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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