Treating Patellofemoral Pain Syndrome: What Comes First: Hip or Knee?
By Tejal Ramaiya, DPT, CSCS
Patellofemoral Pain Syndrome (PFPS) is one of the most common conditions physical therapist’s encounter and yet one of the most challenging to treat. Hip weakness, quadricep weakness, and poor flexibility are just some of the factors that can contribute to PFPS, not to mention sub-par footwear, sport technique, joint arthrokinematics and/or foot abnormalities. Flexibilty exercises for psoas, quadricep, hamstrings, and gastroc-soleus are staple protocol when treating PFPS, however when it comes to strengthening, what is the most effective approach for the early stages of rehabilitation? Is there a difference between an early stage quadricep versus hip musculature strengthening approach?
A recent study published in Journal of Orthopedic and Sports Physical Therapy studied the effects of isolated hip strengthening compared to isolated quadricep strengthening prior to initiating a functional weight-bearing strengthening program in women with PFPS. This study included exclusively females due to their epidemiologically higher incidence of PFPS. The study was a randomized clinical trial where 33 women were randomly assigned to either a hip strengthening group or a quadricep strengthening group. The hip group performed exclusively hip abduction and external rotation strengthening for 4 weeks while the quadricep group performed only quadricep strengthening exercises for 4 week. At 4 weeks, both groups initiated a weight-bearing strengthening program.
Treatment was as follows: both groups performed stretching of the quadriceps, hamstrings, and triceps surae (3 times for 30 seconds each) throughout the 8-week program in addition to their respective strengthening programs (hip vs. quadricep).
Measures taken at baseline and at 8 weeks:
- Strength
- Pain (Visual Analog Scale)
- Step-down Test
- Lower Extremely Functional Scale (LEFS).
Hip group exercises (weeks 0-4):
- Standing hip abduction
- Sidelying combination hip abduction and external rotation (clams)
- Seated hip external rotation
Quadricep group exercises (weeks 0-4):
- Quad sets
- Short-arc quads
- Terminal knee extensions
- Straight leg raises
Weight-bearing strengthening exercises (weeks 4-8):
- Single leg balance with front pull
- Wall slides with resistance
- Lateral step-downs
- Calf raises
- Lunges
The results of this study found that both groups experienced an overall increase in strength and improved function over the 8-week period, however, the hip group had a significant decrease in pain during the first 4 weeks of treatment whereas as the quadricep group reported no change in pain. The results of this study suggests that isolated hip strengthening in the early stages of treating patients with PFPS may be the more clinically efficient way of reducing pain and increasing function.
Click on the video below to see the correct technique for performing sidelying combination hip abduction and external rotation (clams). For videos of all other exercises mentioned in this post, please visit the FORCE Therapeutics online store.
Clams
embedded by Embedded Video
Reference
1. Dolak, K. et. al. Hip Strengthening Prior to Functional Exercises Reduces Pain Sooner Than Quadriceps Strengthening in Females With Patellofemoral Pain Syndrome: A Randomized Clinical Trial. J Ortho Sports Phys Ther 2011; 41(8): 560-571.
Tejal Ramaiya is National Client Representative at Force Therapeutics. Force Therapeutics provides a web and mobile application that extends physical therapy patient care beyond the office visit. The application provides physical therapists with clinically tested platform to manage patients, track compliance and effortlessly assign exercise videos. Tejal owns a private practice in NJ where she uses the Force Therapeutics platform to prescribe video based exercise programs to her patients. Please visit www.forcetherex.com for more information.
FORCE Therapeutics Introduces New App to Extend Patient Care Beyond the Walls of the Physical Therapy Clinic
FORCE Therapeutics is introducing a new web and mobile application today for physical therapy practices, providing therapists with a tool that allows them to extend clinical patient care beyond the clinic. The new product, called FORCE TherEx, is a clinically tested, browser-based software product that provides both therapists and patients an easy way to view exercise videos, track progress and securely communicate with one another.
FORCE TherEx contains a video library containing hundreds of clinically tested exercise demonstration videos that were created by a team of prominent physical therapists. These videos can be used to demonstrate clinically correct exercises to patients, whether they are at the clinic, or in the comfort of their own homes. They show patients precisely how each prescribed exercise is to be completed and they can be viewed on any browser-enabled device, whether that be a computer, a phone or even an Apple iPad.
“The product was designed to address the specific clinical challenges that face physical therapists,” said Bronwyn Spira, a veteran physical therapist and a co- founder of FORCE Therapeutics. Chief among those challenges is that “the average first time patient leaves a clinic with between 4 – 10 prescribed exercises as a part of their physical therapy program.” Those patients are then expected to return home and remember precisely how each of those exercises should be performed.
Using FORCE TheEX, a therapist can prescribe any number of exercises and provide the patient with access to those professionally produced, clinically correct videos that can be used as a reference by the patient between visits.
According to Ms. Spira, FORCE TherEx was designed as “clinical tool for therapists that enables them to be more effective, to be more current with their technology and to run their practices in a cooler, more time efficient way. I believe it really achieves that and is a huge time saver for Physical Therapists. I know, I use it myself in my own practice.” She continued by saying that “Patients love the technology as well because they are looking to manage their own healthcare using their mobile devices or home computers.”
While the videos are a big part of the product, it can also serve as a practice portal allowing therapists to view and update their daily schedules, securely communicate with patients and track patient progress. The fact that the product is browser based allows the therapist to use it on a desktop computer while updating schedules or communicating with patients, or at the point of patient care with a mobile device.
“Using the FORCE App in our practice has resulted in a significant improvement in patient outcomes,” says Claude Hillel, PT. “It saves us so much time and the patients love it. FORCE TherEx has transformed my practice by providing an easy-to-use tool that greatly enhances a patient’s rehab experience.”
In the coming months FORCE Therapeutics will also be adding electronic medical record (EMR) functionality to the product which will allow physical therapy clinics to more easily communicate and exchange medical records with the EMR savvy physicians that refer patients to them. This product will be called FORCE TherEx Plus and the company hopes to introduce it during the first quarter of 2012.
Physical Therapists interested in trying FORCE TherEX can sign up for a free trial of the service at www.forcetherex.com. The company will also offer individual exercise videos to consumers who may not be visiting a clinic that uses FORCE TherEX.
New Physical Therapy Tool Empowers Patients and Your Practice
Bronwyn Spira, President and Co-founder of Force Therapeutics speaks to the physical therapy community through a podcast interview with Jeff Worrell.
Taken from PTtalker.com:
Poor patient compliance is one of the leading factors behind unsatisfactory patient outcomes. To help improve patient outcomes and compliance tracking, this week’s expert developed an online solution for physical therapists. Brownwyn Spira, PT is a practicing physical therapist and owner of FORCE Physical Therapy. She’s also the president of FORCE Therapeutics which provides digital health applications for the physical therapy industry.
The inspiration behind FORCE Therapeutics was Spira’s frustration with the way physical therapists deliver exercise instruction to patients. Instead of handing a paper with written instructions on ways to do a specific exercise, she turned to technology to provide patients with videos that provide clear visual and verbal instructions to patients. The collection of videos and patient management tools are combined together in a subscription based online application, FORCE TherEx. This intuitive online solution allows physical therapists to provide professional home exercise video programs to their patients from their own website. The videos are easily accessed online from any computer or mobile device.
After years of testing, FORCE TherEx is slated to launch on September 12, 2011. Physical therapists can give the program a try for free by signing up for their free 14-day trial. Click here to listen to the full podcast now.
Exercises to Normalize Scapular Kinematics
By Tejal Ramaiya, DPT, CSCS
Most experienced clinicians would agree that patients with shoulder pathology commonly also exhibit abnormal scapular kinematics. Decreased scapular upward rotation, external rotation, and posterior tilt are typical of this scapular dysfunction. A study by Oyama, et. al. studied the effects of widely used scapular stabilization exercises on the kinematics of the scapula to hone in on which exercises provide the most significant effects on the scapula.
Prone scapular retraction exercises were performed by 25 healthy adults:
Exercise 1
Prone, shoulders at 90 degrees abduction, neutral humeral rotation (palms facing floor)
Exercise 2
Prone, shoulders at 90 degrees abduction and external rotation (thumb toward ceiling)
Exercise 3
Prone, shoulders at 120 degrees abduction, neutral humeral rotation (palms facing floor)
Exercise 4
Prone, shoulders at 120 degrees abduction and external rotation (thumb toward ceiling)
Exercise 5
Prone, shoulders abducted to 45 degrees with 90 degrees elbow flexion
Exercise 6
Full extension
Participant performing exercises 1 through 6
Scapular kinematics were measured using surface EMG.
Exercises 2 and 5 resulted in the most significant movement in scapular external rotation, upward rotation, posterior tilt, and retraction compared to all the other exercises. If the goal of treatment is to normalize motion in a pathological shoulder which also demonstrates scapular dysfunction, performing these scapular retraction exercises may be beneficial. Clinicians should choose their exercises appropriately depending on pre-existing conditions, strength deficits, and available range of motion. In my clinical practice I refer to these exercises as T's and W's to help the patient envision the position in which their arms should end up.
Click on the videos below to see the correct way of performing these exercises.
Prone W
embedded by Embedded Video
YouTube Direkt
Prone T (With Shoulder External Rotation)
embedded by Embedded Video
YouTube Direkt
Reference
1. Oyama S, Myers J, Wassinger C, Lephart S. Three-Dimensional Scapular and
Clavicular Kinematics and Scapular Muscle Activity During Retraction Exercises
J Ortho Sports Phys Ther 2010; 40(3): 169-179.
Tejal Ramaiya is National Sales Representative at Force Therapeutics, a web-based comprehensive patient management solution for physical therapists. She owns a private physical therapy practice in New Jersey where she treats orthopedic, sports and spine patients.
Just Press Play
Co-authored by Bronwyn Spira, PT, and Tejal Ramaiya, DPT, CSCS
embedded by Embedded Video
YouTube Direkt
A Force Therapeutics Exclusive Video
Gone are the days of paperback novels, letter writing and printed bank deposits. We are in the digital age and access to everything is a smartphone or a click away. Whole industries have reinvented themselves online, creating immense benefits for their customers and their businesses. To its detriment, the physical therapy industry hasn’t kept up - in a most glaring example, we still hand out paper photocopies of home exercise programs. Physical therapists are set in their ways, at their own peril.
Patients want to access their home exercise programs on the go; whether at the office, the gym, on a business trip or in their home... and want to know that they are doing their exercises correctly. It is time to replace stick figures in static postures printed on a piece of paper. Our digital future lies in video based home exercise programs. Recent advances in streaming technology allows physical therapists to deliver exercise videos anytime, anywhere.
Video based home exercise programs can be beneficial to both the patient and the therapist. For the patient; videos can significantly improve performance, proficiency, motivation, and confidence.1,2 The visual and auditory cues from a video markedly improve performance and learning versus paper base descriptions. When it is easy to view and learn, patients quickly develop confidence in their exercise performance.
Video based home exercises can be extremely beneficial to the physical therapist as well. Decreased training time in the clinic (reviewing the basic exercise program only once or twice) along reducing time spent in follow on visits correcting poor technique allows therapists to focus their treatment time on manual therapy and neuromuscular re-education. The combination of these
factors is sure to significantly improve patient outcomes.
The time has come to rethink our legacy paper-based practices and embrace what is possible - video technology is the new home exercise prescription solution.
1. Reo JA, Mercer VS. Effects of live, videotaped, or written instruction on learning an upper-extremity exercise program. Physical Therapy 2004; 84:622-33, http://ptjournal.apta.org/content/84/7/622.full
2. Roddey et. al. Videotape instruction versus illustrations for influencing quality of performance, motivation, and confidence to perform simple and complex exercises in healthy subjects. Physiotherapy Theory and Practice, Volume 18, Number 2, 1 June 2002 , pp. 65-73(9). http://www.ingentaconnect.com/content/apl/uptp/2002/00000018/00000002/art0
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