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edicine and Rehabilitation Archives of Physical M journal homepage: www.archives-pmr.org Archives of Physical Medicine and Rehabilitation 2020;101:265-74 ORIGINAL RESEARCH 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, MSc, PT,a,b Soha Bervis, PhD, PT,a,b Soraya Piroozi, PhD, PT,a Alireza Motealleh, PhD, PTa,c From the aPhysical Therapy Department, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz; bStudent Research Committee, Shiraz University of Medical Science, Shiraz; and cRehabilitation Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. 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 (NZ40), who were randomly assigned to the exercise therapy (Ex group) or exercise-therapyþdry needling (ExþDN group) group. Interventions: The Ex group received exercise therapy for 4 weeks, and the ExþDN 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 ExþDN 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. Archives of Physical Medicine and Rehabilitation 2020;101:265-74 ª 2019 by the American Congress of Rehabilitation Medicine Patellofemoral pain (PFP) is a highly prevalent knee problem that is often observed in female athletes.1 People with PFP typically complain of diffuse retropatellar or peripatellar pain, which may Supported by the Shiraz University of Medical Sciences, Vice Chancellery for Research Af- fairs (contract no. 96-16373). Clinical Trial Registration No.: IRCT20120411009440N20. Disclosures: none. 0003-9993/19/$36 - see front matter ª 2019 by the American Congress of Re https://doi.org/10.1016/j.apmr.2019.07.009 Downloaded for Joseph Santos (joseph.santos.5513@hstviseu.min-saude.pt) at H For personal use only. No other uses without permission impair functional activities such as stair climbing, running, squatting, prolonged sitting,2 and static and dynamic balance.3,4 Patellar maltracking and increased patellofemoral joint stress are among the accepted theoretical causes of PFP.5 These condi- tions may be related to inappropriate vastus medialis and vastus lateralis neuromuscular control.6,7 Recent studies have evaluated the function of core muscles in people with PFP. These studies identified differences in core muscle function between those with habilitation Medicine ospital de Sao Teotonio from ClinicalKey.com by Elsevier on May 29, 2020. . Copyright ©2020. Elsevier Inc. All rights reserved. http://crossmark.crossref.org/dialog/?doi=10.1016/j.apmr.2019.07.009&domain=pdf https://doi.org/10.1016/j.apmr.2019.07.009 http://www.archives-pmr.org https://doi.org/10.1016/j.apmr.2019.07.009 266 H. Zarei et al and without PFP. Altered core muscle recruitment patterns,8,9 decreased trunk strength,10,11 and lateral trunk muscle cross- sectional area12 have been reported in people with PFP. In addi- tion, the altered trunk and hip kinematics and postural control11,13 noted in other studies suggested that these factors may be related to abnormal torque and stress at the patellofemoral joint in PFP.11,14,15 According to recent PFP management guidelines, core exercises are beneficial for people with PFP.16-19 Although it was shown that core manipulation might improve EMG activity of the knee and hip muscles in people with PFP,13 recent systematic reviews indicated that this kind of treatment did not improve pain and function.16,18 Myofacial trigger points (TrPs) are a common impairment in many musculoskeletal pain conditions20 such as PFP. The exact prevalence of core muscle TrPs in people with PFP is unknown. However, a higher prevalence of TrPs in gluteus medius (GM) and quadratus lumbarum (QL) has been reported in people with PFP than healthy individuals.21,22 There is evidence that TrPs may alter muscle strength, tension, activation pattern, and motor con- trol.23-25 It can therefore be hypothesized that TrPs in the GM and QL may cause alterations in their functioning. These muscles are the most relevant core muscles in frontal hip and trunk stability, and are thus involved in optimal knee mechanics.15,26 In unilateral PFP, the ipsilateral GM and contralateral QL provide this frontal stability and prevent hip adduction, which may increase the load on the patellofemoral joint.27,28 Optimizing mediolateral control of the pelvis has been suggested as an important factor in PFP management.9,15,29 It is therefore possible that targeting in- terventions to treat GM and QL TrPs may have beneficial effects in PFP rehabilitation. Dry needling (DN) is one of the most common methods of TrP deactivation.30,31 There is no consensus on the effectiveness of TrP therapy in PFP managements.16 However, this view was based on studies focused only on TrPs in quadriceps muscles. To our knowledge, no study to date has evaluated the effects of GM and QL DN on pain and function in people with PFP. Therefore, the aim of this study was to compare the effects of exercise therapy plus GM and QL DN versus exercise therapy alone on pain, function, and dynamic balance in female athletes with PFP. We hypothesized that adding GM and QL DN to exercise therapy would lead to greater improvements than exercise alone in (first) pain and (second) function and dynamic balance. Materials and methods Study design and participants This study was a parallel-group, single-blind randomized clinical trial with an allocation ratio of 1:1. It was approved by the local institutional review board and registered in the Iranian Clinical Trials database as IRCT20120411009440N20. 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 Downloaded for Joseph Santos (joseph.santos.5513@hstviseu.min-saude.pt) at Hos For personal use only. No other uses without permission. C Participants with a diagnosis of PFP who were referred from orthopedic clinics at centers affiliated with our university were screened for eligibility criteria at a physiotherapy clinic. The inclusion and exclusion criteria are shown in table 1.8,9,32 All participants provided written informed consent in accordance with guidelines approved by the local ethics committee. Interventions In this study, 1 group received exercise therapy (Ex group) and the other received the same exercise therapy protocol in combination with DN (ExþDN group). Both groups performed 2 sessions of exercise therapy at the clinic and 3 sessions at home per week, for 4 weeks. An experienced physiotherapisttaught the exercises to the participants in each session and supervised them individually to ensure that the exercises were done correctly. However, the home exercise program was not supervised. In recent studies, knee and proximal muscle exercises have been shown to be effective in the management of PFP, so we selected the exercises specified in appendix 1.16-18,33 Previous studies indicated a high prevalence of QL and GM TrPs in persons with PFP21,22 and noted the relation between these TrPs and knee biomechanics.27,28 Accordingly, the GM ipsilateral and the QL contralateral to the involved knee were selected for DN in the ExþDN group. Dry needling was applied once a week for 4 weeks by an experienced physiotherapist with 0.30�50-mm and 0.30�100-mm needles.a Further details are presented in appendix 2.34,35 During each visit, the participants were monitored for any related adverse events such as increase in their symptoms, post- DN soreness, nausea, bruising, bleeding, or symptoms of vaso- vagal shock, so that suitable interventions could be used if needed. Patients in both groups did not receive any other intervention during the study, except for the occasional use of nonsteroidal anti-inflammatory drugs as needed. The participants were not allowed to use any nonsteroidal anti-inflammatory drugs 48 hours prior to measurement of the outcomes. The duration of each session was approximately 15-40 min (2- 5min longer for DN in the ExþDN group). All participants in both groups completed all the treatment sessions. When necessary, the exercises were tailored based on individual symptoms and abili- ties. No measurements of adherence were recorded in this study. Outcome measures All outcomes were measured before (baseline), 4 weeks after (post-treatment), and 6 weeks after the start of treatment (follow- up) by a physical therapist blinded to the treatment allocations. The primary outcome was average knee pain intensity in the previous week, measured with an 11-point numerical pain rating scale on which 0 indicated no pain and 10 the worst imaginable pain. Secondary outcomes were functional level and pain pressure threshold (PPT). The step-down36 and modified star excursion balance test (mSEBT)37 along with the Persian versions of the Kujala questionnaire38 were used to evaluate objective and sub- jective functional performance, respectively. The validity and reliability of all measurement tools were verified and reported previously.36-40 The Persian version of the Kujala Patellofemoral Scale38 has 13 items and a score range of 0-100, with lower scores indicating greater pain and disability. For the mSEBT, participants were asked to stand on their affected leg, reach in 3 directions (anterior, posteromedial, www.archives-pmr.org pital de Sao Teotonio from ClinicalKey.com by Elsevier on May 29, 2020. opyright ©2020. Elsevier Inc. All rights reserved. http://www.archives-pmr.org Table 1 Inclusion and exclusion criteria Inclusion Criteria Exclusion Criteria 1. Female athletes (regular sports activity at least 2h per day 3 times per week) 1. Bilateral anterior knee pain 2. Age between 18 and 45 years 2. Osteoarthritis 3. Unilateral prepatellar or retropatellar pain unrelated to trauma for at least 3 mo, aggravated with at least 2 daily activities such as prolonged sitting, kneeling, squatting, running, hopping, or stair climbing 3. Ligament or meniscus injury 4. Positive Clarke’s sign 4. Patellar instability, plica syndrome, Osgood-Schlatter, Sinding-Larsen-Johansson syndromes 5. Average pain in the previous week >3 on numeric pain rating scale. 5. Marked structural deformity and known pathological condition of back, hip, and ankle 6. Kujala questionnaire score <85 of 100 6. Any metabolic or neurologic disease such as diabetes or radicular pain 7. Trigger points in GM on the affected side and in QL on the nonaffected side 7. Contraindication for dry needling, such as cardiovascular and coagulation disease, anticoagulation therapy, pregnancy, cancer, fear of needles 8. Completed consent form 8. Physical therapy for knee pain within the previous year Gluteus medius and quadratus lumborum dry needling and PFPS 267 posterolateral) with their other leg, touch their toes as far away as possible, and return to standing on their stance leg.37 The reach distance in centimeters was normalized to each participant’s lower extremity length. The mean of 3 test repetitions was recorded for each direction. The participants were asked to do the test without supporting their unaffected leg on the floor, lifting their stance leg, or losing their balance. The step-down test was conducted on a 20-cm step by asking participants to stand on the step with their affected leg, try to touch the opposite heel to the floor in front of them, and then return to their previous stance position. The number of completed repeti- tions of the task in 30 seconds was recorded. The test was per- formed 3 times and the mean of the 3 measurements was considered as the final value for analysis.36 A rest interval of 1-2 min was allowed between trials to prevent fatigue. To measure PPT, a digital pressure algometerb was used with perpendicular pressure on the TrP. Each point was evaluated 3 times with a 30-second rest between measurements. The mean algometer reading from the 3 repetitions was used as the final value for analysis. Sample size To detect a mean between-group difference of 2 points in the numerical pain rating scale score41 with a standard deviation of 1.7, 90% power, and an alpha level of 0.05, the sample size was calculated as 15 participants per group. A 30% dropout rate was assumed, so the final estimated sample size was 20 participants per group. Randomization and blinding Of the 50 volunteers, 40 eligible participants based on the inclu- sion and exclusion criteria were enrolled by a physical therapist, and 20 participants were randomly assigned to each group. Group assignment was conducted with random allocation software (block sizeZ4, block numberZ10) by a biostatistician, and all alloca- tions were concealed from both the participants and the www.archives-pmr.org Downloaded for Joseph Santos (joseph.santos.5513@hstviseu.min-saude.pt) at H For personal use only. No other uses without permission physiotherapist who administered the interventions in presealed opaque envelopes. The participants and physiotherapist in each group were blinded to group allocations until the treatments were started. The assessor remained completely blinded to all group allocations. Statistical analysis Descriptive and statistical analyses were done with SPSS version 16.c The 1-sample Kolmogorov-Smirnov test was used to verify normal distribution of the data for all variables. To compare within- and between-group differences, analysis of variance (2 groups�3 times) was used. The time variables were baseline, week 4 and week 6, and the group variables were ExþDN group and Ex group. If the group�time interaction was significant, repeated measures tests were used in each group to evaluate the effects of time, and independent t tests were used to identify significant differences between groups in the score changes between baseline and week 4, baseline and week 6, and week 4 and week 6. Bonferroni correction was used to adjust for multiple pairwise comparisons over time to prevent alpha inflation. Moreover, to compare the differences between groups, the P value was adjusted as 0.05/3Z0.016. The minimal detectable changes in pain and Kujala score were considered 2 and 8 points, respec- tively.41,42 The minimal detectable changes in PPT and mSEBT were reported, respectively, as 0.45 kg force and 3.5% improve- ment in previous studies.43,44 Results Participants Of the 50 volunteers, 40 met the eligibility criteria and were included in the study; 20 women were randomly allocated to each group. None of the participants dropped out of the study, and all 20 women in each group received the allocated intervention. None ofthe participants was lost to follow-up, and data for all partici- pants were included in the analysis (fig 1). ospital de Sao Teotonio from ClinicalKey.com by Elsevier on May 29, 2020. . Copyright ©2020. Elsevier Inc. All rights reserved. http://www.archives-pmr.org Fig 1 Flowchart showing numbers of participants in the eligibility and enrollment, allocation, follow-up, and analysis stages. 268 H. Zarei et al Demographic characteristics and variables measured at base- line are shown in table 2. Except for minimal soreness, which resolved in the following visit, no adverse events were reported in either group. Table 2 Baseline and demographic characteristics of patients in the Ex group and ExþDN group Parameter Study Group (nZ20) (Mean � SD) Control Group (nZ20) (Mean � SD) Age (y) 22.25�3.25 25.65�8.49 Height (m) 1.59�0.05 1.61�0.07 Weight (kg) 52.10�6.95 55.70�7.73 NPRS (0-10) 5.90�0.85 6.00�0.72 Kujala score (0-100) 73.95�6.41 72.80�6.52 Step-down test 13.10�4.26 10.80�3.42 PPTQL (kgf) 3.68�0.78 3.69�0.72 PPTGM (kgf) 4.12�0.82 3.71�0.49 mSEBT (anterior) 0.76�0.12 0.76�0.14 mSEBT (posterolateral) 0.74�0.12 0.74�0.12 mSEBT (posteromedial) 0.67�0.11 0.66�0.10 Abbreviations: mSEBT, modified star excursion balance test; NPRS, numerical pain rating score; PPTGM, pressure pain threshold gluteus medius; PPTQL, pressure pain threshold quadratus lumborum. Downloaded for Joseph Santos (joseph.santos.5513@hstviseu.min-saude.pt) at Hos For personal use only. No other uses without permission. C Outcomes The results showed a significant group�time interaction for all variables (fig 2). Comparisons of the baseline versus week 4 measures showed significant improvements in pain, Kujala score, step-down performance, mSEBT performance (all 3 di- rections), and PPT in the QL and GM in both groups (table 3). Comparisons between baseline versus week 6 yielded the same findings in both groups (see table 3). Comparisons between week 4 and week 6 in the Ex group yielded significant changes only for pain and Kujala score (see table 3). In the ExþDN group, comparisons between week 4 and week 6 detected significant changes in all outcomes except step-down test performance (see table 3). Between-group comparisons of the changes in outcomes from baseline to week 4 showed significantly greater improvements in the ExþDN group in pain, Kujala score, step-down test, PPT in QL and GM, and mSEBT (all 3 directions) (table 4). Comparisons of the changes from baseline to week 6 also showed significantly greater improvements in the ExþDN group (see table 4). Com- parisons of the changes from week 4 to week 6 showed signifi- cantly greater improvements in Kujala score, GM PPT, and mSEBT (anterior and posterolateral directions) in the ExþDN group. For mSEBT performance, the improvement in the poster- omedial direction was greater in ExþDN group than the Ex group, but the difference was not significant (PZ.05) (see table 4). www.archives-pmr.org pital de Sao Teotonio from ClinicalKey.com by Elsevier on May 29, 2020. opyright ©2020. Elsevier Inc. All rights reserved. http://www.archives-pmr.org 0 20 40 60 80 100 1 2 3 M ea n sc or e (0 -1 00 ) Time Kujala score Intervention Control 0 5 10 15 20 25 1 2 3 M ea n sc or e Time Step-down test Intervention Control 0 1 2 3 4 5 6 7 8 1 2 3 M ea n sc or e (k gf ) Time Quadratus lumborum pain pressure threshold Intervention Control 0 1 2 3 4 5 6 7 8 1 2 3 M ea n sc or e (k gf ) Time Gluteus medius pain pressure threshold Intervention Control 0.65 0.7 0.75 0.8 0.85 0.9 0.95 1 2 3 M ea n sc or e Time Modified star excursion balance test (anterior) Intervention Control 0.65 0.7 0.75 0.8 0.85 0.9 1 2 3 M ea n sc or e Time Modified star excursion balance test (postrolat) Intervention Control 0.6 0.65 0.7 0.75 0.8 1 2 3 M ea n sc or e Time Modified star excursion balance test (postromed) Intervention Control 0 2 4 6 8 1 2 3 M ea n sc or e (0 - 1 0) Time Numerical pain rating score Intervention Control P value <0.001* P value <0.001* P value <0.001* P value <0.001* P value <0.001* P value <0.001* P value <0.001* P value <0.001* Fig 2 Effects of group�time course interactions according to analysis of variance. )Significant group�time course interaction. Gluteus medius and quadratus lumborum dry needling and PFPS 269 Discussion This study aimed to compare the effects of a combination of ex- ercise therapy and DN for the QL and GM muscles versus exercise therapy alone in female athletes with PFP. The results demon- strated that both treatment protocols led to statistically significant improvements in pain, function (Kujala score, step-down test, mSEBT), and PPT after treatment and at 6 weeks of follow-up. Based on the minimal detectable changes in pain (2 points), Kujala score (8 points), PPT (0.45 kg force), and mSEBT (3.5% improvement),41-44 the present results in the ExþDN group were clinically relevant for all outcomes. However, in the Ex group only the improvements in pain, Kujala score, and mSEBT performance (all 3 directions) were clinically significant. Comparisons between www.archives-pmr.org Downloaded for Joseph Santos (joseph.santos.5513@hstviseu.min-saude.pt) at H For personal use only. No other uses without permission the 2 groups showed that combined exercise therapy and DN had significant added beneficial effects in all outcomes. In line with previous studies, our results support the beneficial effects of exercise therapy on pain and function.45-49 Both groups in the present study benefited from exercise therapy. Quadriceps, hip abductor, and external rotator strengthening exercises may optimize pelvic and femur motion and knee alignment, thus ulti- mately decreasing patellofemoral joint stress.50-53 Lower extrem- ity kinetics and kinematic improvements after exercise therapy may enhance tissue healing and subsequently help reduce pain.54 The results of pain reduction and biomechanical optimization might lead to functional improvements, as seen in the present findings. One cause of increased mSEBT scores may be related to improved knee proprioception and neuromuscular control,50,55 and ospital de Sao Teotonio from ClinicalKey.com by Elsevier on May 29, 2020. . Copyright ©2020. Elsevier Inc. All rights reserved. http://www.archives-pmr.org Table 3 Time course effects in the Ex and ExþDN group according to repeated measures test and Bonferroni correction Group Variable Changes Baseline (Mean � SD) Fourth Week (Mean � SD) Sixth Week (Mean � SD) P Value Control NPRS (0-10) 6.00�0.72 4.10�0.91 3.50�1.05 <.001*,y,z Kujala score (0-100) 72.80�6.52 78.20�5.94 80.75�6.06 <.001*,y,z Step-down test 10.80�3.42 13.85�3.46 14.15�2.92 <.001*,y PPTQL (kgf) 3.69�0.72 3.91�0.70 4.15�0.37 <.001*,y PPTGM (kgf) 3.71�0.49 3.97�0.36 3.97�0.40 <.001*,y mSEBT Anterior 0.76�0.14 0.81�0.14 0.81�0.13 <.001*,y Posterolateral 0.74�0.12 0.78�0.12 0.77�0.11 <.001*,y Posteromedial 0.66�0.10 0.69�0.10 0.70�0.10 <.001*,y Study NPRS (0-10) 5.90�0.85 2.10� 1.11 1.40� 0.82 <.001*,y,z Kujala score (0-100) 73.95�6.41 86.00�5.31 92.10�4.41 <.001*,y,z Step-down test 13.10�4.26 20.30�4.31 21.30�3.42 <.001*,y PPTQL (kgf) 3.86�0.78 6.66�0.78 7.03�0.72 <.001*,y,z PPTGM (kgf) 4.10�0.82 6.94�0.94 7.42�0.74 .001*,y,z mSEBT Anterior 0.76�0.12 0.89�0.11 0.90�0.11 <.001*,y,z Posterolateral 0.74�0.12 0.83�0.11 0.85�0.11 <.001*,y,z Posteromedial 0.67�0.11 0.77�0.10 0.78�0.10 <.001*,y,z Abbreviations: mSEBT, modified star excursion balance test; NPRS, numerical pain rating score; PPTGM, pressure pain threshold gluteus medius; PPTQL, pressure pain threshold quadratus lumborum. * Comparison of baseline versus fourth week P<.05. y Comparison of baseline versus sixth week P<.05. z Comparison of fourth versus sixth week P<.05. Table 4 Differences between the ExþDN and Ex groups in changes from baseline to week 4, baseline to week 6, and week 4 to week 6 according to independent t test Variable TimeStudy Group (Mean � SD) Control Group (Mean � SD) Mean Difference (Mean � SD) P Value 95% CI of Mean Difference (Upper/Lower) NPRS Fourth week-baseline e3.80�0.61 e0.78�1.90 e0.22�1.90 <.001 e1.44 e2.35 Sixth week-baseline e4.50�0.76 e1.00�2.50 e0.28�2.00 <.001 e1.43 e2.56 Sixth-fourth week e0.70�0.86 e0.99�0.60 e0.29�1.00 .74 0.49 e0.69 Kujala score Fourth week-baseline 12.05�3.45 2.37�5.40 0.93�6.65 <.001 8.54 4.75 Sixth week- baseline 18.15�3.91 3.01�7.95 1.10�10.20 <.001 12.43 7.96 Sixth-Fourth week 6.10�3.37 1.93�2.55 0.86�3.55 <.001 5.30 1.79 Step-down test Fourth week-baseline 7.20�1.36 1.05�3.05 4.15�0.38 <.001 4.92 3.37 Sixth week-baseline 8.20�1.93 1.49�3.35 4.85�0.54 <.001 5.95 3.74 Sixth-fourth week 1.00�1.74 1.17�0.30 0.47�0.70 .14 1.65 e0.25 PPTQL Fourth week-baseline 0.80�2.98 0.20�0.21 0.18�2.77 <.001 3.14 2.39 Sixth week-baseline 0.82�3.35 0.74�0.45 0.24�2.90 <.001 3.40 2.39 Sixth-fourth week 0.32�0.37 0.72�0.24 0.17�0.12 0.47 0.48 e0.23 PPTGM Fourth week-baseline 1.04�2.81 0.43�0.25 0.25�2.55 <.001 3.07 2.40 Sixth week-baseline 0.99�3.30 0.53�0.26 0.25�3.03 <.001 3.54 2.52 Sixth-fourth week 0.56�0.48 0.28�0.00 0.17�0.47 <.001 0.76 0.19 mSEBT anterior Fourth week-baseline 0.03�0.09 0.01�0.03 0.00�0.05 <.001 0.07 0.03 Sixth week-baseline 0.03�0.14 0.01�0.04 0.09�0.02 <.001 0.1 0.07 Sixth-fourth week 0.01�0.01 e0.01�0.00 0.00�0.01 <.001 0.02 0.00 mSEBT posterolateral Fourth week-baseline 0.03�0.09 0.01�0.03 0.00�0.05 <.001 0.07 0.03 Sixth week-baseline 0.03�0.10 0.02�0.03 0.00�0.07 <.001 0.09 0.05 Sixth-fourth week 0.01�0.01 e0.01�0.00 0.00�0.01 <.001 0.02 0.00 mSEBT posteromedial Fourth week-baseline 0.05�0.09 0.01�0.03 0.01�0.05 <.001 0.08 0.03 Sixth week-baseline 0.05�0.10 0.01�0.03 0.01�0.06 <.001 0.09 0.04 Sixth-fourth week 0.01�0.01 0.01�0.00 0.00�0.00 .05 0.01 e0.00 Abbreviations: mSEBT, modified star excursion balance test; NPRS, numerical pain rating score; PPTGM, pressure pain threshold gluteus medius; PPTQL, pressure pain threshold quadratus lumborum. 270 H. Zarei et al www.archives-pmr.org Downloaded for Joseph Santos (joseph.santos.5513@hstviseu.min-saude.pt) at Hospital de Sao Teotonio from ClinicalKey.com by Elsevier on May 29, 2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved. http://www.archives-pmr.org Gluteus medius and quadratus lumborum dry needling and PFPS 271 consequently balance progression56 after closed-chain hip and quadriceps exercises. Improved neuromuscular control and kine- matics in the hips and knees, as reported after strengthening ex- ercises,52,57,58 may be another reason for the better step-down test scores in the present study. One of our findings was the increased PPT after exercise therapy. This finding was in line with evidence indicating that exercise therapy might lead to increased remote TrPs PPT due to decreased nervous system sensitization.59 The results of our study support the hypothesis that combining DN for the GM and QL muscles with exercises may have superior beneficial effects over exercise alone on pain, function, and PPT in female athletes with PFP. Although QL and GM PPT showed statistically significant increases in both groups, the changes were clinically relevant only in the ExþDN group. The greater increases in PPT in our ExþDN group may thus be due to the addition of DN for the QL and GM muscles. Dry needling can efficiently treat TrPs by affecting gate control, increasing local blood flow, oxygen supply, and endogenous opioid release. This may provide an optimized environment for tissue healing.20 In line with our results, previous studies showed that adding quadriceps DN in patients with PFP led to earlier or greater im- provements in pain and function.32,34,60 Although earlier research used DN for the quadriceps muscles, the improvements in QL and GM function in the present study may be due to a similar mechanism. Because of the important roles of GM and QL in frontal plane hip and trunk stability, these muscles may contribute to optimal kinetics and kinematic control of the knee joint.15,26 In addition, optimizing mediolateral control of the lumbo-pelvic-hip complex has been shown to contribute to biomechanical im- provements in patients with PFP.9,15,26,29 TrPs in muscles may alter muscle activation patterns and potentially lead to pathol- ogy.25 The higher prevalence of TrPs in the GM and QL in people with PFP compared to asymptomatic people21,22 suggests that the normal functioning of knee mechanics may be affected. Therefore, effective treatment with DN for GM and QLTrPs may have helped to optimize overall knee mechanics. Consequently, this might have contributed to the added beneficial effects on pain and functional measures such as Kujala score, mSEBT, and the step- down test compared to our control group. In addition to the possible biomechanical effects of treating TrPs in the QL and GM, central neurophysiological mechanisms involved in DN may also have contributed to our results. Dry needling can release analgesic substances in the bloodstream and cerebrospinal fluid by stimulating A-delta fibers. This in turn may cause pain relief in remote areas other than the site of treatment.61 This mechanism is thus another potential explanation for the greater reductions in knee pain in our ExþDN group. Recent evidence showed local and remote pain sensitization in females with PFP due to the increased excitability of nociceptive neu- rons.59 Any approach (including DN) that modulates nervous system sensitization might thus improve PPT in females with PFP.62 Moreover, there is evidence that pain catastrophism and kinesiophobia are increased in patients with PFP, and that changes in these factors are predictive of improved function and better outcomes of pain treatments.63-65 Therefore, DN might lead to less pain and improved function via this mechanism. However, in this study we did not evaluate these 2 psychological factors. A final factor is the possible placebo effect of DN, which may also have contributed in the improvements in our study. Further research is needed to better understand the mechanisms that account for the improvements in patients with PFP after GM and QL DN. www.archives-pmr.org Downloaded for Joseph Santos (joseph.santos.5513@hstviseu.min-saude.pt) at H For personal use only. No other uses without permission The results of this study are in line with the recent consensus statement on PFP management, which recommends combined knee and proximal-focused exercise therapy.16,18 In addition, our main finding suggests that targeting TrPs in proximal muscles (ipsilateral GM and contralateral QL) relative to the affected knee is a potentially effective adjunct treatment for unilateral PFP. However, further studies are needed. Study limitations This study had some limitations. First, we did not include men or persons with unilateral PFP, and this may have limited the general- izability of the results. Second, we had no Exþplacebo group, so the patients were not blind to the use of DN. Third, the home exercise programwas unsupervised, sowewere not able toverify adherence to the home exercise protocol. Fourth, the exercise therapy protocolwas limited to 4 weeks and so was not aligned with current best practice recommendation for PFP management. Finally, our follow-up was limited to 6 weeks after the start of treatment; studies with longer follow-up periods are therefore advisable. Conclusions Dry needling of TrPs in the ipsilateral GM and contralateral QL combined with exercise therapy can improve pain, function, and dynamic balancemore than exercise therapy alone.Therefore, adding GMandQLmuscledryneedling toexercise therapymaybe advisable to enhance the effects of unilateral PFP rehabilitation. Suppliers a. Needle; Wujiang City Shenlong Medical Health Product Co, Ltd. b. Digital pressure algometer; Wagner Instruments. c. SPSS version 16; SPSS Inc. Keywords Exercise therapy; Patellofemoral pain syndrome; Postural balance;Rehabilitation; Trigger points 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. E-mail address: motealleh@sums.ac.ir. Acknowledgments We thank the Research Consultation Center at Shiraz University of Medical Sciences for statistical advice. We also thank K. Shashok (AuthorAID in the Eastern Mediterranean-translator and editorial consultant) for improving the use of English in the article. ospital de Sao Teotonio from ClinicalKey.com by Elsevier on May 29, 2020. . Copyright ©2020. Elsevier Inc. All rights reserved. mailto:motealleh@sums.ac.ir http://www.archives-pmr.org Appendix 1 Exercise therapy protocol Week Exercises Description* 1 Hamstring stretch Quadriceps stretch Quadriceps exercisey Supine straight-leg raising (hip flex with knee ext), cyclic stretch, 2 sets�15 repetitions�10 seconds hold (for all sessions) Thomas test position (hip ext with knee flex close to the edge of the table), cyclic stretch, 2 sets�15 repetitions�10 seconds hold (for all sessions) Supine, isometric terminal knee ext, 3 sets�10 repetitions, 5 seconds hold 2 Quadriceps exercise Side-lying straight-leg raises Side-lying clamshells Supine, isometric terminal knee ext, 3 sets, 15 repetitions in each set, 5 seconds hold 3 sets, 15 repetitions in each set 3 sets, 15 repetitions in each set 3 Quadriceps exercise Side-lying straight-leg raises Side-lying clamshells Plank exercise Side plank exercise Supine, isometric terminal knee ext, 3 sets, 20 repetitions in each set, 5 seconds hold 3 sets, 20 repetitions in each set 3 sets, 20 repetitions in each set 3 sets, 20 repetitions in each set, 5 seconds hold 3 sets, 20 repetitions in each set, 5 seconds hold 4 Quadriceps exercise Side-lying straight-leg raises Side-lying clamshells Plank exercise Side plank exercise Mini-squats Mini-lunge Step-down Supine, isometric terminal knee ext, 3 sets, 25 repetitions in each set, 5 seconds hold 3 sets, 25 repetitions in each set 3 sets, 25 repetitions in each set 3 sets, 25 repetitions in each set, 5 seconds hold 3 sets, 25 repetitions in each set, 5 seconds hold 3 sets, 25 repetitions in each set 3 sets, 25 repetitions in each set Exercise on a step with 18-cm height, 3 sets, 25 repetitions in each set * The number of repetitions in each set of exercises increased each week. Also, new exercises were added each week to the previous week’s program. y Isometric quadriceps exercise progressed by adding weights (about 1-2.5 kilogram) in each week. Appendix 2 The procedure of DN techniques Muscle Locating the TrPs DN Technique Quadratus lumbarum lateral third of the lumbar transverse processes in side lying position* For all TrPs, the skin at the site of TrP was cleaned by alcohol. A fast-in and fast-out technique was applied while the patient was in the side lying position, 3 times for each TrP. When the investigator felt the first local twitch response, the needle was moved up/down with no rotation. For safety considerations DN for QL was performed below the level of the L2 vertebra. Gluteus medius TrP1 upper lateral quadrant of the buttock between the region proximal to the greater trochanter and inferior to the iliac crest in side lying position* TrP2 The region immediately anterior to TrP1 in side lying position* TrP3 Anterior to the tensor fascia latae muscle by rolling the thumb perpendicular to the muscle fibers in side lying position* Abbreviation: TrP, trigger point. * The criteria for TrP identification were taut band, jump sign, and tenderness. 272 H. Zarei et al References 1. Smith BE, Selfe J, Thacker D, et al. Incidence and prevalence of patellofemoral pain: a systematic review and meta-analysis. PLoS One 2018;13:e0190892. 2. Crossley KM, Stefanik JJ, 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. 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Materials and methods Study design and participants Interventions Outcome measures Sample size Randomization and blinding Statistical analysis Results Participants Outcomes Discussion Study limitations Conclusions Suppliers Keywords Keywords Corresponding author aflink7 Acknowledgments References
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