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Manual Therapy 14 (2009) 252e263 www.elsevier.com/math

Original Article

Disability in patients with chronic patellofemoral pain syndrome: A randomised controlled trial of VMO selective training versus general quadriceps strengthening
G. Syme a,*, P. Rowe b, D. Martin c, G. Daly d
a

Department of Orthopaedic Surgery, St. Johns Hospital in Howden, Livingston, United Kingdom b HealthQWest, Bioengineering Unit, University of Strathclyde, Glasgow, United Kingdom c Centre for Rehabilitation Science, University of Teesside, Middlesbrough, United Kingdom d Department of Physiotherapy Royal Inrmary of Edinburgh, Edinburgh, United Kingdom

Received 31 October 2007; received in revised form 6 February 2008; accepted 18 February 2008

Abstract This study was a prospective single blind randomised controlled trial to compare the eects of rehabilitation with emphasis on retraining the vastus medialis (VMO) component of the quadriceps femoris muscle and rehabilitation with emphasis on general strengthening of the quadriceps femoris muscles on pain, function and Quality of Life in patients with patellofemoral pain syndrome (PFPS). Patients with PFPS (n 69) were recruited from a hospital orthopaedic clinic and randomised into three groups: (1) physiotherapy with emphasis on selectively retraining the VMO (Selective); (2) physiotherapy with emphasis on general strengthening of the quadriceps femoris muscles (General ); and (3) a no-treatment control group (Control ). The three groups were then compared before and after an eight-week rehabilitation period. The Selective and General groups demonstrated statistically signicant and moderate to large eect size reductions in pain when compared to the Control group. Both the Selective and General groups displayed statistically signicant and moderate and large eect size improvements in subjective function and Quality of Life compared to the Control group. Knee exion excursion during the stance phase of gait, demonstrated that there were no statistical signicant dierences and only trivial to small eect size dierences between the Selective or General groups and the Control group. A large number of PFPS patients can experience signicant improvements in pain, function and Quality of Life, at least in the short term, with quadriceps femoris rehabilitation, with or without emphasis on selective activation of the VMO component. Both approaches would seem acceptable for rehabilitating patients with PFPS. It may be appropriate to undertake exercises involving selective activation of the vastus medialis early in the rehabilitation process, however, clinicians should not overly focus on selective activation before progressing rehabilitation, especially in more chronic cases with signicant participation restrictions. 2008 Elsevier Ltd. All rights reserved.
Keywords: Patellofemoral; Patellofemoral pain syndrome; Randomised controlled trial

1. Introduction Patellofemoral pain syndrome (PFPS) is reported to be a common, yet dicult to manage musculoskeletal
* Corresponding author. Tel.: 44 01506 522063; fax: 44 01506 522064. E-mail address: grant.syme@wlt.scot.nhs.uk (G. Syme). 1356-689X/$ - see front matter 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2008.02.007

condition (Run and Kiningham, 1993; Biedert, 2004; Vega et al., 2006), although the incidence and prevalence of PFPS remains to be adequately evaluated (Callaghan and Selfe, 2007). There is debate as to whether rehabilitation should be based on exercises strengthening the quadriceps femoris muscle group or specically targeting the vastus medialis oblique (VMO) or vastus lateralis (VL) muscles in isolation (Callaghan and Oldham,

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1996). The rst approach places emphasis on generally strengthening the quadriceps musculature (Wilk and Reinold, 2001; Witvrouw et al., 2004; Bolgla and Malone, 2005), one theory being that, if the force generated by the VMO is essential to proper patella tracking, then general quadriceps femoris strengthening, especially closed chain exercises (Boling et al., 2006), will bring the VMO up to a threshold necessary for optimal tracking (Grabiner et al., 1994). The second approach places emphasis on the selective activation and reeducation of the VMO component of the quadriceps femoris muscles (McConnell, 1986; Grelsamer and McConnell, 1998). The premise is that an imbalance in muscle activation timing between the VMO and VL muscles can lead to maltracking of the patella, abnormal loading of the patella mechanism and pain (Neptune et al., 2000; Cowan et al., 2001, 2002a, b). Whether the vastus medialis, or more specically the VMO component, can be selectively activated is a contentious issue (Goh, 2000; Davies et al., 2001). Mean timing dierences between the onset of VMO and VL activity have been reported for some patients with PFPS, with the delay in onset of the VMO relative to the VL reported to be between 15 and 19 ms compared to healthy controls (Cowan et al., 2001). Electromyographic biofeedback has been used to retrain VMO activation (Cowan et al., 2002b; Crossley et al., 2002). However, it is questionable whether such small timing dierences can be retrained with this approach given the limited temporal resolution of most electromyographic biofeedback machines and the limitation of human capacity to discriminate between two such closely timed events (Karst and Willet, 1995). Furthermore, it is also debatable whether the VMO is a separate anatomical entity within the vastus medialis muscle, there being proponents for (Bose et al., 1980; Ono et al., 2005) and against this view (Hubbard et al., 1997; Nozic et al., 1997; Peeler et al., 2005). Such equivocal evidence raises doubts about the validity of the use of selective VMO activation in the clinical management of PFPS. Several RCTs investigating PFPS have examined the benet of selective activation of the VMO by comparing conventional open and closed kinetic chain exercise programs with and without electromyographic biofeedback (Dursun et al., 2001; Yip and Ng, 2006; Qi and Ng, 2007; Ng et al., 2008). Dursun et al. (2001) reported no additional clinical improvement between the groups at three-months follow-up. Yip and Ng (2006) reported no statistical dierences in clinical outcome between the groups at two months follow-up, but suggested that the addition of biofeedback may hasten recovery. Improvements in VMO/VL ratios in the biofeedback groups have been reported (Qi and Ng, 2007; Ng et al., 2008), but no signicant dierences were noted regarding pain (Qi and Ng, 2007). It is notable that these studies lacked a control, the randomisation process was not

described, and they did not use all the components of the McConnell-based rehabilitation program (Grelsamer and McConnell, 1998). The study presented here is a pragmatic trial, aiming to compare the general strengthening approach with a more selective VMO approach in the management of PFPS. A no-treatment control group and a blinded block randomisation procedure were used. In accordance with the World Health Organization (WHO, 2001) recommendations, information was collected on impairments of body functions and structures and activity and participation. 2. Methods The study design was a RCT with three groups. The treatment groups consisted of Selective group (VMO selective activation treatment approach), General group (quadriceps femoris strengthening group) and Control group C (no-treatment control group). Following ethical approval (NHS Lothian Research Ethics Committee, Edinburgh) and signed informed consent, patients were recruited from an orthopaedic knee clinic (St. Johns Hospital, Livingston, Scotland) and referred to the researcher by the orthopaedic medical sta. Inclusion and exclusion criteria for the study were based on those outlined in previous studies (Table 1) , 1997; Timm, 1998; Harrison (Kowall et al., 1996; Thomee et al., 1999; Cowan et al., 2001). To date, attempts to evaluate functional outcome and pathokinesiology in PFPS have used varied motion analysis approaches to assess the knee joint complex. Such studies have highlighted several activity limitations in PFPS patients: reduced gait velocity (Powers et al., 1997, 1999) and reduced knee exion angles at gait midstance (Dillon et al., 1983; Nadeau et al., 1997) and during stair ambulation (Crossley et al., 2005). Given these study ndings, sample size was based upon the primary outcome measure of knee exion excursion during gait (measured with exible electrogoniometers). This selection can also be supported as walking is a common functional activity and it is arguable that a reduced ability and desire to articulate the knee joint would be associated with knee pain. The calculation used gures from a previous PFPS study (Nadeau et al., 1997) as no information existed for exible electrogoniometry. Assuming a normal mean knee exion angle of 13.4 at 10% of stride length, with power 80% and alpha 0.05, the aim was to recruit a minimum of 28 patients for each group. Five physiotherapists, each with a minimum of ve years clinical musculoskeletal experience, volunteered to provide physiotherapy management for the intervention groups. All of the physiotherapists received four one-hour training sessions regarding the physiotherapy management regimes to be used and could subsequently manage either Group A or Group B allocated patients.

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Table 1 Study inclusion/exclusion criteria for patients with patellofemoral pain syndrome. Inclusion criteria: Males and females to be included. Age range 16e40 years. Unilateral or bilateral patellofemoral pain longer than three months. Willing to complete an eight-week rehabilitation program and attend the hospital clinic for assessments. Anterior or retropatellar pain reported on at least two of the following activities: prolonged sitting, ascending or descending stairs, squatting, running, kneeling, and hopping/jumping. In addition to the above, at least two of the following clinical examination ndings: Patellar pain with manual compression of the patella against the femur. Patellar tenderness with palpation of the posteromedial and posterolateral borders of the patella. Patellar pain during resisted dynamic knee extension. Patellar pain with manual compression of the patella against the femur during isometric knee extension contraction. Exclusion criteria: Previous knee surgery or trauma. Ligamentous instability and/or internal derangement. (Subjects were referred for arthroscopy or Magnetic Resonance Imaging based on the criteria outlined by Acton and Craig (2000).) History of patella subluxation or dislocation or patella laxity. Traumatic lesions. Joint eusion when the midpatellar girth was 105% or more than the non involved knee, where applicable. True knee joint locking and/or giving way. Concurrent medical illness. Inammatory joint pathology. Infection. Conrmed osteoarthritis of tibiofemoral and/or patellofemoral joints. Knee radiograph abnormalities. Circulatory or neurological abnormalities. Pre/infera or pes anserine bursitis, patella tendonitis, iliotibial tract tendonitis, Osgood Schlatters disease, Sinding-Larsen Johansson Syndrome, muscle tears or knee plica. Subjects unable or unwilling to give informed to written consent. Subjects awaiting surgery for another lower limb joint problem(s). History of low back, sacroiliac or ankle/feet problems longer than 3 days duration. Subjects already involved in active lower limb training programs. Malignancy. Pregnancy or breast feeding. Ongoing litigation related to lower limb injuries. No patient could be under the care of or have been under the care of another physiotherapist out with the study in the previous one-year prior to the study commencing.

Patients were assigned a physiotherapist using a rolling list system from a pre-designated list of physiotherapists. 2.1. Selective group: (vastus medialis selective activation approach) Subjects attended the Department of Physiotherapy at St. Johns Hospital, Livingston for assessment, education modication and progression of the treatment plan. Specic details of the Selective group treatment protocol are shown in Table 2. 2.2. General group: (quadriceps femoris strengthening approach) Training programs consisting of 2e3 training sessions per week have been indicated to improve strength for the novice trainer (Kraemer and Ratamess, 2004; Loudon et al., 2004). Thus, participants were required

to attend a supervised training session twice weekly. Specic details of the General group treatment protocol are shown in Table 3. It was deemed unethical to deny patients the use of knee taping/strapping given the weight of evidence supporting the premise that can reduce patellofemoral pain at least in the short term (Aminaka and Gribble, 2005). To avoid using taping that has been purported to specifically alter VMO activation (Cowan et al., 2002c) an alternative taping/strapping method was sought. Thus, the general quadriceps strengthening group employed a knee sling strapping (Crozier, 1989).

2.3. Control group: (no treatment) Patients assigned to the control group were assessed then reassessed after a period of eight weeks and received no treatment during the eight-week study period. The control group was advised to refrain from

G. Syme et al. / Manual Therapy 14 (2009) 252e263 Table 2 Selective group treatment protocol.

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Physiotherapists were instructed that they could use all components of the McConnell approach, such as VMO muscle re-education, exibility stretching exercises, patella mobilisation, patella taping, electromyographic biofeedback and commercially available prefabricated orthotics (Grelsamer and McConnell, 1998). Exercises Lower limb exercises emphasising selective activation and retraining of the VMO muscle relative to the VL muscle was undertaken by using a dual channel surface electromyographic biofeedback unit (NeuroTrac, Verity Medical, Hampshire, England. Guidelines based on previous research suggested that a minimum of six sessions should be given during the eight-week treatment period (Crossley et al., 2002)). Correction of any dynamic lower limb malalignment (Powers, 2003) and gluteus medius muscle retraining was also encouraged (Grelsamer and McConnell, 1998). Participants were prescribed daily home exercises and provided with standardised home exercise information sheets (Physio Tools McConnell Exercises). Taping Patella taping for pain relief in Group A was as advocated by McConnell (Grelsamer and McConnell, 1998). Non-rigid hypoallergic tape (Fixomull Stretch Beiersdorf, Hamburg, Germany) was used to provide skin protection and rigid zinc oxide tape (Leukotape P Beiersdorf Hamburg, Germany) was used for taping corrections. The aim, if possible, was to achieve an immediate reduction in pain intensity of at least 50% (Grelsamer and McConnell, 1998). Participants were taught to independently apply the taping corrections and were instructed to reapply the tape daily and wear the tape during all waking hours until the pain subsided and exercises could be undertaken pain free. Stretching Soft tissue stretches were included for the quadriceps, hamstrings, iliotibial band, gastrocnemius/soleus and anterior hip structures (Grelsamer and McConnell, 1998). The aim was to maintain the stretches for 30 s and repeat each three times over (Shrier and Gossal, 2000). The patella was mobilised by the physiotherapist (Manske and Davies, 2003) and combined with deep frictional massage where necessary. The aim was three repetitions of 60 s each per treatment session (Crossley et al., 2002). Restrictions Physiotherapists were informed not to use isokinetic training, electrotherapy, acupuncture or place the subject on a regular gymnasium based training program for the lower limb(s). Advice All patients were supplied with an advice sheet about patellofemoral pain prior to the start of their treatment.

undertaking any new forms of exercise programs until reassessed eight weeks following initial assessment. Group C controls were oered treatment at the end of the trial. All participants were advised to continue with existing medication but not to alter or begin any new knee related medications. Pre-existing foot orthoses were allowed. No patient could be under the care of or have been under the care of another physiotherapist out with the study in the previous one-year prior to the study commencing. One independent physiotherapist carried out the individual randomisation procedure out of view of the researcher. Block randomisation (in blocks of three) was employed through assigning numbers to permutations of the ABC sequence with each letter representing an arm of the study (Altman and Bland, 1999). These sequence blocks were placed in opaque sealed envelopes and randomly shued. For each three-sequence block a new envelope was opened and the patient assigned to the appropriate group based on the sequence order from left to right. This was done without the researchers knowledge. The researcher (blind assessor) was not involved in the management of the study participants until their involvement in the study had been completed. Blinding of participants was not possible owing to the nature of the study.

Participants were instructed not to reveal information about the nature of their treatment to the researcher. 3. Outcome measures 3.1. Personal information All outcome measures were completed before and after the eight-week trial period. The following information was recorded: age, height, weight, body mass index (BMI), lower limb dominance, site and duration of pain and previous knee treatment. 3.2. Primary outcome measure Two exible electrogoniometers were used to measure knee exioneextension angles with respect to time. The method advocated has been shown to be valid and reliable in healthy subjects (Rowe et al., 2001). Heel and toe foot-switches for both feet were used to aid identication of the stance and swing phases of gait. Data were recorded at 200 Hz. The subjects were asked to undertake two functional activities: (1) level walking between two markers 5 m apart and (2) perform an eccentric step down weightbearing on the painful lower limb from a standard

256 Table 3 General group treatment protocol.

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, 1997; Lephart and Lower limb exercises were based on widely accepted concentric, eccentric and proprioceptive rehabilitation principles (Thomee Fu, 2000; Ellenbecker and Davies, 2001). Exercises The strengthening protocol aimed for 3e5 exercises consisting of 1e3 exercise sets of 10 repetitions, at 60e70% of the one repetition maximum , 2003; Kraemer and Ratamess, 2004). This strengthening protocol was suggested as a guideline intensity (DeLorme, 1945; Grimby and Thomee and physiotherapists were advised to instruct patients to stop any prescribed exercise if pain intensity exceeded 5 on a 0e10 verbal rating scale, , 1997) and to adjust training loads accordingly. (0 no pain and 10 worst possible pain) (Thomee Correction of any dynamic lower limb malalignment (Powers, 2003) was encouraged during the exercises. Taping A knee sling U shaped strapping was applied if necessary, which uses 2.5 cm wide zinc oxide Elastoplast (BSN Medical Ltd., England) to support the knee and patellofemoral joints. The strapping was only applied during the initial pain control stages. Stretching Soft tissue stretches were included for the quadriceps, hamstrings, iliotibial band, gastrocnemius/soleus and anterior hip structures (Grelsamer and McConnell, 1998). The aim was to maintain the stretches for 30 s and repeat each three times over (Shrier and Gossal, 2000). The patella was mobilised by the physiotherapist (Manske and Davies, 2003) and combined with deep frictional massage where necessary. The aim was three repetitions of 60 s each per treatment session (Crossley et al., 2002). Restrictions Physiotherapists were informed not to use isokinetic training, electrotherapy, acupuncture, electromyographic biofeedback training or to specically try and rehabilitate the VMO muscle during the treatment of this group. Advice All patients were supplied with an advice sheet about patellofemoral pain prior to the start of their treatment.

gymnasium wooden bench (height 31 cm) as far as comfortable without putting full weight onto the opposite lower limb. Subjects performed a prior practice to familiarise themselves with the equipment and functional task. Recordings were taken in quiet standing prior to the functional activities and used as baseline values 0 indicating the neutral position of the knee. All subsequent recordings were measured relative to this baseline 0 . During gait, where a number of cycles were available, a cycle was selected from the middle of the data stream to avoid cycles during initiation or termination of the activity. As recommended by Maupas et al. (1999) data analysis focused on knee excursions angles: (1) the knee exion excursion during the stance phase of gait; and (2) the knee excursion during the step down task (excursion being the dierence between maximum and minimum angles). Gait time was calculated as the time taken to walk 5 m. Subjects were instructed to execute all tasks at a self-selected speed. 3.3. Pain, function and Quality of Life questionnaires Participants completed three valid and reliable instruments namely the McGill Pain Questionnaire (MPQ) (Melzack, 1975), the Modied Functional Index Questionnaire (MFIQ) (Selfe et al., 2001a, b) and the Short Form-36 Health Evaluation questionnaire (SF-36) (Jenkinson et al., 1996; Ware et al., 2000). Patients also completed the Patient Generated Index (PGI) (Ruta et al., 1994). The PGI is a patient generated Quality of Life

questionnaire, which asks the same questions of all patients, but allows them to specify their own response (Ruta et al., 1994). The PGI has been reported to be reliable and valid (Ruta et al., 1994, 1999). The NRS-101 pain intensity scale has been shown to be a reliable and valid measure of pain intensity (Jensen et al., 1986). The scale consisted of a scale from 0 to 100 with end points labelled no pain and worst possible pain with the subject asked to rate their average pain intensity in previous one month (PIM). The triple hop test of lower limb function was performed as described by Noyes et al. (1989). The method has been shown to be a reliable measure of lower limb functional performance (Risberg et al., 1995; Bolgla and Keskula, 1997). The subject undertook three consecutive forward hops in a straight line on the dominant limb. The best of three trials was used for analysis. The procedure was then repeated for the non-dominant limb. Personal data and dependent variables measured preintervention and post-intervention for the most painful limb were analysed with SPSS (version 12) for Windows (SPSS Inc., Chicago, IL). MedCalc software Version 7.6.0.0 (MedCalc Software, Belgium) was used to calculate DAgostino Omnibus tests of normality. A Condence Intervals Analysis program version 2.0.0 (Altman et al., 2000) was used to calculate median dierences and 95% condence intervals. An Eect Size Calculator spreadsheet (Microsoft XP Excel, www Version, University of Durham) (Coe, 2000) was used to calculate standardised mean dierence eect size indices. Post-RCT scores from each group were compared using a one-way ANOVA for normally distributed data

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and KruskaleWallis for non-normally distributed data, with alpha 0.05. Post-hoc analyses were executed using either independent samples t-tests or Manne Whitney U as appropriate, with a limited Bonferroni adjusted p < 0.017 for each group within each variable measured. The standardised mean dierence eect size (Cohens d ) (Coe, 2000) was chosen as the eect size index. Nonparametric Cohen type eect sizes were calculated using a method suggested by Hopkins (2000). In this case the non-normal distributed variable is rank transformed without regard to grouping, the mean and standard deviations of the rank transformed data for each group can then be calculated as previously outlined

for the parametric standardised mean dierence Cohen d (Hopkins, 2000). Intervention trial data were analysed on an intentionto-treat basis (Hollis and Campbell, 1999). 4. Results One hundred and ten patients were considered eligible on initial screening in the orthopaedic outpatient clinic (Fig. 1). Of these, 22 patients did not take up the service and three did not consent to the trial. A further 16 did not meet the inclusion criteria. Hence, 69 patients were randomised into three groups (Selective n 23, General n 23 and Control n 23). Two from

PFPS patients considered eligible for trial at outpatient clinics (n = 110)

22 patients failed to contact department to register for study or arrange routine physiotherapy 3 patients unwilling to participate in study (n = 25)

Patients ineligible as they did not meet inclusion/exclusion (n = 16) 5 evidence of meniscal pathology 2 patella tendinopathy 1 congenital foot deformity 1 plicae 2 involved in legal claims 2 significant back pain 1 previous dislocation 1 previous arthroscopy 1 pregnant

PFPS patients consented and randomised (n = 69)

Group A Selective vastus medialis oblique activation group (n = 23)

Group B General quadriceps femoris strengthening group (n = 23)

Group C Control no treatment group (n = 23)

Withdrawals (n = 2) 2 withdrew owing to work commitments

Withdrawals (n = 1) 1 withdrew no further contact with department

Withdrawals (n = 3) 1 withdrew no further contact with department 1 withdrew owing to pregnancy 1 withdrawn owing to undisclosed insurance claim

Completed 8-week intervention and follow up assessment (n = 21)

Completed 8-week intervention and follow up assessment (n = 22)

Completed 8-week intervention and follow up assessment (n = 20)

Fig. 1. Flow diagram showing the progression of patients through the clinical study.

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the Selective group, one from the General group and three from the Control group failed to complete the study for various reasons (Fig. 1). There were minimal dierences between the groups prior to treatment delivery and none were statistically signicant (Table 4). Results of the hypothesis tests between the groups post-treatment delivery are shown in Table 5 and the effect sizes, mean/median dierences and 95% condence intervals shown in Table 6. There were no statistically signicant dierences among the groups in knee exion excursion during the stance phase of gait. The step down task demonstrated a statistically signicant increase in knee excursion in the General group compared to the Control group and, although not statistically signicant, there was also an improvement in the Selective group compared to the Control group. There was no statistically signicant dierence between the Selective and General groups. The results of the MPQ total scores supported the results of the NRS-101 ratings. Both the Selective and General groups revealed statistically signicant reductions in comparison to the Control group. There was no statistical dierence between the Selective and General groups. There were no statistically signicant dierences for the triple hop for distance test between the groups. Null hypothesis testing demonstrated that there were no statistically signicant dierences between the three groups post-intervention for the MFIQ scores. A review of the median dierences and 95% condence intervals, however, revealed that there was a trend for greater reductions in pain between the Selective compared with the

Control group (median dierence 10.0 units, 95% CI 20.0 to 0.0) and between the General group and Control group (median dierence 15.0 units; 95% CI 25.0 to 0.0), than between the Selective and General groups (median dierence 0.0 units; 95% CI 5.0 to 15.0). There was a statistically signicant improvement in SF-36 physical function in the Selective group compared to the Control groups and between the General and Control. There was no statistically signicant dierence between the Selective and General groups. There were no statistically signicant dierences between the three groups for SF-36 mental function. SF-36 questionnaire physical function revealed a large eect size improvement in the Selective group compared to the Control group (large ES 1.22; 95% CI 0.59 to 1.84) and a moderate eect size improvement in the General group compared to the Control group (moderate ES 1.04; 95% CI 0.22 to 1.65). There was only a trivial dierence between the Selective and General groups (trivial ES 0.00; 95% CI 0.58 to 0.58). Only trivial to small eect size dierences were observed across the groups for SF-36 mental function. The PGI demonstrated statistically signicantly greater scores in the Selective group compared to the Control group and in the General group compared to the Control group. There was no statistically signicant dierence between the Selective and General groups. 5. Discussion This study demonstrated that both general quadriceps strengthening and VMO specic training reduced pain and improved activity and participation, but that there was no dierence between the approaches. Our results

Table 4 Pre-intervention data. Variable Age (years) Height (metres) Duration of pain (months) Activity (hours) Body weight (kg s) (back log transformed) Body mass index (kg s/m2) (back log transformed) Gender Side dominance Painful side A Selective (n 23) 28.8 (8.0)a 1.68 (0.77)a 49.0 (37.5)a 1.2 (2.3)a 71.8 (1.2)b 25.5 (1.3)b 13 Females 10 Males 20 Right sided 3 Left sided 5 Right side 2 Left side 6 Both sides, but right worse 10 Both sides, but left worse n5 B General (n 23) 27.3 (7.9)a 1.69 (0.73)a 45.5 (35.3)a 1.4 (2.3)a 72.4 (1.3)b 25.5 (1.3)b 13 Females 10 Males 21 Right sided 2 Left sided 7 Right side 3 Left side 4 Both sides, but right worse 7 Both sides, but left worse 2 Both sides equally painful n9 C Control (n 23) 28.5 (6.4)a 1.69 (0.87)a 50.5 (41.3)a 1.3 (2.3)a 74.5 (1.2)b 26.2 (1.2)b 15 Females 8 Males 18 Right sided 5 Left sided 3 Right side 4 Left side 7 Both sides, but right worse 5 Both sides, but left worse 4 Both sides equally painful n6

Previous recipient of physiotherapy for knee problem


a b

Mean and standard deviation. Geometric mean and geometric standard deviation.

G. Syme et al. / Manual Therapy 14 (2009) 252e263 Table 5 Results of body functions and structures and activities and participation measures. Variable Primary outcome measure Gait minimum to peak stance knee excursion Time point Pre Post A Selective B General C Control ANOVA Post-hoc tests (if applicable)

259

13.9a (5.9) 14.7a (6.2) 47.7a (29.6) 21.4a (24.7)

17.8a (3.3) 18.3a (5.2) 51.3a (29.4) 28.1a (28.5)

14.9a (7.3) 15.2a (5.4) 59.6a (21.8) 49.3a (22.5)

0.070g

Body functions and structures measures NRS-101 average pain Pre Post intensity previous month

0.001g,**

A vs B 0.395h A vs C p < 0.001h,* B vs C 0.008h,* A vs B 0.270j A vs C 0.014j,* B vs C 0.003j,*

McGill pain questionnaire total score

Pre Post

17.5a (6.1) 9.0c (9.0)

20.1a (8.8) 7.0c (12.0)

21.0a (9.4) 17.0c (14.0)

0.004i,**

Activities and participation measures Step down excursion range Pre Post of motion angle

59.8a (16.7) 62.3a (14.2)

63.0a (10.0) 66.0a (12.9)

55.3a (11.8) 56.1a (11.9)

0.040g,**

A vs B 0.362h A vs C 0.124h B vs C 0.012h,*

Gait time (seconds) Triple hop for distance (cm) Modied functional index questionnaire SF-36 physical component summary score

Pre Post Pre Post Pre Post Pre Post

4.9a (1.1) 4.5a (0.6) 370.7a (142.1) 374.3a (120.7) 33.0a (13.2) 25.0c (30.0) 44.96a (7.69) 53.11c (10.27)

4.2a (1.0) 4.3a (0.9) 373.0a (137.1) 390.4a (133.9) 34.8a (17.9) 10.0c (35.0) 46.67a (7.85) 54.26c (12.33)

4.3a (0.5) 4.5a (0.8) 348.8a (105.5) 349.9a (119.3) 33.0a (15.3) 30.0c (25.0) 46.45a (8.57) 40.38c (18.46)

0.530g 0.484i 0.070i 0.001i,** A vs B 0.991j A vs C p < 0.001j,* B vs C 0.001j,*

SF-36 mental component summary score Patient generated index

Pre Post Pre Post

44.96a (7.69) 46.32c (10.38) 5.0a (1.8) 6.3a (2.8)

46.67a (7.85) 50.32c (7.51) 3.9a (2.4) 6.3a (2.5)

46.45a (8.57) 49.33c (11.79) 3.8a (1.7) 4.0a (1.4)

0.199i 0.001g,** A vs B 0.933h A vs C 0.001h,* B vs C p < 0.001h,*

*p < 0.017; **p < 0.05. a Mean and standard deviation. c Median and inter quartile range. g One-way analysis of variance. h Independent samples t-test. i Kruskal-Wallis test. j ManneWhitney U test.

question whether the time and eort in specically reeducating the VMO muscle is warranted. The conclusions supported previous work, which demonstrated minimal added value of selective VMO training in improving pain and function (Dursun et al., 2001; Yip and Ng, 2006; Qi and Ng, 2007). Contrary to previous ndings, there were no statistically signicant dierences in the electrogoniometer gait parameters (Dillon et al., 1983; Nadeau et al., 1997). The present ndings, although slightly underpowered, support suggestions that gait analysis may not be sensitive enough (Chesworth et al., 1989) to detect clinically useful changes in pain and function in patients with PFPS, and that motion analysis measures may not correlate with more prolonged or physically demanding walking tasks involved in participation in normal life

situations (Mulder et al., 1998). Gait velocity (Powers et al., 1999), pain severity, methodological variations and sample size may explain dierences between studies. There was some evidence of improvement in the step down task, in both the Selective and General groups, with a slightly greater improvement in the General group, but no additional benet of incorporating selective VMO retraining. The results of the NRS-101 and MPQ total pain scores indicated that both the Selective and General groups demonstrated statistically signicant reductions in pain in the short term supporting the work of previ , 1997; ous investigators (Ganey et al., 1992; Thomee Clark et al., 2000; Crossley et al., 2002; Loudon et al., 2004). Despite the chronic nature of PFPS exhibited by the patients involved in this study (mean duration

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Table 6 Eect size results for body functions and structures and activities and participation measures. Variable Eect sizes and 95% condence intervals A vs C, Selective vs Control Primary outcome measure Gait minimum 0.0 (0.65 to 0.50) to peak stance knee excursion Body functions and structures measures NRS-101 average 1.17 (1.80 to 0.55) pain intensity previous month McGill pain 0.8 (1.42 to 0.21) questionnaire total score Activities and participation measures Step down 0.48 (0.11 to 1.06) excursion range of motion angle Gait time (seconds) 0.00 (0.58 to 0.58) B vs C, General vs Control 0.51 (0.08 to 1.10) A vs B, Selective vs General 0.62 (1.21 to 0.03) Mean/median dierence and 95% condence intervals

A vs B A vs C B vs C A vs B A vs C B vs C A vs B A vs C B vs C A vs B A vs C B vs C A vs B A vs C B vs C A vs B A vs C B vs C A vs B A vs C B vs C A vs B A vs C B vs C A vs B A vs C B vs C A vs B A vs C B vs C

3.6a (7.6 to 0.3) 0.6a (4.6 to 3.4) 3.1a (0.9 to 7.0) 6.7a (24.7 to 11.2) 28.0a (45.9 to 10.0) 21.2a (39.1 to 3.3) 2.0b (2.0 to 7.0) 6.0b (11.0 to 1.0) 8.0b (14.0 to 4.0) 3.7a (12.9 to 5.5) 6.2a (3.0 to 15.4) 9.9a (0.7 to 19.1) 0.2a (0.3 to 0.8) 0.0a (0.5 to 0.6) 0.2a (0.8 to 0.3) 16.1a (104.4 to 72.1) 24.4a (63.8 to 112.7) 40.6a (47.7 to 128.8) 0.0b (5.0 to 15.0) 10.0b (20.0 to 0.0) 15.0b (25.0 to 0.0) 0.08b (3.42 to 4.02) 10.75b (5.13 to 17.36) 10.57b (4.66 to 16.76) 4.36b (7.87 to 0.24) 2.64b (7.56 to 3.30) 1.17b (3.51 to 6.19) 0.01a (1.6 to 1.6) 2.3a (1.0 to 3.7) 2.3a (1.1 to 3.5)

0.89 (1.49 to 0.28)

0.23 (0.81 to 0.35)

1.03 (1.65 to 0.42)

0.31 (0.27 to 0.89)

0.8 (0.21 to 1.41)

0.2 (0.85 to 0.31)

0.31 (0.89 to 0.27)

0.03 (0.55 to 0.61)

Triple hop for distance (cm) Modied functional index questionnaire SF-36 physical component summary score SF-36 mental component summary score Patient generated index

0.28 (0.30 to 0.86)

0.42 (0.16 to 1.00)

0.12 (0.70 to 0.45)

0.58 (1.17 to 0.01)

0.62 (1.22 to 0.03)

0.19 (0.39 to 0.77)

1.22 (0.59 to 1.84)

1.04 (0.42 to 1.65)

0.00 (0.58 to 0.58)

0.32 (0.92 to 0.26)

0.22 (0.36 to 0.80)

0.56 (1.15 to 0.03)

1.14 (0.52 to 1.76)

1.28 (0.64 to 1.91)

0.00 (0.58 to 0.58)

Eect size qualiers: trivial, 0 to 0.19; small, 0.20 to 0.59; moderate, 0.60 to 1.19; large, 1.11 to 1.19; very large, 1.20 to 3.9; extremely large, 4 to N. a Mean dierence. b Median dierence.

48.4 months) the results indicated that pain could be reduced in some cases, at least in the short term. The triple hop for distance test results were contrary to the ndings of Yildiz et al. (2003) who reported statistically signicant improvements in triple hop for distance measures in a study investigating isokinetic training in an athletic population with PFPS. However, results from studies involving athletes may not be directly generalisable to non-athletic populations, owing to potential, psychological and physical dierences between athletic and non-athletic populations (Filho et al., 2005; Torstveit and Sundgot-Borgen, 2005). Selfe et al. (2001b) proposed that for the MFIQ results to be clinically signicant the preepost dierences had to be at least 10 units. Both the Selective and General groups had preepost median dierences of 10 units and 15 units, respectively. Hence, both intervention groups demonstrated improved function clinically.

From the SF-36 scores participants experienced an improvement in perceived physical function, but not mental function. It is interesting to note that Ware and Kosinski (2001) reported that for SF-36 mental function a value of less than 42 units was predictive of a diagnosis of clinical depression, with a sensitivity and specicity of 73.7% and 80.6%, respectively. Using the 42-unit cut-o point, 22 of 69 (31.9%) of our participants fell within this category perhaps supporting the claims of coexisting psychological impairments in some patients with PFPS (Carlsson et al., 1993; Witonski et al., 1998; Jensen et al., 2005). The PGI measure aorded patients the opportunity to set their own goals in relation to activities and participation in daily living. Post-intervention the PGI scores demonstrated a statistically signicant improvement in both the Selective and General groups compared to the Control group again supporting the nding of improved perceived function.

G. Syme et al. / Manual Therapy 14 (2009) 252e263

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As is a common criticism of many physiotherapy intervention studies (Feine and Lund, 1997) this study had a relatively short intervention period and follow-up. That said, the study did reect current clinical practice, where patients receive an average of 6e8 treatments sessions. The pragmatic nature of the interventions in this study means that the relative importance of dierent elements of the rehabilitation program cannot be evaluated. However, physiotherapists often use a range of treatment approaches (Bithell, 2000; Grimmer et al., 2000); therefore, single research interventions are uncharacteristic of routine clinical practice (Grimmer et al., 2004). Hence, the nature of the interventions used in this study enhances the external validity and generalisability of the results. Arguably, the inclusion of VMO retraining exercises in the initial stages of the rehabilitation process merely reects the rst stage of a program of quadriceps femoris strengthening. Furthermore, Powers (2003) suggested that optimising lower limb alignment of the femur relative to the patella, by enhancing pelvic and femoral control, may be as pertinent as focusing on rehabilitating muscles that directly control the patella. If this is the case then the timing and content of the optimal treatment regime in patients with PFPS remains to be established. Diculty in establishing the optimum rehabilitation regime, however, is compounded by issues related to the subclassication and diagnosis of PFPS (Witvrouw et al., 2005; Na slund et al., 2006; Nijs et al., 2006). In conclusion, the study demonstrated that physiotherapy involving either selective VMO retraining exercises or a general quadriceps femoris strengthening program reduced pain, improved function and Quality of Life in PFPS patients. This study did not demonstrate that rehabilitation with selective VMO exercise signicantly improves outcome above that provided by general open and closed chain strengthening exercises (Malone et al., 2002; Witvrouw et al., 2004; Bolgla and Malone, 2005). In light of these ndings, clinicians should not overly focus on selective activation before progressing rehabilitation, especially in more chronic cases with signicant participation restrictions.

NHS Scotland and the Chief Scientists Oce of the Scottish Government.

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