Julio Zago, Fellipe Amatuzzi, Tatiana Rondinel, João Paulo Matheus | Year 2020

Osteopathic Manipulative Treatment Versus Exercise Program in Runners With Patellofemoral Pain Syndrome

Pathology:

Patellofemoral pain

Type of study:

Randomized controlled trial

Date of publication of the study’:

2020/Dec/17

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Purpose of the study

  • Objective: to evaluate the efficacy of OMT, compared to an exercise program, in runners with patellofemoral pain syndrome
  • Measured outcomes:
    • Primary: knee pain through Visual Analog Scale (VAS)
    • Secondary: knee functionality through Lysholm Knee Scoring Scale, dynamic knee valgus through step-down test, plantar pressure in middle foot through static baropodometry, posterior thigh flexibility through sit and reach test, range of motion (ROM) of hip extension through fleximetry

Participants

  • Number: 82 people (48 female and 34 male)
  • Criteria of inclusion:runners (running at least 3 times a week), age 18-35 years, with a diagnosis of patellofemoral pain syndrome (recurrent pain in the anterior part of the knee for at least 3 months and and while carrying out 2 or more activities that would normally cause the pain) issued by one of the researchers in the study; articular hypomobility in at least one of the following joints: lumbar curve, sacroiliac, hips, kneese, ankles; pain in the anterior region of one of both knees with an intensity of at least 5 on VAS
  • Criteria of exclusion: diagnoses of pathologies different from patellofemoral pain syndrome
  • Groups of study: 3 groups obtained by randomization
    • Group 1: OMT, 30 people (18 female and 12 male, mean age 31.36 years)
      • 3 people were lost at the follow-up
    • Group 2: exercise program, 28 people (17 female and 11 male, mean age 34.88 years)
      • 2 people were lost at the follow-up
    • Group 3: waiting list, 24 people (13 female and 11 male), mean age 32.94 years)

Interventions and evaluations

To determine the inclusion in or exclusion from the study:

  • Evaluation of articular hypomobility: lumbar curve through Mitchel Test and test of palpatory sensitivity; sacroiliac joints through Distraction, Thigh Thrust, Compression, Sacrum Thrust and Gillet Tests; hips through Gaenslen Test and Patrick & Faber Test; knees through tests of fibular mobility and tibial rotation; ankles by testing of distal fibular mobility, navicular bone and astragalus
    • differential diagnosis issued by an osteopath physician for other musculoskeletal disorders
  • Evaluation of knee pain through VAS, dynamic knee valgus through step-down test and posterior thigh flexibility through sit and reach test at baseline, after each of the 6 intervention and after 30 days from the end of the study
  • Evaluation of functionality through LKSS, dynamic knee valgus through step-down test, plantar pressure in middle foot through static baropodometry and ROM of hip extension through fleximetry at the first and sixth intervention and 30 days after the end of the study
  • 6 40-minute sessions of OMT or physical exercise, twice a week, at a distanced of at least 48 hours from one another
  • OMT: high-velocity low amplitude techniques directed at the lumbar curve, sacroiliac joints, knees, ankle and, when required, myofascial release techniques directed towards the lumbar region muscles, tensors of the fascia lata, iliopsoas, pyriformis, quadriceps and gastrocnemius muscles
  • Exercises program: specific exercises focused on quadriceps and ischiocrural muscles, bending, abduction, adduction, external rotation and extension of the hips, extension of the knees, squats, lateral steps, passive stretching of ischiocrural muscles, iliotibial tract and plantar flexors
  • Waiting list: physical therapy at the end of the study
  • OMT performed by one osteopath with 8-years experience
  • The participants were instructed not to follow other physical therapy treatments, use medications and run during the study
    • otherwise, they had to inform the researchers

Results

  • Primary outcomes: both OMT and exercise program induced a statistically significant reduction in pain compared to the control group already from the first session. The significance was maintained throughout the study, including at the 30-day follow-up.
  • Secondary outcomes: both OMT and exercise program induced an improvement in functionality measured by LKSS and in flexibility of the back thigh compared to the control group in a statistically significant way. In the dynamic knee valgus test, OMT induced a statistically significant reduction compared to both exercise program and control. Likewise, the plantar pressure decreased statistically significantly in the OMT group compared to both the other groups. With regard to the ROM, instead, the exercise program produced a statistically significant improvement compared to both OMT and control groups. With the exception of the ROM, all results remained statistically significant at the follow up.

Discussion

Despite some intrinsic limitations of the study (eg, the inability to check whether the participants followed the recommendations), both OMT and exercise program, with some difference, induced major improvements in runners suffering from patellofemoral pain syndrome. These results, in particular regarding lower pain and increased functionality, were not only statistically significant, but also clinically significant.

While the exercises may have strengthened the muscles (although no measurements have been made to actually assess this possibility), the OMT may have improved joint functionality, favoring a better redistribution of the loads on the knee when under stress. This hypothesis could be confirmed by the change of the plantar pressure occurring in the OMT group.

The other results obtained did not have a major clinical impact: however, they can favor a reduction of the risk of injury and, therefore, should be taken under consideration. In this regard, the greater flexibility of the back thigh in the OMT group may depend on the reduction of the tension of muscles and fascia induced by the myofascial release techniques. Consequently, in the therapy for patellofemoral pain syndrome, both OMT and exercise program can be considered particularly valid interventions.

The review of Osteopedia

By Marco Chiera

Strengths:very accurate description of the inclusion criteria, the instrumental tests used and the interventions; calculation of the sample size (how many people to recruit); several results obtained (eg, pain and functionality) were also clinically significant, that is, they indicated an effective improvement in the clinical condition; evaluation with a follow up at 30 days; calculation of effect sizes (the relevance of the effect of an intervention), useful for future studies.

Limits:in the calculation of the sample size, since the values of mean and standard deviation of pain have not been indicated, it is difficult to reproduce the calculation; as reported by the authors, the lack of radiographic examinations to diagnose patellofemoral pain syndrome may have prevented them from discovering the cause of pain in other coexisting lesions; no assessment of any adverse effects seems to have been carried out. In addition, the effect of the exercise is explained only by a simple strengthening of the muscles, without considering any evidence that unties pain from muscle strength and the importance of proprioceptive and interoceptive improvements, that is in the sensorimotor organization. Similarly, regarding the myofascial release effects, they are generically reported as reduction of muscular and fascial tensions.

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