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Role of Hip Abductor Strengthening in the Treatment of Patellofemoral Pain Syndrome Leduc, Yves; Hamm, Alyssa; Abel, Marilyn; Zarrinkamar, Pantea; Wiefelspuett, Silas 2009

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Presented by:Marilyn Abel, Alyssa Hamm, Yves Leduc, Silas Wiefelspuett, Pantea ZarrinkamarSupervisor: 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 CONCLUSIONNo universally accepted definition Retropatellar or peripatellar pain of insidious onset in the absence of other diagnosed pathological conditionsDescribes a spectrum of orthopedic abnormalities Most common diagnosis of knee pain in active adults and adolescents1 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 determineConsidered multi-factorialMain Current Theory:  Patellar maltracking within femoral trochlear notch caused by abnormal muscular and biomechanical forcesContributing Factors: ↑  Q angle Hypermobile patella Patella alta Pes planus  Weak quads↓  Flexibility of:QuadricepsHamstrings 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 femur2. 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 kinematicsPrins & Wurff, 2009Females with patellofemoral pain syndrome have weak hip muscles: a systematic reviewReview of 5 studies that measured hip strength in females with PFPSConcluded that females with PFPS show decreased strength in hip abduction, external rotation and extension when compared to healthy controls2. Femoral Internal Rotation/Adduction3. Relative Lateral Patellar Movement1. Weak Hip Musculature4. Knee PainIncreased femoral internal rotation in PFPS with functional movementsIncreased hip adduction angle in a prolonged runCurrent rehabilitation of PFPS focuses mainly on knee musculatureUse 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 CONCLUSIONPatellofemoral Pain Syndrome: anterior or retropatellar pain not associated with other identifiable pathological conditionsMEDLINE 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 33Additional databases searched:CINAHL, EMBASE, PEDro, SPORTDiscusGrey literature searchedGoogle, Google Scholar, Papers First, ProQuest Dissertation and ThesisReferences of selected articles were scannedAuthors in the field were contacted for additional information on unpublished data and studiesArticles were screened by 2 reviewersIn the case of a disagreement, consensus was met through a meeting of the reviewersThird party mediation was not neededScreening StrategyHip abductor strength as a component of Patellofemoral Pain Syndrome treatmentArticle 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) Subjects clinically diagnosed with Patellofemoral Pain Syndrome _____Intervention includes specific hip abductor strengthening _____Intervention is at least 4wks in duration, minimum 2-3 days/wk _____Comparisons are able to be drawn regarding the use of hip abductor strengthening as an effective component of treatment_____Study uses pain and hip abductor strength as a primary outcome _____Study is published in English, French, or German _____Subjects clinically diagnosed with PFPSSpecific hip abductor strengthening as part or whole of interventionIntervention duration minimum 4wks, 2-3 days/wkUses pain and hip abductor strength as outcome measuresComparisons are able to be drawn regarding the use of hip abductor strengthening as an effective component of treatmentStudies published in English, French or GermanSubjects with recent knee injuries in addition to PFPSSubjects with additional knee pathologies PEDro Scale was used to assess quality of included studiesProcess similar to that of Screening processData extraction tool used to collate relevant dataIndependently extracted by 2 reviewers and compared for consistencyIt 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 CONCLUSIONSearch StrategyOf 182 articles screened, 3 were eligibleArticles were excluded based on:Lack of interventionType of interventionFocus on other knee pathologies (i.e. ITBS, OA, TKA, etc)Auto alerts set up in MEDLINE, SPORTDiscus, Embase, and CINAHL1 article was retrieved from Embase  went to full text  included in the reviewMascal et al. 2003, Management of Patellofemoral Pain Targeting Hip, Pelvis and Trunk Muscle Function: 2 Case ReportsTyler et al. 2006, The Role of Hip Muscle Function in the Treatment of Patellofemoral Pain SyndromeNakagawa et al. 2008, The Effect of Additional Strengthening of Hip Abductor and Lateral Rotator Muscles in Patellofemoral Pain Syndrome: a Randomized Controlled Pilot StudyFirst 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 lengtheningQuad strengthening with hip abductor and external rotation strengthening (intervention group):↓ Pain during functional activitiesDid not identify which muscle group had greater contribution↑ hip eccentric ER and hip abd torque: not statistically significant but clinically significantSmall n & short Tx time → statistically insignificant↑ Hip motor control → clinically significantCommon PEDro trends amongst 3 included studies:Similar baseline groupsMeasured at least one key outcome in >85% of the subjectsProvided either treatment or control condition to all of their subjectsNone of the three studies blinded their therapists providing the treatmentStudies were not similar enough to compare quantitativelyData from studies was extracted and qualitatively compared based on PICO headings (Population, Intervention, Comparison, Outcomes)StudyParticipantsInterventionComparisonOutcomesMascal et al. (2003)2 ♀14 wksClinic: 1-2/wk & HEP: 2/day- Glut max/med, ext rotators, core, pelvic floorPre/Post measures, no control groupMuscle strength, Pain, Fxn’l status, P-F jt exam, Dynamic Ax, Biomech AxTyler et al. (2006)29 ♀ 6 ♂(8 bilat, total 43 knees)6 wksClinic: ~2/wk & HEP: 1/day - Hip flexors, abductors, adductorsPre/Post measures, no control groupMuscle strength, Pain,Flexibility, Physical ExamNakagawa et al. (2008)10 ♀ 4 ♂6 wksClinic: 1/wk and HEP: 4/wk - All: quads- Intervention group: TA, hip abductors, ext rotatorsControl group vs. Intervention groupMuscle strength, Pain,EMGAll 3 studies used the Visual Analog Scale (VAS):Nakagawa et al. (2008): squatting and prolonged sittingMascal et al. (2003): walkingTyler et al. (2006): ADLs and exerciseAll 3 looked at the presence of pain with completion of stairsTyler 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. studiesTyler 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 CONCLUSIONAim: investigate whether patients with PFPS could benefit from hip abductor strengthening to reduce their symptomsConclusion: limited amount of clinical research supporting this theory presentlyFurther research required to clarify role of hip muscle strengthening for certain PFPS patientsSimilar 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 kinematicsTreatment Approach: focus on hip musculature control of femoral movementChronological progressive improvement in quality of study designMascal et al. (2003) – case studyTyler et al. (2006) – cohort studyNakagawa et al. (2008) – RCTComparable outcome measures in all three studies:1. ∆ hip abductor strength 2. ∆ painHip abductor strength ↑ as a result of each treatment protocolMascal et al. & Nakagawa et al. Combination of ↑ hip muscle strength (abd & ER) & motor control → improvement of L.E. kinematicsTyler et al.Hip abductor strengthening not clinically significantSuggests other hip musculature reduces femoral internal rotationMascal 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 articlesPossible increases in core and hip motor control may contribute to the decrease of PFPS symptomsSmall number of studies availableTotal of 51 participants were studied: 	→ limits the conclusions that can be made from the 	resulting dataHeterogeneity between the included articles: 	→ analysis and comparison more difficult 	→ may result in themes being overlooked and not 	identified for discussionRCTsIncrease sample size Longitudinal studies with short, medium and long-term follow-up periodsExercise protocols with core strengthening and hip motor control exerciseDifferentiation 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 CONCLUSIONPhysiotherapy CanadaDistributed to a large population of our peersReach PTs across different domainsPresent research does not conclusively identify the benefits of hip abductor strengthening for PFPS treatmentPFPS patients present with unique biomechanical dysfunctionsExcessive femoral internal rotation and adduction pathology Multiple hip muscles may be involvedPatients with insidious knee pain require thorough assessment of the hip, as well as the knee, to determine cause of pain and best course of treatmentDr. Donna MacIntyreCharlotte Beck Dr. Darlene ReidDr. Elizabeth Dean ****************************** P resented by: M arilyn Abel, Alys sa Hamm, Yves Leduc, S ilas Wiefels puett, P antea Zarrinkamar S upervis or: D r. D onna M acIntyre   INTR ODUC TION  P FP S O verview  P FP S Theory  S ys tematic R eview P urpos e   METHODS  S earch S trategy  S creening S trategy  Q uality As ses sment  D ata Analysis   R ES ULTS  S earch S trategy  Q uality As ses sment  D ata E xtraction  O utcomes   DIS C US S ION  C ONC LUS ION    No univers ally accepted definition    R etropatellar or peripatellar pain of insidious onset in the abs ence of other diagnos ed pathological conditions    D escribes a spectrum of orthopedic abnormalities    M ost common diagnosis of knee pain in active adults and adoles cents    1 in 4 of total population; females > men      E xacerbated by prolonged sitting & repetitive weight-bearing activities ↓ Q uality O f Life   ↓ P articipation in exercises or sports    ↑ E conomic burden (medical cost, days off work, etc)    D ifficult to determine    C onsidered multi-factorial    Main C urrent Theory:   P atellar maltracking within femoral trochlear notch caused by abnormal muscular and biomechanical forces  C ontributing Factors : Q angle Hypermobile patella P atella alta P es planus Weak quads   ↑        ↓      Flexibility of: Q uadriceps Hamstrings G astrocnemius Iliotibial band (ITB )    P otential mechanis ms of patellar maltracking: 1. VL tends to be s tronger and/or activates prior to the VM O  P atella tracks laterally in the trochlear groove of the  femur  2. Weak hip abductors  E xcess ive femoral internal rotation and adduction under patella  R elative lateral distraction of patella  Increas e patellofemoral joint stress    P rins & Wurff, 2009   Females with patellofemoral pain syndrome have weak hip muscles: a systematic review  R eview of 5 studies that measured hip strength in  females with P FP S  C oncluded that females with P FP S show  decreased strength in hip abduction, external rotation and extension when compared to healthy controls  1. Weak Hip Musculature  2. Femoral Internal Rotation/Adduction 3. Relative Lateral Patellar Movement  4. Knee Pain    Increas ed femoral internal rotation in P FP S with functional movements    Increas ed hip adduction angle in a prolonged run    C urrent rehabilitation of P FP S focuses mainly on knee mus culature    Use of hip abductor strengthening as a treatment option needs to be investigated   INTR ODUC TION  P FP S O verview  P FP S Theory  S ys tematic R eview P urpos e   METHODS  S earch S trategy  S creening S trategy  Q uality As ses sment  D ata Analysis   R ES ULTS  S earch S trategy  Q uality As ses sment  D ata E xtraction  O utcomes   DIS C US S ION  C ONC LUS ION    Patellofemoral Pain S yndrome: anterior or retropatellar pain not ass ociated with other identifiable pathological conditions  MEDLINE s earch 1. P atellofemoral P ain S yndrome/  2. patellofemoral pain.ti,ab. 3. knee pain.mp. 4. runner's knee.mp. 5. pfps.mp. 6. anterior knee pain.mp 7. peripatellar pain.mp 8. retropatellar pain.mp. 9. chondromalacia patella.mp 10. patellofemoral.mp 11. patellofemoral arthralgia.mp. 12. patellar pain.mp 13. patellar pain syndrome.mp 14. patellofemoral syndrome.mp 15. 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 14 16. physical therapy.mp 17. R ehabilitation/  18. rehabilitation.mp. 19. physiotherapy.mp. 20. exp E xercise Therapy/ or exp E xercis e/ 21. M uscle S trength/ 22. s trength*.mp 23. resistance training.mp 24. "P hysical Therapy (S pecialty)"/ or exp P hys ical Therapy M odalities/ 25. exp weight lifting/ 26. 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 27. hip abduct*.mp. 28. hip muscle*.mp 29. 27 or 28 30. Hip Joint/ 31. Hip/ 32. 30 or 31 33. 26 and 29 and 32 34. 15 and 33    Additional databas es s earched:     C INAHL, E M BAS E , P E D ro, S P O R TD iscus  Grey literature s earched   G oogle, G oogle S cholar, P apers First, P roQ uest D issertation and Thesis    R eferences of s elected articles were scanned    Authors in the field were contacted for additional information on unpublis hed data and studies  S creening S trateg y   Articles were screened by 2 reviewers    In the cas e of a dis agreement, consensus was met through a meeting of the reviewers    Third party mediation was not needed  Hip abductor s treng th as a component of Patellofemoral Pain S yndrome treatment Article S creening Form (Adapted from Westby, M D ) R efWorks ID : _________________ S creening date: ________________ R eviewer: AH, Y L C itation:________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ ____________________ Level of R eview: Title - Appropriate? YE S _____ NO _____ (reason) __________________ Abstract - Appropriate? YE S _____ NO _____ (reason) __________________ Included for full text review? YE S _____ NO _____ (reason) __________________   Full Text Article R eview: S tudy D esign: R C T _____ C C T or Quasi-R C T _____ C rossover _____ R eview _____ C ase-C ontrol _____ S ingle S ubject_____  C ohort _____ P re-P ost (no control) ____  C ase S eries _____    S election C riteria: (all 6 of the selection criteria must be met for inclusion to the systematic review)   1. S ubjects clinically diagnosed with P atellofemoral P ain S yndrome _____ 2. Intervention includes specific hip abductor s trengthening _____ 3. Intervention is at least 4wks in duration, minimum 2-3 days/wk _____ 4. C omparisons are able to be drawn regarding the use of hip abductor strengthening as an effective component of treatment_____    S ubjects clinically diagnosed with P FP S    Uses pain and hip abductor s trength as outcome meas ures    S pecific hip abductor strengthening as part or whole of intervention      Intervention duration minimum 4wks, 2-3 days/wk  C omparisons are able to be drawn regarding the use of hip abductor s trengthening as an effective component of treatment    S tudies publis hed in E nglish, French or G erman    S ubjects with recent knee injuries in addition to P FP S    S ubjects with additional knee pathologies    P E D ro S cale was used to asses s quality of included s tudies    P roces s similar to that of S creening process    D ata 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   INTR ODUC TION  P FP S O verview  P FP S Theory  S ys tematic R eview P urpos e   METHODS  S earch S trategy  S creening S trategy  Q uality As ses sment  D ata Analysis   R ES ULTS  S earch S trategy  Q uality As ses sment  D ata E xtraction  O utcomes   DIS C US S ION  C ONC LUS ION    S earch S trateg y   O f 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 , O A, TKA,  etc)   Auto alerts set up in M E D LINE , S P O R TD iscus, E mbase, and C INAHL  1 article was retrieved from E mbas e  went to full text   included in the review    Mas cal et al. 2003, M anagement of P atellofemoral P ain Targeting Hip, P elvis and Trunk M us cle Function: 2 C as e R eports    Tyler et al. 2006, The R ole of Hip M uscle Function in the Treatment of P atellofemoral P ain S yndrome    Nakag awa et al. 2008, The E ffect of Additional S trengthening of Hip Abductor and Lateral R otator M us cles in P atellofemoral P ain S yndrome: a R andomized C ontrolled P ilot S tudy    Firs t study to assess the role of hip musculature in P FP S treatment    P rogres sive hip muscle strengthening (glut max and med, hip abd, and E R ):   P ain relief and improved biomechanical kinematics in a step-down exercise (decreased hip adduction and femoral internal rotation)    S trengthened hip flexors, abductors, adductors & stretched hip flexors and ITB    ↑ Hip abductor s trength: not s ignificant for pain relief    C ombined iliops oas strengthening & lengthening with ITB lengthening    Quad s trengthening with hip abductor and external rotation s trengthening (intervention group): ↓ P ain during functional activities  D id not identify which muscle group had greater contribution     ↑ hip eccentric E R and hip abd torque: not statistically s ignificant but clinically significant   S mall n & short Tx time → statistically insignificant    ↑ Hip motor control → clinically significant    C ommon P E D ro trends amongs t 3 included studies:  S imilar baseline  groups   M easured  at leas t one key outcome in >85% of the subjects   P rovided  either treatment or control condition to all of their subjects   None  of the three s tudies blinded their therapis ts providing the treatment    S tudies were not similar enough to compare quantitatively    D ata from s tudies was extracted and qualitatively compared bas ed on P IC O headings (P opulation, Intervention, C omparison, O utcomes )  S tudy  Participants  Intervention  C omparis on  Outcomes  M ascal et al. (2003)  2♀  14 wks C linic: 1-2/wk & HE P : 2/day - Glut max/med, ext rotators, core, pelvic floor  P re/P os t meas ures, no control group  M uscle strength, P ain, Fxn’l status, P -F jt exam, D ynamic Ax, B iomech Ax  Tyler et al. (2006)  29 ♀ 6♂ (8 bilat, total 43 knees)  6 wks C linic: ~2/wk & HE P : 1/day - Hip flexors, abductors, adductors  P re/P os t meas ures, no control group  M uscle strength, P ain, Flexibility, P hysical E xam  Nakagawa et al. (2008)  10 ♀ 4♂  6 wks C linic: 1/wk and HE P : 4/wk - All: quads - Intervention group: TA, hip abductors, ext rotators  C ontrol group vs. Intervention group  M uscle strength, P ain, EMG    All 3 studies us ed the Visual Analog S cale (VAS ): Nakagawa et al. (2008): s quatting and prolonged s itting  M as cal et al. (2003): walking  Tyler et al. (2006): AD Ls and exercise     All 3 looked at the pres ence of pain with completion of stairs Tyler et al. (2006): climbing s tairs (Y/N ques tionnaire)  Nakagawa et al. (2008): ascending & des cending stairs (VAS )  M as cal et al. (2003): s tairs in general (VAS )     Large ↓ in pain in participants in the M ascal et al. and Nakagawa et al. studies    Tyler et al. had a ↓ in their participant’s pain but at a smaller reduction   INTR ODUC TION  P FP S O verview  P FP S Theory  S ys tematic R eview P urpos e   METHODS  S earch S trategy  S creening S trategy  Q uality As ses sment  D ata Analysis   R ES ULTS  S earch S trategy  Q uality As ses sment  D ata E xtraction  O utcomes   DIS C US S ION  C ONC LUS ION    Aim: inves tigate whether patients with P FP S could benefit from hip abductor strengthening to reduce their symptoms    C onclus ion: limited amount of clinical research s upporting this theory presently   Further research required to clarify role of hip muscle strengthening for certain P FP S patients    S imilar PFPS theoretical framework:   Lack of hip control and/or weak hip musculature   E xcess ive femoral internal rotation and adduction under patella  R elative 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    C hronological progres sive improvement in quality of s tudy des ign M ascal et al. (2003) – case study 2. Tyler et al. (2006) – cohort s tudy 3. Nakagawa et al. (2008) – R C T 1.    C omparable outcome measures in all three studies: 1. ∆ hip abductor s trength 2. ∆ pain    Hip abductor strength ↑ as a res ult of each treatment protocol    M ascal et al. & Nakagawa et al.     C ombination of ↑ hip muscle strength (abd & E R ) & motor control → improvement of L.E . kinematics  Tyler et al.    Hip abductor strengthening not clinically significant S uggests other hip musculature reduces femoral internal rotation    M ascal 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 s pecifically evaluated and tabulated in any of the included articles    P os sible increas es in core and hip motor control may contribute to the decrease of P FP S symptoms    S mall number of s tudies available    Total of 51 participants were s tudied: → limits the conclus ions that can be made from the res ulting data    Heterogeneity between the included articles: → analys is and comparison more difficult → may result in themes being overlooked and not identified for discussion    R C Ts    Increas e s ample s ize    Longitudinal s tudies with s hort, medium and long-term follow-up periods    E xercise protocols with core strengthening and hip motor control exercise    D ifferentiation for hip external rotation, extens ion and abduction musculature   INTR ODUC TION  P FP S O verview  P FP S Theory  S ys tematic R eview P urpos e   METHODS  S earch S trategy  S creening S trategy  Q uality As ses sment  D ata Analysis   R ES ULTS  S earch S trategy  Q uality As ses sment  D ata E xtraction  O utcomes   DIS C US S ION  C ONC LUS ION    P hysiotherapy C anada D istributed to a large population of our peers  R each P Ts across different domains     P resent research does not conclusively identify the benefits of hip abductor strengthening for P FP S treatment    P FP S patients present with unique biomechanical dys functions    E xcess ive femoral internal rotation and adduction pathology     M ultiple hip muscles may be involved  P atients with ins idious knee pain require thorough assessment of the hip, as well as the knee, to determine cause of pain and best course of treatment    D r. D onna M acIntyre    C harlotte Beck    D r. D arlene R eid    D r. E lizabeth D ean  

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