Sports Medicine Research: In the Lab & In the Field: A Novel Rehabilitation Program To Improve Patellofemoral Pain Syndrome Outcomes (Sports Med Res)
Friday, March 28, 2014

A Novel Rehabilitation Program To Improve Patellofemoral Pain Syndrome Outcomes

Effects of Functional Stabilization Training on Pain, Function, and Lower Extremity Biomechanics in Females with Patellofemoral Pain: A Randomized Clinical Trial.

Baldon RD, Serrao FV, Silva RS, Piva SR. J Ortho Sports Phys Ther. 2014 Feb 25. [Epub ahead of print]

Take Home Message: A rehabilitation program that uses hip and trunk strengthening with verbal feedback and proper instruction during rehab provided greater pain reduction, improved strength, and improved squatting mechanics compared with a standard rehabilitation program that was focused on quadriceps strengthening.

Patellofemoral Pain Syndrome (PFPS) is a common knee pathology that is often challenging for clinicians because there are many contributing factors. Clinicians have started to focus on proximal strengthening for patients with PFPS but there is limited evidence about whether these programs influence lower extremity biomechanics.  If these programs improve lower extremity biomechanics then it may help explain how proximal strengthening programs influence pain and suggest that these programs may modify an important risk factor for PFPS.  Therefore, Baldon and colleagues compared two rehabilitation programs among female individuals with PFPS to assess changes in pain, Lower Extremity Functional Scale, Global Rating of Change, single-leg triple hop distance, muscle strength, muscle endurance, and single-leg squat kinematics.  The authors randomized 31 females with PFPS into two 8-week treatment groups: 1) a standard rehabilitation program that focused on quadriceps strengthening or 2) a functional stabilization program, which included hip and trunk strengthening exercises as well as verbal cues during lower extremity and trunk movements. Both groups improved in pain immediately after the intervention and at a 3-month follow up compared with prior to treatment; however, those in the functional stabilization program had greater improvements in pain.  Both groups also had improvements in the Lower Extremity Functional Scale score immediately following the intervention and at the 3-month follow up.  More participants in the functional stabilization group (14 out of 14 participants) perceived themselves as moderately better at the end of the intervention compared with participants in the standard rehabilitation program (12 out of 16 participants).  Those in the functional stabilization group also had better hopping distance, trunk endurance, and eccentric hip abductor and knee flexor strength. Individuals in the functional stabilization group also had improved biomechanics during a single-leg squat immediately after the intervention. For example, increased hip flexion and decreased ipsilateral trunk inclination, contralateral pelvis depression, hip adduction, and knee abduction.

These findings show the value of using a functional stabilization program compared with just quadriceps strengthening programs for individuals with PFPS.  The authors demonstrated that the functional stabilization program and not the standard rehabilitation program influenced a participant’s single-leg squat biomechanics. Patients with PFPS perform functional tasks with more hip adducted, knee abducted, and ipsilateral trunk inclination, which may place more pressure on the lateral patellofemoral joint.  Since the functional stabilization program modified these mechanics it might indicate that trunk and gluteus medius strengthening with proper verbal cures can modify movement patterns and minimize pain and stress placed on the patellofemoral joint. What is unclear from this study is which component of the stabilization program is beneficial for improving biomechanical assessment; gluteus medius strengthening, trunk strengthening, verbal cues during exercise or a combination of the three? Future research needs to continue to examine functional deficits in the PFPS population, find the most effective components for a rehabilitation program, and how we can individualize programs. Overall, this study supports the use of functional stabilization programs over standard rehabilitation programs because it provided greater pain relief and improved biomechanics, which may decrease the high levels of recurrent rates for individuals experiencing PFPS (up to 91%)

Question for DiscussionDo you currently use hip strengthening with your patients who have PFPS?  How have your long-term outcomes faired with this rehabilitation approach?

Written by: Neal Glaviano
Reviewed by: Jeffrey Driban

Related Posts:

Baldon RD, SerrĂ£o FV, Silva RS, & Piva SR (2014). Effects of Functional Stabilization Training on Pain, Function, and Lower Extremity Biomechanics in Females With Patellofemoral Pain: A Randomized Clinical Trial. The Journal of Orthopaedic and Sports Physical Therapy PMID: 24568258

8 comments:

Scott Porter said...

I have two athletes suffering from PFPS right now. I have found that Gluteus Med. strengthening along with a verbal cues to maintain patella alignment over the 2nd and 3rd ray during squat/lunge exercises is vital. Although 1 athlete was a significant Q angle limitation, maintaining VMO activation and strengthening the adductors / hip internal rotators have also seemed to help over the course of 2 weeks.

Paul Murata said...

I work with DI women's basketball and along with our strength & conditioning coach we have implemented a Corrective Exercise approach that includes functional stability but we emphasis quad strength on those with pfps. I'm not sure if you'll ever eliminate pain especially if they have a biomechanical disadvantage such as patella alta but we've found a significant pain reduction. In some cases complete reduction. We'll slowly build a base with freshman and I'll do the traditional treatment and use some kind of pat-stap but after some time, the patient will no longer feel the need for them. I feel the hardest part is helping them through the strengthening stage. Everyone needs to be on the same page and know when to push, know when to hold back and understand how to recover. Diet, exercise scheduling and sleep play a huge role as well but to focus on this article I would, in short say I agree.

Paul Murata said...

Our strength and conditioning coach just reminded me of another point. Ankle mobility is a big issue as well. If they do not have adequate Rom of their ankle then that will affect hip ROM

Neal said...

Scott - I agree, with some of my previous experiences in the past introducing hip abduction exercises has produced positive results in some of my PFPS patient. The interesting thing would be to see the recurrence rate in these individuals. I am unfamiliar of any research that has looked at long term results besides a "traditional" quadriceps rehab plan in the PFPS literature.

Paul - I think you bring up some excellent points. Having a treatment plan that includes the strength and conditioning coach when available can have a profound outcome for the patient. I like your approach at using functional stability early in their career. Have you seen a reduction in the overall number of injuries in these athletes since implementing this model?

Your strength and conditioning coach also brings up a very interesting topic that is sometimes over looked - ankle mobility. Dr. Piva from the current paper has previously looked at a variety of limitations seen in PFPS patients. She found that improvements in gastrocnemius flexibility over time was the only limitation that predicted improved functional outcomes. I think this shows value in an individualized rehabilitation program that uses a multifaceted approach for PFPS patients.

Paul Murata said...

Neal, we really haven't had any significant injuries this season but it's still too early to say if our model is the reason why. This is our 1st full season using it (starting in June). I can tell you that the team was averaging 2 surgeries a year but (knock on wood) we haven't had any this season. We had one ankle and one shoulder sprain but both were very early in the season (November) and we haven't had anything else since. We're heading into the NCAA Sweet 16 with a full, healthy team (again, knock on wood). We've been pretty fortunate this year but there are a few things that could be better. We'll see what happens next year.

Perry Singer said...

I use hip strengthening with my patients who have PFPS. This is a quite effective rehabilitation program having a good degree of success.

Sarah Coronel said...

Thank you for sharing your article! I found it very interesting to see which rehabilitation program was more successful. In the articles that I have been reading about patients with patellofemoral pain syndrome (PFPS), the results have been showing hip weakness. The results of this article support the others by showing a greater reduction of pain and improved mechanics after the functional stabilization rehabilitation. I have learned that it is important to incorporate quadriceps strengthening during rehabilitation of patients with PFPS, but even more important to strengthen the hip and trunk stabilizers.

Neal said...

Sarah,

I agree, it is important to incorporate strength training to both the quadriceps and gluteal muscles. These patients often present with such a wide range of symptoms and impairments it really makes things challenging for optimal treatment. I found clinically that some patients will not tolerate weight bearing quadriceps exercises early due to increased pain when loading the patellofemoral joint. Research by Dolak et al. and Ferber et al. have both found that using a hip focused program decreases knee pain sooner that just quadriceps focused exercise, which may help those patients.

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