Author Names

Motealleh, A., Barzegar, A., and Abbasi, L.

Reviewer Name

Elizabeth Farmer, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy

 

Paper Abstract

Background Patellofemoral pain (PFP) is a common musculoskeletal disorder. Quadriceps and core muscle neuromuscular control impairments are frequently associated with PFP. Lumbopelvic manipulation (LPM) has been shown to improve quadriceps and core muscle activation and decrease their inhibition, but changes in balance and knee joint position sense (JPS) after this intervention remain unknown.  Objective To determine whether LPM decreases knee pain and JPS error and increases balance performance in patients with PFP.  Design Randomized controlled trial.  Setting Biomechanics laboratory at a rehabilitation science research center.  Methods Forty-four patients with PFP participated in this study that randomly divided into two equal groups. One group received LPM and the other received sham LPM (positioning with no thrust) in a single session. At baseline and immediately after the intervention, the outcomes of pain using a visual analog scale, balance using the modified star excursion balance test (mSEBT), and JPS at 20° and 60° of knee flexion using a Biodex dynamometer.  Results There was a statistically significant improvement in pain, balance control (anterior direction) and JPS in the LPM group immediately after the intervention. In addition, we observed significant differences between groups in pain, balance control (anterior direction) and JPS at 60° of knee flexion immediately after the intervention.  Conclusion A single session of LPM immediately improved balance control, knee JPS, and pain in patients diagnosed with PFP.  Clinical rehabilitation impact Findings suggest that LPM may be used as a therapeutic tool for immediate improvement of symptoms of PFP. However, more research is needed to determine long term results.

 

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

  1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT?
  • Yes
  1. Was the method of randomization adequate (i.e., use of randomly generated assignment)?
  • Yes
  1. Was the treatment allocation concealed (so that assignments could not be predicted)?
  • Yes
  1. Were study participants and providers blinded to treatment group assignment?
  • No
  1. Were the people assessing the outcomes blinded to the participants’ group assignments?
  • Cannot Determine, Not Reported, or Not Applicable
  1. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
  • Yes
  1. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
  • Yes
  1. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
  • Yes
  1. Was there high adherence to the intervention protocols for each treatment group?
  • Yes
  1. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
  • Yes
  1. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
  • Yes
  1. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
  • Yes
  1. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
  • Cannot Determine, Not Reported, or Not Applicable
  1. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
  • Yes

 

Key Finding #1

There was a statistically significant decrease in pain (measured by VAS, mean change of 1.34 points) after supine rotational lumbopelvic manipulation was performed in patients with patellofemoral pain syndrome. In the control group who received a “sham manipulation” described as the manipulation set up with no thrust, there was no difference in pain levels before vs after the intervention.

Key Finding #2

Knee joint position sense (JPS) error at 20 and 60 degrees decreased significantly when measured via an isokinetic dynamometer immediately after lumbopelvic manipulation. The sham manipulation group did not experience a change in JPS error.

Key Finding #3

Immediately after lumbopelvic manipulation, the experimental group demonstrated as significant increase in anterior excursion distance in the modified star excursion balance test (mSEBT) as compared to both the pre-test results and the results of the sham manipulation group. This increase in anterior excursion represents an improved balance performance post manipulation.

 

Please provide your summary of the paper

This study examined the effect of a supine rotational lumbopelvic manipulation on pain, joint position sense error, and balance performance on patients with patellofemoral pain syndrome. Outcomes were measured via a Visual Analogue Scale rating, isokinetic dynamometer testing of joint position sense at 20 and 60*, and performance and directional excursion during the modified star excursion balance test (mSEBT) immediately following the experimental treatment. 44 participants were randomly allocated to the experimental group receiving the manipulation, or a control group receiving a sham manipulation consisting of the set up for the manipulation but no actual thrust. The study reported a significant decrease in pain, decrease in joint position sense error, and increase in mSEBT scores following manipulation, with no changes in scores for the sham manipulation group. The authors state that these findings are similar to those of studies done on upper extremity joints and cervical manipulations. However, the mechanism through which lumbopelvic manipulations can decrease pain, JPS error, and improve balance has yet to be fully elucidated and further studies should be done to examine the long term effects on manipulation on these variables in participants with patellofemoral pain syndrome.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

This study suggests that lumbopelvic manipulation can play a role in the care of patients with PFPS by not just providing immediate symptom improvement, but improving biomechanic performance as well. The paper builds on a body of literature suggesting that osteopathic manipulations of regions near the region of the primary diagnosis can provide benefit to the patient. The findings highlight the importance of examining the entire kinetic chain while treating a patient. One limitation in the application of these findings to clinical practice is that there is not yet any research suggesting that these gains in balance and proprioception are long-lasting. Finally, as with other osteopathic manipulations, this should not be used as the primary mechanism through which a therapist treats a patients, but rather a way to facilitate participation in other therapeutic exercises necessary for the patient’s recovery.