Theory Systematic Review Purpose
METHODS Search Strategy Screening Strategy Quality Assessment Data Analysis
RESULTS Search Strategy Quality Assessment Data Extraction Outcomes
DISCUSSION CONCLUSION
Physiotherapy Canada Distributed to a large population of our peers Reach PTs across different domains
Present research does not conclusively identify the benefits of hip abductor strengthening for PFPS treatment
PFPS patients present with unique biomechanical dysfunctions
Excessive femoral internal rotation and adduction pathology Multiple hip muscles may be involved
Patients with insidious knee pain require thorough assessment of the hip, as well as the knee, to determine cause of pain and best course of treatment