Sallie M. Cowan

Physical Therapy for Patellofemoral Pain A Randomized, Double-Blinded, Placebo-Controlled Trial

Background Although physical therapy forms the mainstay of nonoperative management for patellofemoral pain, its efficacy has not been established. Hypothesis Significantly more pain relief will be achieved from a 6-week regimen of physical therapy than from placebo treatment. Study Design Multicenter, randomized, double-blinded, placebo-controlled trial. Methods Seventy-one subjects, 40 years of age or younger with patellofemoral pain of 1 month or longer, were randomly allocated to a physical therapy or placebo group. A standardized treatment program consisted of six treatment sessions, once weekly. Physical therapy included quadriceps muscle retraining, patellofemoral joint mobilization, and patellar taping, and daily home exercises. The placebo treatment consisted of sham ultrasound, light application of a nontherapeutic gel, and placebo taping. Results Sixty-seven participants completed the trial. The physical therapy group (N = 33) demonstrated significantly greater reduction in the scores for average pain, worst pain, and disability than did the placebo group (N = 34). Conclusions A six-treatment, 6-week physical therapy regimen is efficacious for alleviation of patellofemoral pain.

Abnormal knee joint position sense in individuals with patellofemoral pain syndrome

The purpose of this cross‐sectional study was to compare knee joint position sense (JPS) in 20 individuals with and 20 without patellofemoral pain syndrome (PFPS). Five active tests with ipsilateral limb matching responses were performed at 20° and 60° flexion under non‐weightbearing conditions, and at 40° flexion under uni‐ and bi‐lateral weightbearing conditions. The response errors were calculated as the difference between each target and response position (accuracy) and the standard deviation of these differences (reliability).

Therapeutic patellar taping changes the timing of vasti muscle activation in people with patellofemoral pain syndrome

ObjectiveTo examine the effect of the application of tape over the patella on the onset of electromyographic (EMG) activity of vastus medialis obliquus (VMO) relative to vastus lateralis (VL) in participants with and without patellofemoral pain syndrome (PFPS). DesignRandomised within subject. SettingsUniversity laboratory. ParticipantsTen participants with PFPS and 12 asymptomatic controls. InterventionsThree experimental taping conditions: no tape, therapeutic tape, and placebo tape. Main Outcome MeasuresElectromyographic onset of VMO and VL assessed during the concentric and eccentric phases of a stair stepping task. ResultsWhen participants with PFPS completed the stair stepping task, the application of therapeutic patellar tape was found to alter the temporal characteristics of VMO and VL activation, whereas placebo tape had no effect. In contrast, there was no change in the EMG onset of VMO and VL with the application of placebo or therapeutic tape to the knee in the asymptomatic participants. ConclusionsThese data support the use of patellar taping as an adjunct to rehabilitation in people with PFPS.

Performance on the Single-Leg Squat Task Indicates Hip Abductor Muscle Function

Background: Contemporary clinical expertise and emerging research in anterior knee pain indicate that treatment of hip muscle function will result in greater effects, if such treatments can be provided to those with hip muscle dysfunction. Thus, it is imperative to develop and evaluate a clinical assessment tool that is capable of identifying people with poor hip muscle function. Hypothesis: The clinical assessment of single-leg squat performance will have acceptable inter- and intrarater reliability. Furthermore, people with good performance on the single-leg squat will have better hip muscle function (earlier onset of gluteus medius activity and greater lateral trunk, hip abduction, and external rotation strength) than people with poor performance. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: A consensus panel of 5 experienced clinicians developed criteria to rate the performance of a single-leg squat task as “good,” “fair,” or “poor.” The panel rated the performance of 34 asymptomatic participants (mean ± SD: age, 24 ± 5 y; height, 1.69 ± 0.10 m; weight, 65.0 ± 10.7 kg), and these ratings served as the standard. The ratings of 3 different clinicians were compared with those of the consensus panel ratings (interrater reliability) and to their own rating on 2 occasions (intrarater reliability). For the participants rated as good performers (n = 9) and poor performers (n = 12), hip muscle strength (hip abduction, external rotation, and trunk side bridge) and onset timing of anterior (AGM) and posterior gluteus medius (PGM) electromyographic activity were compared. Results: Concurrency with the consensus panel was excellent to substantial for the 3 raters (agreement 87%-73%; κ = 0.800-0.600). Similarly, intrarater agreement was excellent to substantial (agreement 87%-73%; κ = 0.800-0.613). Participants rated as good performers had significantly earlier onset timing of AGM (mean difference, –152; 95% confidence interval [CI], –258 to –48 ms) and PGM (mean difference, –115; 95% CI, –227 to –3 ms) electromyographic activity than those who were rated as poor performers. The good performers also exhibited greater hip abduction torque (mean difference, 0.47; 95% CI, 0.10-0.83 N·m·Bw−1) and trunk side flexion force (mean difference, 1.08; 95% CI, 0.25-1.91 N·Bw−1). There was no difference in hip external rotation torque (P > .05) between the 2 groups. Conclusion: Targeted treatments, although considered ideal, rely on the capacity to identify subgroups of people with chronic anterior knee pain who might respond optimally to a given treatment component. Clinical assessment of performance on the single-leg squat task is a reliable tool that may be used to identify people with hip muscle dysfunction.

Intrarater Test-Retest Reliability of Hip Range of Motion and Hip Muscle Strength Measurements in Persons With Hip Osteoarthritis

OBJECTIVE To examine the relative and absolute intrarater test-retest reliability of muscle strength and range of motion (ROM) measurements of the hip performed in people with hip osteoarthritis. DESIGN Repeated measures. SETTING Human movement laboratory of a university. PARTICIPANTS Participants (N=22; 10 men, 12 women; age range, 50-84y) with hip osteoarthritis. INTERVENTIONS On 2 separate occasions, at least 1 week apart, isometric torque measurements were obtained from the hip rotators, flexors, abductors, and extensors. Passive ROMs in hip rotation, flexion, abduction, and extension were also determined. MAIN OUTCOME MEASURES Relative reliability was estimated using the intraclass correlation coefficient, model 2,2 (ICC(2,2)). Absolute reliability was estimated using the coefficient of variation (CV) and the standard error (SE) of measurement. RESULTS For measurements of muscle strength, ICC(2,2) ranged from .84 to .97, and the CV ranged from 8% to 15.7%. Hip extensors and internal and external rotators showed high ICC(2,2) (>.96) and low CV (<9.8%); hip abductors showed the lowest ICC(2,2) (.84) and the highest CV (15.7%). For ROM measurements, ICC(2,2) ranged from .86 to .97 and SE ranged from 3.1 degrees to 4.7 degrees . Hip flexion ROM showed the highest ICC(2,2) (.97) and an SE of 3.5 degrees ; hip extension ROM showed the lowest ICC(2,2) (.86) and the highest SE (4.7 degrees ). CONCLUSIONS Strength and ROM testing of the hip in people with hip osteoarthritis can be performed with good to excellent reliability.

Delayed onset of transversus abdominus in long-standing groin pain.

UNLABELLED Long-standing groin pain is a persistent problem that is commonly difficult to rehabilitate. Theoretical rationale indicates a relationship between the motor control of the pelvis and long-standing groin pain; however, this link has not been investigated. PURPOSE The current experiment aimed to evaluate motor control of the abdominal muscles in a group of Australian football players with and without long-standing groin pain. METHODS Ten participants with long-standing groin pain and 12 asymptomatic controls were recruited for the study. Participants were elite or subelite Australian football players. Fine-wire and surface electromyography electrodes were used to record the activity of the selected abdominal and leg muscles during a visual choice reaction-time task (active straight leg raising). RESULTS When the asymptomatic controls completed the active straight leg raise (ASLR) task, the transversus abdominus contracted in a feed-forward manner. However, when individuals with long-standing groin pain completed the ASLR task, the onset of transversus abdominus was delayed (P < 0.05) compared with the control group. There were no differences between groups for the onset of activity of internal oblique, external oblique, and rectus abdominus (all P > 0.05). CONCLUSIONS The finding that the onset of transversus abdominus is delayed in individuals with long-standing groin pain is important, as it demonstrates an association between long-standing groin pain and transversus abdominus activation.

Altered hip and trunk muscle function in individuals with patellofemoral pain

Objective: The purpose of this study was to investigate the role of hip muscles in patellofemoral pain (PFP), specifically by investigating neuromotor control, strength and range of motion of the hip muscles. Design: Cross-sectional. Setting: University laboratory. Patients: Ten participants diagnosed with PFP and 27 asymptomatic controls were recruited, using standard inclusion and exclusion criteria. Main outcome measures: Electromyographic activity of the vasti and anterior gluteus medius (GM) were recorded using surface electrodes and posterior GM using fine wire electrodes while the participant completed a stair-stepping task. Hip strength and trunk side flexion strength was assessed using a hand-held dynamometer and hip range of motion with an inclinometer. Pain and disability measures were recorded for the PFP participants. Results: When individuals with PFP completed the stair-stepping task there was a delay in activation of both anterior and posterior GM (p<0.02) and an alteration in vasti control (p = 0.001). In addition, trunk side flexion strength was significantly less (29%) in individuals with PFP (p = 0.03). Conclusion: This study provides evidence that trunk side flexion strength and neuromotor control of the GM are affected in people with PFP. This study also confirms the presence of a delayed vastus medialis obliquus relative to vastus lateralis, providing further evidence underpinning the importance of retraining the vasti function in patients with PFP.

Simultaneous feedforward recruitment of the vasti in untrained postural tasks can be restored by physical therapy

Background and purpose: Physical therapy rehabilitation strategies are commonly directed at the alteration of muscle recruitment in functional movements. The aim of this study was to investigate whether feedforward strategies of the vasti in people with patellofemoral pain syndrome can be changed by a physical therapy treatment program in a randomised, double blind, placebo controlled trial.

Delayed Vastus Medialis Obliquus to Vastus Lateralis Onset Timing Contributes to the Development of Patellofemoral Pain in Previously Healthy Men A Prospective Study

Background Delayed onset of vastus medialis obliquus activity has been described in patellofemoral pain patients. No prospective study investigating the development of patellofemoral pain has tested the onset timing of electromyographic activity of the vastus medialis obliquus and vastus lateralis muscles during a functional task. Hypothesis Before the development of patellofemoral pain, subjects demonstrate an altered firing order of the vastus medialis obliquus and vastus lateralis muscles compared with healthy subjects during a functional task. Study Design Cohort study; Level of evidence, 2. Methods The onset of vastus medialis obliquus and vastus lateralis activity was measured with surface electromyography during a functional task (rocking back on the heels) in 79 healthy subjects subsequently submitted to a 6-week strenuous basic military training. Afterward, these subjects were reassessed. Results Thirty-two percent of the recruits developed patellofemoral pain during training. Patellofemoral pain subjects demonstrated a significant delay of onset of vastus medialis obliquus electromyographic activity compared with the healthy controls (P = .023), even before basic military training. In healthy subjects, no significant differences in electromyographic activity onset of the vastus medialis obliquus compared with the vastus lateralis could be identified before and after basic military training. A significant (P < .001) delay could be demonstrated in the patellofemoral pain group after basic military training. A binary logistic regression could be constructed wherein the onset of the electromyographic activity of the vastus medialis obliquus and vastus lateralis was withheld in the model. The most optimal cutoff value, which is based on the receiver operating characteristic curve, is a timing difference of −0.67 milliseconds (vastus medialis obliquus – vastus lateralis). The area under the receiver operating characteristic curve is considered as fair (0.68). Conclusion Delayed onset of electromyographic activity of the vastus medialis obliquus–vastus lateralis is one of the contributing risk factors to the development of patellofemoral pain.

Physiotherapy-led triage clinic for low back pain

The aims of this study were to evaluate a physiotherapy-led triage clinic (PLTC) and investigate general practitioner satisfaction with the PLTC. A retrospective cohort study was undertaken from January to December 2005 at a Melbourne tertiary teaching hospital. Outcomes assessed included waiting times to first appointment, patient attendance and surgery conversion rates. Outcomes were compared with the hospital 2002 benchmark data. GP satisfaction was evaluated by a survey. One-hundred and five new patients attended the PLTC clinic during the evaluation period. Patients waited 9 weeks for a PLTC appointment compared with 26 weeks for the general orthopaedic clinic and 23 weeks for the spinal orthopaedic clinic. Sixty-seven percent of the patients triaged in the PLTC were discharged from the orthopaedic outpatient department without requiring an orthopaedic surgeon consultation. Referring GPs were at least as satisfied with the management of their patients through the PLTC as with usual management in the general orthopaedic clinic. A PLTC can significantly reduce waiting times for orthopaedic outpatient appointments in a public hospital. Many patients can be managed by these experienced physiotherapists and their GPs, without the need for face-to-face contact with an orthopaedic surgeon. Pilot results indicated that GPs whose patients are managed in this PLTC were satisfied with this model for their patients with low back conditions.