Patellofemoral Syndrome Clinical Trial
Official title:
The Evaluation of a Novel Treatment Algorithm for Patients With Patellofemoral Syndrome: A Pilot Study
Patients who are diagnosed with Patellofemoral Pain Syndrome (PFS) and present to our clinic
will be offered the opportunity to participate in the study. If they consent to be in this
study they will randomized into 2 treatment groups. The experimental treatment group will be
treated according to the novel PFS treatment algorithm. The control group will receive
treatment that would be considered standard physical therapy care. To apply standard
physical therapy care in a standardized manner the investigators are using a multimodal
treatment approach that has been previously shown by Lowry to be beneficial in the treatment
of PFS. Both groups of subjects will be seen 2 times per week for a maximum of 12 visits.
Patients can be discharged early if they no longer report pain or impaired function on the
Anterior Knee Pain scale.
The purpose of this study is to see if patients with patellofemoral pain syndrome treated
with the experimental Patellofemoral treatment algorithm experience significant improvements
in function, pain and the number of treatment sessions compared with a previously researched
multimodal approach to the treatment of patellofemoral pain.
The secondary objective of this study is to examine results to determine if a full
randomized controlled clinical trial of the PFS algorithm is justified.
The investigators hypothesize that utilization of the Patellofemoral syndrome treatment
algorithm with evaluation and treatment of patients diagnosed with PFS will lead to
significant improvements in function, pain and the number of treatment sessions when
compared to previously researched treatment of PFS.
Patients referred to for physical therapy with the diagnosis of Patellofemoral Pain Syndrome
will be offered the opportunity to participate in the study. After explaining the study and
answering any patient or parent questions, informed consent will be obtained for those
individuals wishing to participate. The participants will be screened to see if they meet
the inclusion criteria, and will be randomly assigned to either evaluation and treatment
using the novel PFS treatment algorithm(experimental group) or evaluation and treatment
using the multimodal approach to PFS. The evaluating therapist will take all measurements
and perform treatments with the patients, and cannot be blinded to group allocation. The
patient will not be made aware of if they are in the experimental or control group, but
cannot be blinded to the treatment that they receive.
Multimodal approach to PFS: Patients randomized to the control treatment group will be
treated in a manner consistent with a treatment approach previously described in literature
that has been found effective in treating Patellofemoral Syndrome.
Multimodal PFS Evaluation
Postural Exam
- Lower Extremity (LE) Alignment
- Pelvic Rotation
- Navicular Drop
Neurodynamic Testing
- Straight Leg Raise (SLR) Muscle Flexibility
- 90/90 Hamstring (-20 degrees considered positive)
- Quadriceps length (Elys test)
- Standing gastrocnemius length
- Prone Piriformis length
- Supine Modified Thomas Test
- Ober's Test
AROM/PROM
- Hip
- Knee
- Great Toe Dorsiflexion (DF)
- Ankle DF
- Calcaneal/forefoot Valgus
Manual Muscle Testing (MMT) (as described by kendall)
- Gluteus maximus
- Gluteus Medius
- Quadriceps
- Hamstrings
- Hip Internal Rotation (IR)
- Hip External Rotation (ER)
Accessory Motions (to find restricted motion, or pain. Used to guide manual treatment)
- Posterior Anterior (PA) glides of the Lumbar Spine
- Hip
- Patella
- Tibiofemoral joints
Abdominal Recruitment -Palpated Abdominal Drawing-in maneuver (in hook lying position)
Special Tests
-Patellar Compression Test
Functional Tests
- Squat
- Step down test (Forward off 8 inch step)
Treatment using Multimodal Approach
Manual Therapy prior to Exercise
- Lumbopelvic thrust (Used if greater than 15 degrees prone hip IR noticed between sides.
Up to 2 manipulations per side for 2 treatments.)
- Caudal hip non-thrust manipulations (Used if restriction noticed with accessory motion
or pain with hip Range of Motion (ROM) at the start of session.)
- Patellar mobilizations (Inferior patellar joint mobilization used for -patellar
compression test. Otherwise used for limited motion.)
- Proximal Tibiofibular Manipulation (Used if restriction of motion noticed between
sides, or if patient experiences pain with knee flexion.)
Treatment modalities -Patellar Taping (Patient taped for the first 3 weeks of therapy)
McConnell Medial Patellar Taping is attempted if patient reports pain on functional step
down test. Taping used as an intervention if patients reports decreased pain of at least
2/10 with functional step down test after taping
Orthotics -Patient is fitted for and issued orthotics if a >3mm drop with navicular drop
test noted
Non Weight Bearing Exercise (Patient to be able to perform Non Weight Bearing (WB) exercises
properly before progressing to WB)
- Abdominal isometric bracing in hook lying
- Abdominal bracing with heel slide
- Abdominal bracing with bent knee lifts
- Abdominal bracing with straight-leg raise
- Bridging (Patient in hook lying and asked to perform abdominal bracing, while lifting
gluteal muscles from the table)
- Side-lying clamshells (Patient is sidelying, with hip and knees flexed to 45 degrees.)
- Quadruped Upper Extremity and LE lifts (Patient in quadruped and asked to perform
abdominal bracing.)
- Quadruped Hip abduction (Patient in quadruped and asked to perform abdominal bracing)
- Quadruped Hip extension (Patient in quadruped and asked to perform abdominal bracing)
Weight Bearing Exercises (Must be able to complete 2 sets of 10 without substitution of non
WB exercises)
- Double Leg Press ( Total gym/Shuttle)
- Single Leg Press ( Total gym/Shuttle)
- Eccentric Step-Downs (Forward Use a 4inch step)
- Eccentric Step-Downs (Lateral Use a 4inch step)
- Hip abduction sidestepping (Knees and hips slights flexed with theraband at ankles)
- Squats
- Lunge
- Clock Balance and Reach (functional star)
Stretches 3 sets of 30 second holds (only to be performed if tightness is found)
- Supine piriformis stretch
- Supine Gluteus figure-four stretch
- Standing hamstring stretch
- Standing quad stretch
- Standing Iliotibial band Stretch
- Standing gastrocnemius stretch
PFS treatment algorithm:
The PFS treatment algorithm is a objective goal driven treatment program. Treatment is at
the therapist discretion with the objective to meet the requirements for each subgroup.
Evidence from literature guides treatment to best meet these goals.
The first group within the classification system is Fear Avoidance, as research has shown
that a change in fear-avoidance beliefs about physical activity is one of the best
predictors for improved functional outcome.
The second group is Flexibility. This is the second group in the system because research
shows that patients with decreased flexibility are unable to properly perform functional
malalignment test. Also quadriceps length and gastrocnemius/soleus lengths are strongly
associated with PFS.
The third group is Functional Malalignment. This group assesses the patient's form with
functional tasks. If the patient demonstrates impaired mechanics, time is spent with
strengthening and motor control so that the patient will be able to strengthen and return to
full function with proper technique.
The final group is Strengthening/Return to Function. This group will work strengthening of
the lower quarter muscles with particular attention to the quadriceps, hip abductor and
external rotators. This is also the time to progress the patient back to sport or functional
activity.
-Fear Avoidance Belief Questionaire (A score of 15 or greater on this questionaire results
in being give a PFS fear avoidance booklet and treatment using a Cognitive Behavioral
emphasis)
Primary Muscle Flexibility Requirements (Not meeting 1 of these flexibility measures results
being placed into the flexibility subgroup)
- Quadriceps ≥ 130 degrees
- Gastrocnemius ≥ 12 degrees
- Soleus ≥ 20 degrees
- WB DF ≥ 50 degrees
Secondary Muscle Flexibility (Having tightness in at least 3 of the following tests results
in being placed into the flexibility subgroup)
- Thomas test
- Ober's Test
- Hamstring SLR ≥ 80 degrees
- Adductor Flexibility
Functional Malalignment (Score of great than 1 results in being placed into functional
malalignment subgroup)
- Lateral Step Down test
- Single Leg Squat test
Strengthening/Functional Progression (A limb symmetry index score of >=90% for each of these
test is used to determine adequate LE strength and function)
- Single Hop Test
- Triple Hop Test
- Crossover Hop for Distance test
- Timed Step Down test
;
Allocation: Randomized, Endpoint Classification: Safety/Efficacy Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Treatment
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