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Presented by: Marilyn Abel, Alyssa Hamm, Yves Leduc, S ilas Wiefelspuett, Pantea Zarrinkamar S upervisor: Dr. Donna MacIntyre  INTRODUCTION  PFPS  Overview  PFPS  Theory  S ystematic Review Purpose  METHODS  S earch S trategy  S creening S trategy  Quality Assessment  Data Analysis  RES ULTS  S earch S trategy  Quality Assessment  Data Extraction  Outcomes  DIS CUS S ION  CONCLUS ION  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  S ystematic Review Purpose  METHODS  S earch S trategy  S creening S trategy  Quality Assessment  Data Analysis  RES ULTS  S earch S trategy  Quality Assessment  Data Extraction  Outcomes  DIS CUS S ION  CONCLUS ION  Patellofemoral Pain S yndrome: anterior or retropatellar pain not associated with other identifiable pathological conditions MEDLINE search 1. Patellofemoral Pain 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. Rehabilitation/ 18. rehabilitation.mp. 19. physiotherapy.mp. 20. exp Exercise Therapy/ or exp Exercise/ 21. Muscle S trength/ 22. strength*.mp 23. resistance training.mp 24. "Physical Therapy (S pecialty)"/ 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 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 databases searched:  CINAHL, EMBAS E, PEDro, S PORTDiscus  Grey literature searched  Google, Google S cholar, 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 S creening S trategy Hip abductor s trength as  a component of Patellofemoral Pain S yndrome treatment Article S creening Form (Adapted from Westby, MD)              RefWorks ID: _________________  S creening date: ________________ Reviewer: AH, YL C itation:________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ ____________________ Level of Review: Title - Appropriate? YES  _____ NO _____ (reason) __________________ Abstract - Appropriate?  YES  _____ NO _____ (reason) __________________ Included for full text review? YES  _____ NO _____ (reason) __________________   Full Text Article Review: S tudy Design: RCT _____ CCT or Quasi-RCT _____ Crossover _____ Review _____ Case-Control _____ Cohort _____ Case S eries _____ S ingle S ubject_____ Pre-Post (no control) ____   S election Criteria: (all 6 of the selection criteria must be met for inclusion to the systematic review)   1. S ubjects clinically diagnosed with Patellofemoral Pain S yndrome _____ 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. S tudy uses pain and hip abductor strength as a primary outcome _____ 6. S tudy is published in English, French, or German _____  S ubjects clinically diagnosed with PFPS  S pecific 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  S tudies published in English, French or German  S ubjects with recent knee injuries in addition to PFPS  S ubjects with additional knee pathologies   PEDro S cale was used to assess quality of included studies  Process similar to that of S creening 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  S ystematic Review Purpose  METHODS  S earch S trategy  S creening S trategy  Quality Assessment  Data Analysis  RES ULTS  S earch S trategy  Quality Assessment  Data Extraction  Outcomes  DIS CUS S ION  CONCLUS ION  S earch S trategy  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, S PORTDiscus, Embase, and C INAHL  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 S yndrome  Nakagawa et al. 2008, The E ffect of Additional S trengthening of Hip Abductor and Lateral Rotator Muscles in Patellofemoral Pain S yndrome: a Randomized Controlled Pilot S tudy  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)  S trengthened 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 s ignificant but clinically s ignificant  S mall n & short Tx time → statistically insignificant  ↑ Hip motor control → clinically significant   Common PEDro trends amongst 3 included studies:  S imilar 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  S tudies were not similar enough to compare quantitatively  Data from studies was extracted and qualitatively compared based on PICO headings (Population, Intervention, Comparison, Outcomes) S tudy Participants Intervention Comparison Outcomes Mascal et al. (2003) 2 ♀ 14 wks Clinic: 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 wks Clinic: ~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 wks Clinic: 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 S cale (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  S ystematic Review Purpose  METHODS  S earch S trategy  S creening S trategy  Quality Assessment  Data Analysis  RES ULTS  S earch S trategy  Quality Assessment  Data Extraction  Outcomes  DIS CUS S ION  CONCLUS ION  Aim: investigate whether patients with PFPS could benefit from hip abductor strengthening to reduce their symptoms  Conclus ion:  limited amount of clinical research supporting this theory presently  Further research required to clarify role of hip muscle strengthening for certain PFPS  patients  S imilar 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 study 2. Tyler et al. (2006) –  cohort study 3. Nakagawa et al. (2008) –  RCT  Comparable outcome measures in all three studies: 1. ∆ hip abductor strength 2. ∆ pain  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  S uggests 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  S mall 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  S ystematic Review Purpose  METHODS  S earch S trategy  S creening S trategy  Quality Assessment  Data Analysis  RES ULTS  S earch S trategy  Quality Assessment  Data Extraction  Outcomes  DIS CUS S ION  CONCLUS ION  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  Dr. Donna MacIntyre  Charlotte Beck  Dr. Darlene Reid  Dr. E lizabeth Dean