Application of Motor Learning Principles in the Intervention of Patellofemoral Pain

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1 Application of Motor Learning Principles in the Intervention of Patellofemoral Pain Dorothy Beatty, SPT Virginia Commonwealth University September 29, 2016

2 Patient Introduction 22 y/o white female presenting to an outpatient orthopedic clinic Chief Complaint: Bilateral p! in feet/ankles, lateral lower legs, & patellofemoral joint Patient goal: Wants to participate in her daily boot camp classes without pain Limited by p! reported as high as 8/10 VPS Must modify any ballistic or plyometric movement during class

3 Initial Evaluation: Subjective PMH: Unremarkable. Pain: Better with: rest Worse with: running, jumping, & > 15 mins of walking ascending/descending stairs sitting long periods (knee bent) Onset: 4 weeks prior to IE Patient Reported Outcome Measure: Lower Extremity Functional Scale 69/80

4 Initial Evaluation: Objective MMT: Weakness of BL LE 4/5 Iliopsoas, Glute max, Quads, Hamstrings +4/5 Glute med & hip adductors 5/5 anterior tib, posterior tib, fibularis ms, gastroc, great toe extensors (EHL, EDL) ROM: Dorsiflexion 5 degrees (extended knee) 15 degrees (flexed knee) Special Tests: + Thomas test: BL Illiopsoas and Rectus femoris + Ober s test: BL TFL/ITB + 90/90: Hamstring flexibility limited to 60 degrees BL

Initial Evaluation: Objective Functional Screening: Single Leg Stance: good balance; difficulty keeping foot flat; no contralateral hip drop Overhead Double Limb

5 Initial Evaluation: Objective Functional Screening: Single Leg Stance: good balance; difficulty keeping foot flat; no contralateral hip drop Overhead Double Limb Squat: poor dorsiflexion mobility knee pain genu valgus during movement Single Leg Squat: Observable genu valgus and contralateral hip drop during movement knee pain

6 PT Diagnosis & Assessment Medical Condition Body Structure & Function Impairments Activity Limitations Participation Restrictions Personal Environmental

7 PT Diagnosis & Assessment Eval and Treat Leg and foot p! -Pain in lower legs, anterior knees, & feet/ankles -Poor dynamic hip & knee control -LE muscle weakness -Decreased hip and ankle DF ROM -Difficulty ascending/descending stairs -Difficulty walking >15m -Difficulty running, jumping -Inability to participate in boot camp classes w peers -Inability to take stairs w coworkers to/from lunchbreak. -Inability to participate in family outings, i.e. trip to DC Eager to participate in therapy Access to services

8 Goals Short Term: Report LE p! <4/10 VPS during 3 consecutive boot camp classes within 4 weeks to improve ability to participate in daily exercise. Long Term: Run for at least 30 mins with no increase >1/10 VPS in LE pain in 12 weeks to improve ability to participate fully in exercise classes with peers. Report knee p! <2/10 VPS while ascending and descending two flights of stairs in 12 weeks to improve patient s ability to take stairs with coworkers during her lunch break.

9 Plan of Care Manual Therapy: Stretch/Contract-relax of quads, hip flexors, hamstring Soft Tissue Mobilization Triggerpoint Dry Needling PRN Home Exercise Program: Stretches of hip flexors, quadriceps, hamstrings, gastroc & soleus Side steps with band Runners squat Intrinsic foot exercises Strengthening Exercise: Increasing strength and control of hip and knee Intrinsic foot strength and stability Neuromuscular Reeducation: Correction of faulty mechanics observed during functional screenings

10 Are externally focused attention cues more effective than internally focused attention cues in the reduction of knee pain during squatting activities in a young female presenting with observable dynamic knee valgus? EFA - External focused attention IFA - Internal focused attention

11 The effects of movement pattern modification on lower extremity kinematics and pain in women with patellofemoral pain. Salsich, G. B., Graci, V., & Maxam, D. E. (2012). Objective: To compare hip and knee kinematics and pain during a single-limb squat between 3 movement conditions (usual, exaggerated, & corrected dynamic knee valgus) in women with patellofemoral pain (PFP). Primary outcome measures: (1) Hip and knee frontal and transverse plane angles (hip adduction & medial rotation, knee abduction & lateral rotation angles) (2) Pain scores (Visual Analog Scale (VAS))

12 Study Design (Salsich, et al., 2012) Study Design: Controlled laboratory study (Quantitative, Single session, No control) Participants: 20 women y/o with chronic PFP (defined by at least 2 months of p!). Inclusion Criteria: Average p! week prior 3/10 P! elicited by two of five provocation tests: resisted isometric quadriceps contraction, squatting, prolonged sitting, stair ascent and descent Observable dynamic knee valgus during a single-limb-squat test.

13 Study Design (Salsich, et al., 2012) Kinematic data obtained using an 8-camera, 3-D motion analysis system sampling at 120 Hz with reflective markers placed on LE. Subjects performed 3 trials of unilateral squats on the involved limb in each condition. Subjects completed VAS after each condition to rate average pain during that condition. Usual Condition Exaggerated Condition Corrected Condition Instructed to keep their trunk upright and their arms out to the side, and to bend their knee to at least 60 Instructed to let your knee fall in (medially) during the descent Instructed to keep your knee over the middle of your foot (don t let your knee fall in) during the descent

14 Results (Salsich, et al., 2012) Usual to Exaggerated Usual to Corrected Pain to Kinematic Correlations Increased hip medial rotation (P<.001) and increased knee lateral rotation (P<.001) Pain increased between conditions (P =.007) Decreased hip adduction (P =.001) and decreased knee lateral rotation (P =.06) No difference in pain between conditions (P = 1.0) Increased pain associated with increased knee lateral rotation in both usual (P =.04) and exaggerated (P =.03) conditions.

15 Results (Salsich, et al., 2012) Usual to Exaggerated Usual to Corrected Pain to Kinematic Correlations Increased hip medial rotation (P<.001) and increased knee lateral rotation (P<.001) Pain increased between conditions (P =.007) Decreased hip adduction (P =.001) and decreased knee lateral rotation (P =.06) No difference in pain between conditions (P = 1.0) Increased pain associated with increased knee lateral rotation in both usual (P =.04) and exaggerated (P =.03) conditions.

16 Results (Salsich, et al., 2012) Usual to Exaggerated Usual to Corrected Pain to Kinematic Correlations Increased hip medial rotation (P<.001) and increased knee lateral rotation (P<.001) Pain increased between conditions (P =.007) Decreased hip adduction (P =.001) and decreased knee lateral rotation (P =.06) No difference in pain between conditions (P = 1.0) Increased pain associated with increased knee lateral rotation in both usual (P =.04) and exaggerated (P =.03) conditions.

17 Limitations (Salsich, et al., 2012) Inaccuracies in skin marker placement Only 1 movement task was analyzed Instructions for usual condition may have created an unusual condition Small sample size Low-level evidence Subgroup finding is merely a theory to explain findings contrary to the hypothesis

18 Clinical Relevance (Salsich, et al., 2012) 1. Improving transverse plane kinematics may have an impact on pain 2. Kinematic variables can be able to be manipulated by verbal instruction 3. May positively impact patient s pain during movement in SOME individuals

19 Background EFA is reported as more effective than IFA for skill mastery in: Asymptomatic persons (Wulf et al., 2001), Patients with stroke (van Vliet & Wulf, 2006), Patients with Parkinson s Disease (Landers et al., 2005; Wulf et al., 2009) Not known in patients with musculoskeletal dysfunction OR if this improved learning results in better patient outcomes.

20 Attentional focus of feedback and instructions in the treatment of musculoskeletal dysfunction: A systematic review Sturmberg, C., Marquez, J., Heneghan, N., Snodgrass, S., & van Vliet, P. (2013). Objective: If feedback provided to individuals with musculoskeletal dysfunction is more effective in improving function and decreasing pain when using an EFA rather than an IFA. Selection Criteria: Studies contained at least one intervention inducing an IFA OR EFA vs an opposing attention, a control, a placebo, or no feedback intervention. RCTs, quasi-rct, non-rcts, cross over trials, observational and case-control studies. Any musculoskeletal condition. Primary Outcome Measures of Interest: Pain (ex. VAS) Function (ex. walking distance, return to sport)

21 Study Design (Strumberg et al., 2013) Participants: Seven studies involving 202 humans with musculoskeletal dysfunction Six randomized controlled trials: Budzynski et al., Tension Headaches Stenn et al., Myofascial pain syndrome Yip et al., Patellofemoral pain syndrome (Men) Laufer et al., 2007 & Rotem-Lehrer et al., Lateral ankle sprains Thiengwittaporn et al., Knee osteoarthritis One controlled cohort study: Alexander et al., Above knee amputation

22 Study Design (Strumberg et al., 2013) Laufer et al., 2007 & Rotem-Lehrer et al., 2007 Addressed the effect of attentional focus using verbal EFA vs IFA instructions Did not use pain as their outcome measures Used Postural Stability Index or degree of platform displacement of stabilometer to assess postural control after ankle sprain Three of the five other studies reported pain as an outcome, but did not address EFA vs IFA Perceived pain severity using the Patellofemoral Pain Syndrome Severity Scale (Yip and Ng 2006); Subjective pain rating 10-point scale, (Stenn et al., 1979); Average headache scores 5-point scale (Budzynski et al., 1973).

23 Results (Strumberg et al., 2013) Limited evidence from Laufer et al. (2007) & Rotem-Lehrer and Laufer (2007) suggesting EFA may be superior to IFA during motor learning for postural stability in participants with lateral ankle sprain. Statistically significant improvements in postural stability in groups receiving EFA Also when participants were tested on a more unstable surface. These studies alone provide insufficient evidence to know whether an EFA is more effective in the treatment of patients with musculoskeletal dysfunction. The review suggests that the evidence is stronger when looking at these studies in context of other populations where EFA has been shown to be more effective.

24 Limitations (Strumberg et al., 2013) Subjects did not match my patient (Ankle sprains vs knee pain; Men w PFPS vs young women; etc) Only 7 studies included Stage of learning of participants only in two studies Not all studies employed an EFA vs IFA Few studies used pain as an outcome measure Large variety of musculoskeletal conditions and outcome measures

25 Clinical Relevance (Strumberg et al., 2013) Provides no evidence to support if this increased learning and performance will have influence on a patient s pain with a musculoskeletal condition Supports previous evidence that EFA promotes learning and mastery of skills 95% of physical therapists provide feedback instructions that induce an internal focus (Durham et al., 2009), yet EFA may be a more effective option for teaching for your patient

26 Are externally focused attention cues more effective than internally focused attention cues in the reduction of knee pain during squatting activities in a young female presenting with observable dynamic knee valgus? Maybe. Instructions on kinematic movement variables MAY have an effect in correcting faulty mechanics which secondarily MAY contribute to pain reduction in some individuals. More research needed to determine if EFA is more effective than IFA for improving performance and its impact on a patient s pain in musculoskeletal conditions. Clinical Takeaway: Movement reeducation and performance improvements may best be addressed through various methods of feedback during instruction.

27 Application of Motor Learning Principles in the Intervention of Patellofemoral Pain Dorothy Beatty, SPT Virginia Commonwealth University September 29, 2016

28 References Durham, K., Van Vliet, P. M., Badger, F., & Sackley, C. (2009). Use of information feedback and attentional focus of feedback in treating the person with a hemiplegic arm. Physiotherapy Research International, 14(2), Salsich, G. B., Graci, V., & Maxam, D. E. (2012). The effects of movement pattern modification on lower extremity kinematics and pain in women with patellofemoral pain. journal of orthopaedic & sports physical therapy, 42(12), Sturmberg, C., Marquez, J., Heneghan, N., Snodgrass, S., & van Vliet, P. (2013). Attentional focus of feedback and instructions in the treatment of musculoskeletal dysfunction: A systematic review. Manual therapy, 18(6), Landers, M., Wulf, G., Wallmann, H., & Guadagnoli, M. (2005). An external focus of attention attenuates balance impairment in patients with Parkinson's disease who have a fall history. Physiotherapy, 91(3), Wulf, G., & Prinz, W. (2001). Directing attention to movement effects enhances learning: A review. Psychonomic bulletin & review, 8(4), Van Vliet, P. M., & Wulf, G. (2006). Extrinsic feedback for motor learning after stroke: what is the evidence?. Disability and rehabilitation, 28(13-14), Wulf, G., Landers, M., Lewthwaite, R., & Töllner, T. (2009). External focus instructions reduce postural instability in individuals with Parkinson disease.physical therapy, 89(2),

Research Theme. Cal PT Fund Research Symposium 2015 Christopher Powers. Patellofemoral Pain to Pathology Continuum. Applied Movement System Research

Research Theme. Cal PT Fund Research Symposium 2015 Christopher Powers. Patellofemoral Pain to Pathology Continuum. Applied Movement System Research Evaluation and Treatment of Movement Dysfunction: A Biomechanical Approach Research Theme Christopher M. Powers, PhD, PT, FAPTA Understanding injury mechanisms will lead to the development of more effective