Adding motor control training to muscle strengthening did not substantially improve the effects on clinical or kinematic outcomes in women with patellofemoral pain: A randomised controlled trial

doi:10.1016/j.gaitpost.2017.08.018

Gait & Posture

Volume 58, October 2017, Pages 280-286

https://doi.org/10.1016/j.gaitpost.2017.08.018 Get rights and content

Highlights

•
Knee and posterolateral hip muscle strengthening should be used in the treatment of women with PFP.
•
Hip muscle strengthening caused no significant changes in the movements of the patients during the step down task.
•
Movement control training added to a conventional strength training program did not present better results during four weeks.

Abstract

Design

Randomized controlled trial.

Background

Patients with Patellofemoral pain (PFP) usually present muscular weakness, pain and impaired motor control. Muscle strengthening is an effective treatment strategy for PFP, but the additional benefits of movement control training remain unknown. Therefore, the aim of this study was to compare the effects of movement control training associated with muscle strengthening, with a conventional program of strengthening alone in women with PFP.

Methods

Thirty-four women were randomly assigned to two groups. The Strengthening group (S group) performed 12 sessions to strengthen the knee and hip muscles. The Movement Control & Strengthening group (MC&S group) performed the same exercises and movement control training of the trunk and lower limbs. Effects of the treatment (i.e., between-group differences) were calculated using linear mixed models. Primary outcomes were function and pain intensity after completion of the treatment protocol. Secondary outcomes were; muscle strength and kinematic outcomes during the step down task after 4 weeks of treatment; and function and pain intensity 3 and 6 months after randomization.

Results

The MC&S group did not present significantly better function (MD −2.5 points, 95% CI;−10.7–5.5) or pain (MD −0.3 points, 95% CI;−1.7–1.0) at 4 weeks. There was a small difference in favour of the MC&S group for AKPS scores at 3 months (MD −8.5 points; 95% CI;−16.8 to −0.3). No significant between-group differences were observed for the other outcomes.

Conclusion

Movement control training was no more effective than the isolated strengthening protocol, in terms of pain, function, muscle strength, or kinematics.

Introduction

Patellofemoral pain (PFP) is one of the most common knee disorders in clinical practice [1]. PFP affects both young and active individuals [2] and is more common in women than in men [3]. The etiology has been described as multifactorial [4] and as a result, diagnosing and treating PFP have become a clinical challenge [5]. In this context, it has been suggested that proximal factors, such as hip muscle weakness [5], [6] and altered movements of the trunk and lower limbs, such as increased ipsilateral trunk lean, contralateral pelvic drop, hip adduction, and internal rotation [5], [7], [8], besides local factors, such as weak quadriceps [4], [5], seem to play an important role in the development of PFP.

Concerning the treatment of PFP, strengthening the knee, hip, and trunk muscles is a well-known method of improving functional capacity and decreasing pain in the short and long term [9], [10], [11], [12]. Given the above, it seems plausible that justification for the success of strengthening programs is through correction of the biomechanical alterations [9], [10]. However, research demonstrates that, despite the clinical improvement, muscle strengthening alone is not sufficient to change the kinematics of healthy individuals [13], [14] or those with PFP [15], [16], [17].

In contrast, research investigating the effects of neuromuscular training on PFP observed improvement in pain and alterations in the biomechanical behavior [17], [18], [19]. However, to date there is little evidence on the effects of the association of proximal and local muscle strengthening with motor control training [20], [21]. In this context, to our knowledge, the only clinical trial that addressed these two strategies [21] compared the training of stabilization of movement and trunk, hip, and knee muscular strengthening with stretching and strengthening of the quadriceps, which limited interpretation of the real effect of the addition of movement control training to the proximal and local strengthening program, which is already considered superior to isolated quadriceps strengthening [11], [12].

The aim of this study was to determine if adding movement control training to a conventional knee and hip muscle strengthening program would produce better clinical outcomes and improved muscle strength and kinematics compared to strengthening alone in women with PFP. Our hypothesis was that patients receiving movement control training plus conventional strengthening program would present greater improvements in pain, function, and kinematics.

Section snippets

Design

This was a 2-arm; parallel randomized controlled trial, with a blinded assessor. The trial was conducted in the Human Motion Analysis Laboratory and physiotherapy clinic of the Nove de Julho University, Brazil. It was approved by the local Ethics Committee and registered on ClinicalTrials.gov (NCT01804608). Patients were recruited between April 2013 and August 2014 from our university community. All patients who agreed to participate signed the consent form.

Firstly, when we registered the

Results

A total of 50 individuals were screened for this study and 16 were excluded for the reasons expressed in Fig. 1. Therefore, 34 patients were treated and assessed after the 4 weeks of intervention (0% loss to post-intervention). All patients from both groups completed the 12 sessions without adverse effects. Two individuals from the MC&S group missed follow-up appointments, one after 3 months and the other after 6 months. One patient in the S group missed the 3-month follow-up (Fig. 1).

Table 2

Discussion

No previous clinical trial has compared a program that associated hip and knee strengthening and movement control training with an isolated hip and knee strengthening protocol. In general, the results of this study showed that both groups exhibited less pain and better functional capacity at the end of the treatment and that adding movement control training did not provide better clinical or biomechanical outcomes.

Studies suggest that anterior knee pain and functional impairment experienced by

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgement

We gratefully acknowledge the financial support (scholarships) from Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Brazil).

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There was large and statistically significant improvement at 8 and 12 weeks for average knee pain (η_p² = 0.334, p < 0.001), worst knee pain (η_p² = 0.351, p < 0.001), SLSD (η_p² = 0.161, p = 0.001), AKPS (η_p² = 0.463, p < 0.001), and UWRI (η_p² = 0.366, p < 0.001). A medium to large effect and statistically significant improvement in pressure pain threshold testing was found for all local and remote structures (η_p² range, 0.110 to 0.293, range p < 0.001 to p = 0.009) at 8 and 12 weeks.
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Analyze whether the effects of lower limb resistance training on pain and self-reported function were associated with the exercise volume prescribed for women with patellofemoral pain (PFP).
A systematic search was undertaken in four databases from inception to May 2023. Eligible trials examined the effects of resistance training programs on pain (visual analogue scale or numerical pain scale) and function (Anterior Knee Pain Scale) in women with PFP. Meta-analysis was undertaken with a random-effects model. The association of resistance training volume-related variables with mean difference effects on pain and function were tested by exploratory univariable meta-regression models.
From 1,404 estudies retained for screening after duplicate removals, 16 studies (579 patients) were included. Changes in knee pain were inversely associated with weekly training frequency (β = 0.5 ± 0.2, P = 0.012). No associations were found between the amount of resistance exercise prescribed per session or per week and effects on pain. Changes in function were associated with the number of sets per week (β = 0.1 ± 0.1, P = 0.044) and number of sets per session (β = 0.6 ± 0.2, P < 0.001) over the intervention. Most favorable results were achieved with 17 to 27 sets per session and >45 sets per week.
The amount of prescribed resistance exercise does not seem to be critical for pain reduction in women with PFP. However, our findings support a dose-response effect in terms of improving function.
Adding neuromuscular training to a strengthening program did not produce additional improvement in clinical or kinematic outcomes in women with patellofemoral pain: A blinded randomised controlled trial
2023, Musculoskeletal Science and Practice
Patellofemoral pain (PFP) is a knee pain condition with multifactorial aetiology, twice common in women. The recommended conservative treatment is based on strengthening of the core, hip, and knee musculatures. Addition of neuromuscular training to a strengthening protocol might provide further benefits on pain, function, and kinematics in PFP individuals. However, evidence for the effectiveness of this protocol is lacking.
To investigate whether adding neuromuscular training to strengthening program could provide any additional improvements of pain, function, and kinematics in PFP women.
71 PFP women were randomly into two groups and submitted to different interventions for 12 weeks. The strengthening group (SG) performed strengthening exercises for the trunk, hip, and knee muscles, while the neuromuscular training group (NMTG) performed the same exercises as SG, plus neuromuscular training from the 4th week onwards. The primary outcomes were pain intensity, function, and 2-D kinematics of the trunk and lower limb. The secondary outcomes were isometric muscle strength and patient satisfaction level. All outcomes were evaluated at 12 weeks, immediately post-treatment.
At 12 weeks, there was no evidence of between-group differences for any outcome, but both interventions provided clinically significant improvements for pain intensity (SG: mean difference −3.9, 95% confidence interval [CI] −5.0, −2.9; NMTG: mean difference −3.1, 95% CI -4.1, −2.0) and function (SG: mean difference 15.3, 95% CI 11.5, 19.2; NMTG: mean difference 16.9, 95% CI 13.2, 20.7).
Neuromuscular training did not produce any additional benefits for pain, function, or kinematics at 12 weeks of treatment.
Is there a correlation between isometric muscle strength and the kinematics of the pelvis, hip and knee during functional tasks in women with patellofemoral pain?
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To evaluate the correlation between isometric muscle strength of the hip abductors (HABD) and lateral rotators (HLR) with the range of motion (ROM) of the pelvis/hip in the frontal/transverse planes, respectively, and between the strength of the knee extensors (KExt) with the ROM of the knee in the sagittal plane during seven tasks.
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Laboratory.
Thirty-five women with patellofemoral pain.
Maximum isometric muscle strength of the HABD, HLR, and KExt was measured using a manual dynamometer, and pelvis and lower limbs kinematics were evaluated using 3D optical system during gait, ascending and descending stairs, the forward and lateral step down tests, and the propulsion and landing phases of the single leg hop test (SLHT).
A weak correlation was found between KExt strength and knee ROM in the sagittal plane (p = 0.05; r = −0.33) during SLHT landing, and a moderate correlation between HABD strength and ROM of pelvic obliquity (p < 0.01; r = 0.50) during ascending stairs.
The lower strength of KExt has a weak correlation with higher knee flexion during the landing phase of the SLHT, and the lower strength of HABD has a moderate correlation with lower pelvis ROM in the frontal plane when ascending stairs.
Hip torques and the effect of posture in side-stepping with elastic resistance
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The way movement-based exercises affect targeted muscles is not always obvious. Side stepping with an elastic band around the forefeet is aimed at strengthening hip abductors and lateral rotator muscles, with the premise that it creates an external torque of adduction and medial rotation of the femur around the pelvis that needs to be counteracted by hip muscles. However, hip torques during this exercise have not been previously quantified.
Is the premise that the side-stepping exercise creates an external torque of adduction and medial rotation of the femur around the pelvis correct?
Thirty-six adults performed the exercise in an upright and a squat posture while 3D kinetic and kinematic data were collected. Hip muscle torques were calculated using inverse dynamics. The effect of posture and potential interactions with sex, side-stepping phases, and trailing/leading directions were analyzed using Pearson correlation and mixed-model ANOVAs.
A hip net muscle torque of extension, abduction and medial rotation was required to perform the exercise, regardless of phase and direction. The net muscle torque towards medial rotation required during the exercise was smaller (P < 0.001) in the upright (0.05–0.12 N m kg^-1 m^-1 across phases) compared to the squat posture (0.10–0.24 N m kg^-1 m^-1). In contrast, hip abductor torque was not affected by posture. When averaged across phases and directions, the normalized hip medial rotator muscle torque was highly correlated with knee flexion (r = 0.93, P < 0.001).
The assumption that the side-stepping with the elastic band on the forefeet creates an external hip torque of medial rotation is erroneous. The resistance imposed to the hip during this exercise is consistent with the goal of strengthening the muscles that contribute to hip abduction and hip medial (not lateral) rotation. Changing the knee flexion angle is an effective way to manipulate hip rotator torque when prescribing this exercise in strength training and rehabilitation programs.
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2021, Physical Therapy in Sport
Citation Excerpt :
Studies (Powers et al., 2017; Salsich & Perman, 2007) may have focused on the idea that posterolateral hip musculature strengthening could improve lower limb alignment and consequently the patellofemoral kinematics, which would reduce the patellofemoral compression loads and improve pain. However, this theory has not been supported by previous studies (Earl & Hoch, 2011; Esculier et al., 2018; Ferber et al., 2011; Palmer, Hebron, & Williams, 2015; Rabelo et al., 2017) in which patients had improved pain and function after hip strengthening but no changes found in the lower limb kinematics. Corroborating these findings, the two groups in our research showed improvements in pain intensity, function, GPE and pain during the step down but no changes in the dynamic knee valgus.
To compare the effectiveness of adding anteromedial versus posterolateral hip musculature strengthening to knee strengthening in women with patellofemoral pain (PFP).
Randomized controlled trial.
University physiotherapy clinic.
Fifty-two women with PFP were randomized to receive either anteromedial (AMHG) or posterolateral (PLHG) hip musculature strengthening.
The primary outcomes were pain intensity by the numeric pain rating scale and function by the Anterior Knee Pain Scale in six weeks. Secondary outcomes were pain and function at six months, global perceived effect at six weeks and six months, pain in step down, isometric torque of abductors, adductors and hip rotators measured with hand-held dynamometer, and dynamic knee valgus by step down in six weeks.
Both groups showed improvement in primary outcomes; however, no differences were found between groups in pain intensity and function in six weeks and the secondary outcomes. Group x time interaction found superior gains in abductor strength in the PLHG and increase in the strength of the adductors and internal rotators in AMHG.
There was no difference between the addition of anteromedial or posterolateral hip musculature strengthening to knee strengthening in improving pain and function in women with PFP.

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Full length articleAdding motor control training to muscle strengthening did not substantially improve the effects on clinical or kinematic outcomes in women with patellofemoral pain: A randomised controlled trial

Highlights

Abstract

Design

Background

Methods

Results

Conclusion

Introduction

Section snippets

Design

Results

Discussion

Funding

Acknowledgement

Gait Posture

Gait Posture

Clin. Biomech. (Bristol, Avon)

Arch. Phys. Med. Rehabil.

Hum. Mov. Sci.

Gait Posture

J. Physiother.

Arch. Phys. Med. Rehabil.

Phys. Ther. Sport

The epidemiology of patellofemoral disorders in adulthood: a review of routine general practice morbidity recording

Prim. Health Care Res. Dev.

Gender differences in the incidence and prevalence of patellofemoral pain syndrome

Scand. J. Med. Sci. Sports

Prospective predictors of patellofemoral pain syndrome: a systematic review with meta-analysis

Sports Health

Patellofemoral pain: consensus statement from the 3rd international patellofemoral pain research retreat held in Vancouver, September

Br. J. Sports Med.

A Comparison of hip strength between sedentary females with and without patellofemoral pain syndrome

J. Orthop. Sports Phys. Ther.

Propulsion phase of the single leg triple hop test in women with patellofemoral pain syndrome: a biomechanical study

PLoS One

Kinematic and kinetic analysis of the single-leg triple hop test in women with and without patellofemoral pain

J. Orthop. Sports Phys. Ther.

Short-term effects of hip abductors and lateral rotators strengthening in females with patellofemoral pain syndrome: a randomized controlled clinical trial

J. Orthop. Sports Phys. Ther.

Hip posterolateral musculature strengthening in sedentary women with patellofemoral pain syndrome: a randomized controlled clinical trial with 1-year follow-up

J. Orthop. Sports Phys. Ther.

Full length article
Adding motor control training to muscle strengthening did not substantially improve the effects on clinical or kinematic outcomes in women with patellofemoral pain: A randomised controlled trial