of Manual Therapy Combined With Physical Therapy in Treatment of
Pain Syndrome: Systematic Review

GV, Amal-Gomez A, Balasch-Bernat M, & Ingles M. J Chiropr Med. 2017; 16(2): 139-146.
Take Home Message: Rehabilitation with manual therapy are
effective at managing patellofemoral pain syndrome.  The benefits are further augmented when the
hip is targeted in rehabilitation. 
Patellofemoral pain syndrome (PFPS)
is a common cause of knee pain in the athletic and physically active
populations.  Treatment and management
can be challenging, but often include therapeutic exercises, in addition to other
approaches such as anti-inflammatory medication, taping/supporting, and manual
therapy.  The authors conducted a systematic
review of randomized controlled clinical trials to determine if manual therapy with
other rehabilitation components (e.g, therapeutic exercises, taping, modalities)
was effective at managing PFPS.   The
authors included “high quality” trials (Jadad score ≥3 out of
5) conducted within the last 10 years on adults with PFPS.  The 5 included studies investigated a variety
of manual therapy techniques including mobilizations, stretching, & proprioceptive
neuromuscular facilitation (PNF) stretching. 
Overall, the authors reported that rehabilitation components combined with
manual therapy is effective at reducing pain affiliated with PFPS.  The pain relief was further aided when the
treatment targeted other joints in the closed kinetic chain, such as hip
Clinically, the findings of this
review confirm that a multi-modal and multi-joint approach are beneficial when
dealing with PFPS.  The trials explored a
variety of manual therapy techniques, which prevented the authors from doing a
meta-analysis to determine which technique was most effective.  There is a need to investigate certain
approaches rather than an all-encompassing “manual therapy” group.  Stretching was deemed a manual therapy,
however, it is much different than mobilizations.  It would be interesting to see whether
self-stretching versus clinician-guided stretching were drastically
different.  The authors of this study
echoed previous findings that an approach that includes the entire lower
extremity kinetic chain is important in managing PFPS.  However, there is still more comparison
needed as to whether the addition of manual therapy is better than just
rehabilitation alone.  It would also be
interesting to see if joint mobilizations (or other manual therapy techniques)
applied to the hip or ankle joints would have an effect on pain associated with
PFPS.  Ultimately, this systematic review
confirms that our patients with PFPS can benefit from a rehabilitation program
for the entire kinetic chain that includes manual therapy techniques.
for Discussion:  What exercises are you
sure to include when dealing with PFPS? 
What manual therapy techniques have you found to provide relief in
dealing with PFPS? 
by: Nicole Cattano
by: Jeffrey Driban
Note: The last two courses are still pending review for EBP CEU status but are available for regular BOC CEUs.