Advertisement

Added Value of Gluteus Medius and Quadratus Lumborum Dry Needling in Improving Knee Pain and Function in Female Athletes With Patellofemoral Pain Syndrome: A Randomized Clinical Trial

  • Hanieh Zarei
    Affiliations
    Physical Therapy Department, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran

    Student Research Committee, Shiraz University of Medical Science, Shiraz, Iran
    Search for articles by this author
  • Soha Bervis
    Affiliations
    Physical Therapy Department, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran

    Student Research Committee, Shiraz University of Medical Science, Shiraz, Iran
    Search for articles by this author
  • Soraya Piroozi
    Affiliations
    Physical Therapy Department, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
    Search for articles by this author
  • Alireza Motealleh
    Correspondence
    Corresponding author Alireza Motealleh, PhD, PT, Physical Therapy Department, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Chamran Boulevard, Abiverdi Street, Shiraz, Iran, PO Box 7194633669.
    Affiliations
    Physical Therapy Department, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran

    Rehabilitation Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
    Search for articles by this author
Published:August 26, 2019DOI:https://doi.org/10.1016/j.apmr.2019.07.009

      Abstract

      Objective

      To compare the effects of exercise therapy alone and exercise therapy plus gluteus medius (GM) and quadratus lumbarum (QL) dry needling on pain and function in female athletes with patellofemoral pain (PFP).

      Design

      Single-blind randomized controlled trial with follow-up.

      Setting

      Physiotherapy clinic.

      Participants

      Convenience sample of female athletes with PFP (N=40), who were randomly assigned to the exercise therapy (Ex group) or exercise-therapy+dry needling (Ex+DN group) group.

      Interventions

      The Ex group received exercise therapy for 4 weeks, and the Ex+DN group received exercise therapy in combination with dry needling directed at GM and QL trigger points for 4 weeks.

      Main Outcome Measures

      In all participants, pain intensity, function (Kujala score, modified star excursion balance test, step-down test), and QL and GM pressure pain threshold (PPT) were recorded at baseline and at 4 and 6 weeks after the start of treatment. Analysis of variance (2 groups×3 times) was used to compare within- and between-group differences.

      Results

      The group versus time interaction effect was significant for all variables (P<.05). Both groups showed significant improvements in pain, function, and PPT at weeks 4 and 6 compared to baseline (P<.05). Between-groups comparisons showed significantly greater improvements in pain, function, and PPT in the Ex+DN group (P<.05).

      Conclusions

      Targeting intervention to treat trigger points in the GM and QL muscles combined with exercise therapy had superior beneficial effects compared to exercise alone in managing PFP. Therefore, adding GM and QL muscle dry needling to exercise therapy may be advisable to enhance the effects of PFP rehabilitation.

      Keywords

      List of abbreviations:

      DN (dry needling), GM (gluteus medius), mSEBT (modified star excursion balance test), PFP (patellofemoral pain), PPT (pain pressure threshold), QL (quadratus lumborum), TrP (trigger point)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Smith B.E.
        • Selfe J.
        • Thacker D.
        • et al.
        Incidence and prevalence of patellofemoral pain: a systematic review and meta-analysis.
        PLoS One. 2018; 13e0190892
        • Crossley K.M.
        • Stefanik J.J.
        • Selfe J.
        • et al.
        2016 patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 1: terminology, definitions, clinical examination, natural history, patellofemoral osteoarthritis and patient-reported outcome measures.
        Br J Sports Med. 2016; 50: 839-843
        • Arun B.
        • Vakkachan T.
        • Abraham B.
        Comparison of dynamic postural control with and without patellofemoral pain syndrome using star excursion balance test.
        J Med Sci Technol. 2013; 2: 1-6
        • de Oliveira Silva D.
        • Magalhães F.H.
        • Pazzinatto M.F.
        • et al.
        Contribution of altered hip, knee and foot kinematics to dynamic postural impairments in females with patellofemoral pain during stair ascent.
        Knee. 2016; 23: 376-381
        • Powers C.M.
        • Witvrouw E.
        • Davis I.S.
        • Crossley K.M.
        Evidence-based framework for a pathomechanical model of patellofemoral pain: 2017 patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester, UK: part 3.
        Br J Sports Med. 2017; 51: 1713-1723
        • Chester R.
        • Smith T.O.
        • Sweeting D.
        • Dixon J.
        • Wood S.
        • Song F.
        The relative timing of VMO and VL in the aetiology of anterior knee pain: a systematic review and meta-analysis.
        BMC Musculoskel Disord. 2008; 9: 64
        • Witvrouw E.
        • Lysens R.
        • Bellemans J.
        • Cambier D.
        • Vanderstraeten G.
        Intrinsic risk factors for the development of anterior knee pain in an athletic population: a two-year prospective study.
        Am J Sports Med. 2000; 28: 480-489
        • Biabanimoghadam M.
        • Motealleh A.
        • Cowan S.M.
        Core muscle recruitment pattern during voluntary heel raises is different between patients with patellofemoral pain and healthy individuals.
        Knee. 2016; 23: 382-386
        • Shirazi Z.R.
        • Moghaddam M.B.
        • Motealleh A.
        Comparative evaluation of core muscle recruitment pattern in response to sudden external perturbations in patients with patellofemoral pain syndrome and healthy subjects.
        Arch Phys Med Rehabil. 2014; 95: 1383-1389
        • Leetun D.T.
        • Ireland M.L.
        • Willson J.D.
        • Ballantyne B.T.
        • Davis I.M.
        Core stability measures as risk factors for lower extremity injury in athletes.
        Med Sci Sports Exerc. 2004; 36: 926-934
        • Nakagawa T.H.
        • Maciel C.D.
        • Serrão F.V.
        Trunk biomechanics and its association with hip and knee kinematics in patients with and without patellofemoral pain.
        Man Ther. 2015; 20: 189-193
        • Briani R.V.
        • Waiteman M.C.
        • de Albuquerque C.E.
        • et al.
        Lower trunk muscle thickness is associated with pain in women with patellofemoral pain.
        J Ultrasound Med. 2019; 38: 2685-2693
        • Motealleh A.
        • Gheysari E.
        • Shokri E.
        • Sobhani S.
        The immediate effect of lumbopelvic manipulation on EMG of vasti and gluteus medius in athletes with patellofemoral pain syndrome: a randomized controlled trial.
        Man Ther. 2016; 22: 16-21
        • Hewett T.
        • Zazulak B.
        • Myer G.
        • Ford K.
        A review of electromyographic activation levels, timing differences, and increased anterior cruciate ligament injury incidence in female athletes.
        Br J Sports Med. 2005; 39: 347-350
        • Powers C.M.
        The influence of abnormal hip mechanics on knee injury: a biomechanical perspective.
        J Orthop Sports Phys Ther. 2010; 40: 42-51
        • Collins N.J.
        • Barton C.J.
        • Van Middelkoop M.
        • et al.
        2018 consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain: recommendations from the 5th International Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017.
        Br J Sports Med. 2018; 52: 1170-1178
        • Foroughi F.
        • Sobhani S.
        • Yoosefinejad A.K.
        • Motealleh A.
        Added value of isolated core postural control training on knee pain and function in women with patellofemoral pain syndrome: a randomized controlled trial.
        Arch Phys Med Rehabil. 2019; 100: 220-229
        • Lack S.
        • Neal B.
        • Silva D.D.
        • Barton C.
        How to manage patellofemoral pain–understanding the multifactorial nature and treatment options.
        Phys Ther Sport. 2018; 32: 155-166
        • Motealleh A.
        • Mohamadi M.
        • Moghadam M.B.
        • Nejati N.
        • Arjang N.
        • Ebrahimi N.
        Effects of core neuromuscular training on pain, balance, and functional performance in women with patellofemoral pain syndrome: a clinical trial.
        J Chiropr Med. 2019; 18: 9-18
        • Morihisa R.
        • Eskew J.
        • McNamara A.
        • Young J.
        Dry needling in subjects with muscular trigger points in the lower quarter: a systematic review.
        Int J Sports Phys Ther. 2016; 11: 1
        • Roach S.
        • Sorenson E.
        • Headley B.
        • San Juan J.G.
        Prevalence of myofascial trigger points in the hip in patellofemoral pain.
        Arch Phys Med Rehabil. 2013; 94: 522-526
        • Rozenfeld E.
        • Finestone A.S.
        • Moran U.
        • Damri E.
        • Kalichman L.
        The prevalence of myofascial trigger points in hip and thigh areas in anterior knee pain patients.
        J Bodyw Mov Ther. 2019 May 14; ([Epub ahead of print])
        • Ge H.-Y.
        • Monterde S.
        • Graven-Nielsen T.
        • Arendt-Nielsen L.
        Latent myofascial trigger points are associated with an increased intramuscular electromyographic activity during synergistic muscle activation.
        J Pain. 2014; 15: 181-187
        • Grieve R.
        • Clark J.
        • Pearson E.
        • Bullock S.
        • Boyer C.
        • Jarrett A.
        The immediate effect of soleus trigger point pressure release on restricted ankle joint dorsiflexion: a pilot randomised controlled trial.
        J Bodyw Mov Ther. 2011; 15: 42-49
        • Lucas K.R.
        • Rich P.A.
        • Polus B.I.
        Muscle activation patterns in the scapular positioning muscles during loaded scapular plane elevation: the effects of latent myofascial trigger points.
        Clin Biomech. 2010; 25: 765-770
        • McGill S.
        • Juker D.
        • Kropf P.
        Quantitative intramuscular myoelectric activity of quadratus lumborum during a wide variety of tasks.
        Clin Biomech. 1996; 11: 170-172
      1. Porterfield J. DeRosa C. Mechanical low back pain. 2nd ed. WB Saunders, Philadelphia1991
        • Willson J.D.
        • Dougherty C.P.
        • Ireland M.L.
        • Davis I.M.
        Core stability and its relationship to lower extremity function and injury.
        J Am Acad Orthop Surg. 2005; 13: 316-325
        • Hunt M.
        • Birmingham T.
        • Bryant D.
        • et al.
        Lateral trunk lean explains variation in dynamic knee joint load in patients with medial compartment knee osteoarthritis.
        Osteoarthritis Cartilage. 2008; 16: 591-599
        • Desai M.J.
        • Saini V.
        • Saini S.
        Myofascial pain syndrome: a treatment review.
        Pain Ther. 2013; 2: 21-36
        • Weyer-Henderson D.
        An investigation into the effectiveness of dry needling of myofascial trigger points on total work and other recorded measurements of the vastus lateralis and vastus medialis muscles in patellofermoral pain syndrome in long distance runners [dissertation].
        Durban, South Africa: Durban University of Technology. 2005;
        • Sutlive T.G.
        • Golden A.
        • King K.
        • et al.
        Short term effects of trigger point dry needling on pain and disability in subjects with patellofemoral pain syndrome.
        Int J Sports Phys Ther. 2018; 13: 462
        • Earl J.E.
        • Hoch A.Z.
        A proximal strengthening program improves pain, function, and biomechanics in women with patellofemoral pain syndrome.
        Am J Sports Med. 2011; 39: 154-163
        • Miri Abyaneh H.
        • Mosallanezhad Z.
        • Mohammadalizade H.
        • Bakhshi E.
        • Vahedi G.
        Physiotherapy with and without superficial dry needling affects pain and muscle strength in patients with patellofemoral pain syndrome.
        Iran Rehabil J. 2016; 14: 23-30
        • Dommerholt J.
        • de las Penas C.F.
        Trigger point dry needling e-book: an evidence 397 and clinical-based approach.
        Churchill Livingstone (Elsevier), Edinburgh, UK2013
        • Loudon J.K.
        • Wiesner D.
        • Goist-Foley H.L.
        • Asjes C.
        • Loudon K.L.
        Intrarater reliability of functional performance tests for subjects with patellofemoral pain syndrome.
        J Athl Train. 2002; 37: 256
        • Plisky P.J.
        • Gorman P.P.
        • Butler R.J.
        • Kiesel K.B.
        • Underwood F.B.
        • Elkins B.
        The reliability of an instrumented device for measuring components of the star excursion balance test.
        N Am J Sports Phys Ther. 2009; 4: 92
        • Negahban H.
        • Pouretezad M.
        • Yazdi M.J.
        • et al.
        Persian translation and validation of the Kujala Patellofemoral Scale in patients with patellofemoral pain syndrome.
        Disabil Rehabil. 2012; 34: 2259-2263
        • Crossley K.M.
        • Bennell K.L.
        • Cowan S.M.
        • Green S.
        Analysis of outcome measures for persons with patellofemoral pain: which are reliable and valid?.
        Arch Phys Med Rehabil. 2004; 85: 815-822
        • Reeves J.L.
        • Jaeger B.
        • Graff-Radford S.B.
        Reliability of the pressure algometer as a measure of myofascial trigger point sensitivity.
        Pain. 1986; 24: 313-321
        • Farrar J.T.
        • Young Jr., J.P.
        • LaMoreaux L.
        • Werth J.L.
        • Poole R.M.
        Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale.
        Pain. 2001; 94: 149-158
        • Watson C.J.
        • Propps M.
        • Ratner J.
        • Zeigler D.L.
        • Horton P.
        • Smith S.S.
        Reliability and responsiveness of the lower extremity functional scale and the anterior knee pain scale in patients with anterior knee pain.
        J Orthop Sports Phys Ther. 2005; 35: 136-146
        • Chimera N.J.
        • Smith C.A.
        • Warren M.
        Injury history, sex, and performance on the functional movement screen and Y balance test.
        J Athl Train. 2015; 50: 475-485
        • Walton D.
        • MacDermid J.
        • Nielson W.
        • Teasell R.
        • Chiasson M.
        • Brown L.
        Reliability, standard error, and minimum detectable change of clinical pressure pain threshold testing in people with and without acute neck pain.
        J Orthop Sports Phys Ther. 2011; 41: 644-650
        • Bolgla L.A.
        • Boling M.C.
        An update for the conservative management of patellofemoral pain syndrome: a systematic review of the literature from 2000 to 2010.
        Nt J Sports Phys Ther. 2011; 6: 112
        • Chevidikunnan M.F.
        • Al Saif A.
        • Gaowgzeh R.A.
        • Mamdouh K.A.
        Effectiveness of core muscle strengthening for improving pain and dynamic balance among female patients with patellofemoral pain syndrome.
        J Phys Ther Sci. 2016; 28: 1518-1523
        • van der Heijden R.A.
        • Lankhorst N.E.
        • van Linschoten R.
        • Bierma-Zeinstra S.M.
        • van Middelkoop M.
        Exercise for treating patellofemoral pain syndrome.
        Cochrane Database Syst Rev. 2015; 52110–133
        • Yelvar Y.
        • Deniz G.
        • Çirak Y.
        • et al.
        Impairments of postural stability, core endurance, fall index and functional mobility skills in patients with patello femoral pain syndrome.
        J Back Musculoskelet Rehabil. 2017; 30: 163-170
        • Fagan V.
        • Delahunt E.
        Patellofemoral pain syndrome: a review on the associated neuromuscular deficits and current treatment options.
        Br J Sports Med. 2008; 42: 789-795
        • Boling M.C.
        • Bolgla L.A.
        • Mattacola C.G.
        • Uhl T.L.
        • Hosey R.G.
        Outcomes of a weight-bearing rehabilitation program for patients diagnosed with patellofemoral pain syndrome.
        Arch Phys Med Rehabil. 2006; 87: 1428-1435
        • Mahmoud WSE-d
        • Kamel E.M.
        The effect of additional balance training program to gluteus medius strengthening exercises on patellofemoral pain syndrome.
        Int J Ther Rehabil Res. 2015; 4: 7
        • Nakagawa T.H.
        • Muniz T.B.
        • Baldon Rde M.
        • Dias Maciel C.
        • de Menezes Reiff R.B.
        • Serrão F.V.
        The effect of additional strengthening of hip abductor and lateral rotator muscles in patellofemoral pain syndrome: a randomized controlled pilot study.
        Clin Rehabil. 2008; 22: 1051-1060
        • Piva S.R.
        • Fitzgerald G.K.
        • Wisniewski S.
        • Delitto A.
        Predictors of pain and function outcome after rehabilitation in patients with patellofemoral pain syndrome.
        J Rehabil Med. 2009; 41: 604-612
        • Ferber R.
        • Kendall K.D.
        • Farr L.
        Changes in knee biomechanics after a hip-abductor strengthening protocol for runners with patellofemoral pain syndrome.
        J Athl Train. 2011; 46: 142-149
        • Balci P.
        • Tunay V.B.
        • Baltaci G.
        • Atay A.O.
        The effects of two different closed kinetic chain exercises on muscle strength and proprioception in patients with patellofemoral pain syndrome.
        Acta Orthop Traumatol Turc. 2009; 43: 419-425
        • Carry P.M.
        • Gala R.
        • Worster K.
        • et al.
        Postural stability 457 and kinetic change in subjects with patellofemoral pain after a nine-week hip and core 458 strengthening intervention.
        Int J Sports Phys Ther. 2017; 12: 314
        • Mascal C.L.
        • Landel R.
        • Powers C.
        Management of patellofemoral pain targeting hip, pelvis, and trunk muscle function: 2 case reports.
        J Orthop Sports Phys Ther. 2003; 33: 647-660
        • Powers C.M.
        The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective.
        J Orthop Sports Phys Ther. 2003; 33: 639-646
        • De Oliveira Silva D.
        • Rathleff M.S.
        • Petersen K.
        • Azevedo FMd
        • Barton C.J.
        Manifestations of pain sensitization across different painful knee disorders: a systematic review including meta-analysis and metaregression.
        Pain Med. 2018; 20: 335-358
        • Sayers A.C.
        The effectiveness of chiropractic treatment in combination with dry needling of the vastus medialis oblique muscle in the management of patellofemoral pain syndrome [dissertation].
        Johannesburg, South Africa: University of Johannesburg. 2007;
        • Baldry P.
        Management of myofascial trigger point pain.
        Acupunct Med. 2002; 20: 2-10
        • Cagnie B.
        • Dewitte V.
        • Barbe T.
        • Timmermans F.
        • Delrue N.
        • Meeus M.
        Physiologic effects of dry needling.
        Curr Pain Headache Rep. 2013; 17: 348
        • Doménech J.
        • Sanchis-Alfonso V.
        • Espejo B.
        Changes in catastrophizing and kinesiophobia are predictive of changes in disability and pain after treatment in patients with anterior knee pain.
        Knee Surg Sports Traumatol Arthrosc. 2014; 22: 2295-2300
        • Maclachlan L.R.
        • Matthews M.
        • Hodges P.W.
        • Collins N.J.
        • Vicenzino B.
        The psychological features of patellofemoral pain: a cross-sectional study.
        Scand J Pain. 2018; 18: 261-271
        • Priore L.B.
        • Azevedo F.M.
        • Pazzinatto M.F.
        • et al.
        Influence of kinesiophobia and pain catastrophism on objective function in women with patellofemoral pain.
        Phys Ther Sport. 2019; 35: 116-121