Improvements in Lower-Extremity Function Following a Rehabilitation Program With Patterned Electrical Neuromuscular Stimulation in Females With Patellofemoral Pain: A Randomized Controlled Trial

in Journal of Sport Rehabilitation
Restricted access

Purchase article

USD  $24.95

Student 1 year online subscription

USD  $76.00

1 year online subscription

USD  $101.00

Student 2 year online subscription

USD  $144.00

2 year online subscription

USD  $192.00

Context: Patellofemoral pain (PFP) is a challenging condition, with altered kinematics and muscle activity as 2 common impairments. Single applications of patterned electrical neuromuscular stimulation (PENS) have improved both kinematics and muscle activity in females with PFP; however, the use of PENS in conjunction with a rehabilitation program has not been evaluated. Objective: To determine the effects of a 4-week rehabilitation program with PENS on lower-extremity biomechanics and electromyography (EMG) during a single-leg squat (SLS) and a step-down task (SDT) in individuals with PFP. Study Design: Double-blinded randomized controlled trial. Setting: Laboratory. Patients of Other Participants: Sixteen females with PFP (age 23.3 [4.9] y, mass 66.3 [13.5] kg, height 166.1 [5.9] cm). Intervention: Patients completed a 4-week supervised rehabilitation program with or without PENS. Main Outcome Measures: Curve analyses for lower-extremity kinematics and EMG activity (gluteus maximus, gluteus medius, vastus medialis oblique, vastus lateralis, biceps femoris, and adductor longus) were constructed by plotting group means and 90% confidence intervals throughout 100% of each task, before and after the rehabilitation program. Mean differences (MDs) and SDs were calculated where statistical differences were identified. Results: No differences at baseline in lower-extremity kinematics or EMG were found between groups. Following rehabilitation, the PENS group had significant reduction in hip adduction between 29% and 47% of the SLS (MD = 4.62° [3.85°]) and between 43% and 69% of the SDT (MD = 6.55° [0.77°]). Throughout the entire SDT, there was a decrease in trunk flexion in the PENS group (MD = 10.91° [1.73°]). A significant decrease in gluteus medius activity was seen during both the SLS (MD = 2.77 [3.58]) and SDT (MD = 4.36 [5.38]), and gluteus maximus during the SLS (MD = 1.49 [1.46]). No differences were seen in the Sham group lower-extremity kinematics for either task. Conclusion: Rehabilitation with PENS improved kinematics in both tasks and decreased EMG activity. This suggests that rehabilitation with PENS may improve muscle function during functional tasks.

Glaviano is with the School of Exercise and Rehabilitation Sciences, College of Health and Human Services, The University of Toledo, Toledo, OH, USA. Marshall is with the Department of Health & Exercise Science, Appalachian State University, Boone, NC, USA. Mangum is with the College of Health Professionals and Sciences, University of Central Florida, Orlando, FL, USA. Hart, Hertel, and Saliba are with the Exercise and Sport Injury Laboratory, Department of Kinesiology, University of Virginia, Charlottesville, VA, USA. Hart and Russell are with the Department of Orthopedic Surgery, University of Virginia, Charlottesville, VA, USA.

Glaviano (Neal.Glaviano@UToledo.edu) is corresponding author.

Supplementary Materials

    • Supplementary Figure S1 (PDF 153 KB)
    • Supplementary Figure S2 (PDF 154 KB)
    • Supplementary Figure S3 (PDF 154 KB)
    • Supplementary Figure S4 (PDF 158 KB)
  • 1.

    Glaviano NR, Kew M, Hart JM, Saliba S. Demographic and epidemiological trends in patellofemoral pain. Int J Sports Phys Ther. 2015;10(3):281290. PubMed ID: 26075143

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med. 2002;36(2):95101. PubMed ID: 11916889 doi:10.1136/bjsm.36.2.95

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Boling M, Padua D, Marshall S, Guskiewicz K, Pyne S, Beutler A. Gender differences in the incidence and prevalence of patellofemoral pain syndrome. Scand J Med Sci Sports. 2010;20(5):725730. PubMed ID: 19765240 doi:10.1111/j.1600-0838.2009.00996.x

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Glaviano NR, Baellow A, Saliba S. Physical activity levels in individuals with and without patellofemoral pain. Phys Ther Sport. 2017;27:1216. PubMed ID: 28780340 doi:10.1016/j.ptsp.2017.07.002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Cheung RT, Zhang Z, Ngai SP. Different relationships between the level of patellofemoral pain and quality of life in professional and amateur athletes. PM R. 2013;5(7):568572. PubMed ID: 23375635 doi:10.1016/j.pmrj.2012.12.007

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Stathopulu E, Baildam E. Anterior knee pain: a long-term follow-up. Rheumatology. 2003;42(2):380382. PubMed ID: 12595641 doi:10.1093/rheumatology/keg093

    • Search Google Scholar
    • Export Citation
  • 7.

    Rathleff MS, Roos EM, Olesen JL, Rasmussen S. Exercise during school hours when added to patient education improves outcome for 2 years in adolescent patellofemoral pain: a cluster randomised trial. Br J Sports Med. 2015;49(6):406412. PubMed ID: 25388552 doi:10.1136/bjsports-2014-093929

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8.

    Ireland ML, Willson JD, Ballantyne BT, Davis IM. Hip strength in females with and without patellofemoral pain. J Orthop Sports Phys Ther. 2003;33(11):671676. PubMed ID: 14669962 doi:10.2519/jospt.2003.33.11.671

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Nakagawa TH, Moriya ET, Maciel CD, Serrao FV. Trunk, pelvis, hip, and knee kinematics, hip strength, and gluteal muscle activation during a single-leg squat in males and females with and without patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2012;42(6):491501. PubMed ID: 22402604 doi:10.2519/jospt.2012.3987

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Robinson RL, Nee RJ. Analysis of hip strength in females seeking physical therapy treatment for unilateral patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2007;37(5):232238. PubMed ID: 17549951 doi:10.2519/jospt.2007.2439

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Chester R, Smith TO, 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 Musculoskelet Disord. 2008;9:64. PubMed ID: 18452611 doi:10.1186/1471-2474-9-64

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12.

    Barton CJ, Lack S, Malliaras P, Morrissey D. Gluteal muscle activity and patellofemoral pain syndrome: a systematic review. Br J Sports Med. 2013;47(4):207214. PubMed ID: 22945929 doi:10.1136/bjsports-2012-090953

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Barton CJ, Levinger P, Menz HB, Webster KE. Kinematic gait characteristics associated with patellofemoral pain syndrome: a systematic review. Gait Posture. 2009;30(4):405416. PubMed ID: 19651515 doi:10.1016/j.gaitpost.2009.07.109

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Bolgla LA, Malone TR, Umberger BR, Uhl TL. Comparison of hip and knee strength and neuromuscular activity in subjects with and without patellofemoral pain syndrome. Int J Sports Phys Ther. 2011;6(4):285296. PubMed ID: 22163090

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    Giles LS, Webster KE, McClelland JA, Cook J. Does quadriceps atrophy exist in individuals with patellofemoral pain? A systematic literature review with meta-analysis. J Orthop Sports Phys Ther. 2013;43(11):766776. PubMed ID: 24175596 doi:10.2519/jospt.2013.4833

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16.

    Kaya D, Citaker S, Kerimoglu U, et al. Women with patellofemoral pain syndrome have quadriceps femoris volume and strength deficiency. Knee Surg Sports Traumatol Arthrosc. 2011;19(2):242247. PubMed ID: 20953760 doi:10.1007/s00167-010-1290-2

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Lankhorst NE, van Middelkoop M, Crossley KM, et al. Factors that predict a poor outcome 5–8 years after the diagnosis of patellofemoral pain: a multicentre observational analysis. Br J Sports Med. 2015;50(14):881886. PubMed ID: 26463119 doi:10.1136/bjsports-2015-094664

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 18.

    Boling MC, Bolgla LA, Mattacola CG, Uhl TL, Hosey RG. Outcomes of a weight-bearing rehabilitation program for patients diagnosed with patellofemoral pain syndrome. Arch Phys Med Rehabil. 2006;87(11):14281435. PubMed ID: 17084115 doi:10.1016/j.apmr.2006.07.264

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Earl JE, Hertel J, Denegar CR. Patterns of dynamic malalignment, muscle activation, joint motion, and patellofemoral-pain syndrome. J Sport Rehabil. 2005;14:215233.

    • Search Google Scholar
    • Export Citation
  • 20.

    Cowan SM, Bennell KL, Hodges PW, Crossley KM, McConnell J. Delayed onset of electromyographic activity of vastus medialis obliquus relative to vastus lateralis in subjects with patellofemoral pain syndrome. Arch Phys Med Rehabil. 2001;82(2):183189. PubMed ID: 11239308 doi:10.1053/apmr.2001.19022

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.

    Willson JD, Davis IS. Lower extremity mechanics of females with and without patellofemoral pain across activities with progressively greater task demands. Clin Biomech. 2008;23(2):203211. doi:10.1016/j.clinbiomech.2007.08.025

    • Search Google Scholar
    • Export Citation
  • 22.

    Souza RB, Powers CM. Differences in hip kinematics, muscle strength, and muscle activation between subjects with and without patellofemoral pain. J Orthop Sports Phys Ther. 2009;39(1):1219. PubMed ID: 19131677 doi:10.2519/jospt.2009.2885

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23.

    Prins MR, van der Wurff P. Females with patellofemoral pain syndrome have weak hip muscles: a systematic review. Aust J Physiother. 2009;55(1):915. PubMed ID: 19226237 doi:10.1016/S0004-9514(09)70055-8

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Willy RW, Davis IS. The effect of a hip-strengthening program on mechanics during running and during a single-leg squat. J Orthop Sports Phys Ther. 2011;41(9):625632. PubMed ID: 21765220 doi:10.2519/jospt.2011.3470

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Willy RW, Davis IS. Varied response to mirror gait retraining of gluteus medius control, hip kinematics, pain, and function in 2 female runners with patellofemoral pain. J Orthop Sports Phys Ther. 2013;43(12):864874. PubMed ID: 24175611 doi:10.2519/jospt.2013.4516

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Noehren B, Scholz J, Davis I. The effect of real-time gait retraining on hip kinematics, pain and function in subjects with patellofemoral pain syndrome. Br J Sports Med. 2011;45(9):691696. PubMed ID: 20584755 doi:10.1136/bjsm.2009.069112

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Glaviano NR, Huntsman S, Dembeck A, Hart JM, Saliba S. Improvements in kinematics, muscle activity and pain during functional tasks in females with patellofemoral pain following a single patterned electrical stimulation treatment. Clin Biomech. 2015;32:2027. doi:10.1016/j.clinbiomech.2015.12.007

    • Search Google Scholar
    • Export Citation
  • 28.

    Glaviano NR, Saliba SA. Immediate effect of patterned electrical neuromuscular stimulation on pain and muscle activation in individuals with patellofemoral pain. J Athl Train. 2016;51(2):118128. PubMed ID: 26967547 doi:10.4085/1062-6050-51.4.06

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Ferber R, Bolgla L, Earl-Boehm JE, Emery C, Hamstra-Wright K. Strengthening of the hip and core versus knee muscles for the treatment of patellofemoral pain: a multicenter randomized controlled trial. J Athl Train. 2015;50(4):366377. PubMed ID: 25365133 doi:10.4085/1062-6050-49.3.70

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 30.

    Hamstra-Wright KL, Aydemir B, Earl-Boehm J, Bolgla L, Emery C, Ferber R. Lasting improvement of patient-reported outcomes 6 months after patellofemoral pain rehabilitation. J Sport Rehabil. 2017;26(4):223233. PubMed ID: 27632841 doi:10.1123/jsr.2015-0176

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Glaviano NR, Marshall AN, Mangum LC, et al. Impairment based rehabilitation with patterned electrical neuromuscular stimulation improves lower extremity function in individuals with patellofemoral pain: a preliminary study. J Athl Train. 2019;54(3):255269. PubMed ID: 30721093 doi:10.4085/1062-6050-490-17

    • Search Google Scholar
    • Export Citation
  • 32.

    Crossley KM, Bennell KL, Cowan SM, Green S. Analysis of outcome measures for persons with patellofemoral pain: which are reliable and valid? Arch Phys Med Rehabil. 2004;85(5):815822. PubMed ID: 15129407 doi:10.1016/S0003-9993(03)00613-0

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33.

    Hermens HJ, Freriks B, Disselhorst-Klug C, Rau G. Development of recommendations for SEMG sensors and sensor placement procedures. J Electromyogr Kinesiol. 2000;10(5):361374. PubMed ID: 11018445 doi:10.1016/S1050-6411(00)00027-4

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34.

    Glaviano NR, Langston WT, Hart JM, Saliba S. Influence of patterned electrical neuromuscular stimulation on quadriceps activation in individuals with knee joint injury. Int J Sports Phys Ther. 2014;9(7):915923. PubMed ID: 25540707

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35.

    Glaviano NR, Saliba S. Impairment based rehabilitation for patellofemoral pain patients. Phys Sportsmed. 2016;44(3):311323. PubMed ID: 27311015 doi:10.1080/00913847.2016.1200443

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36.

    Chang M, Slater LV, Corbett RO, Hart JM, Hertel J. Muscle activation patterns of the lumbo-pelvic-hip complex during walking gait before and after exercise. Gait Posture. 2017;52:1521. PubMed ID: 27846435 doi:10.1016/j.gaitpost.2016.11.016

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37.

    Chinn L, Dicharry J, Hart JM, Saliba S, Wilder R, Hertel J. Gait kinematics after taping in participants with chronic ankle instability. J Athl Train. 2014;49(3):322330. PubMed ID: 24840583 doi:10.4085/1062-6050-49.3.08

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38.

    Schwane BG, Goerger BM, Goto S, Blackburn JT, Aguilar AJ, Padua DA. Trunk and lower extremity kinematics during stair descent in women with or without patellofemoral pain. J Athl Train. 2015;50(7):704712. PubMed ID: 25898109 doi:10.4085/1062-6050-49.3.100

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39.

    Powers CM. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther. 2010;40(2):4251. PubMed ID: 20118526 doi:10.2519/jospt.2010.3337

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40.

    Earl JE, Hoch AZ. A proximal strengthening program improves pain, function, and biomechanics in women with patellofemoral pain syndrome. Am J Sports Med. 2011;39(1):154163. PubMed ID: 20929936 doi:10.1177/0363546510379967

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41.

    Hakkinen K, Alen M, Kallinen M, Newton RU, Kraemer WJ. Neuromuscular adaptation during prolonged strength training, detraining and re-strength-training in middle-aged and elderly people. Eur J Appl Physiol. 2000;83(1):5162. PubMed ID: 11072774 doi:10.1007/s004210000248

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42.

    Hakkinen K, Komi PV. Electromyographic changes during strength training and detraining. Med Sci Sports Exerc. 1983;15(6):455460. PubMed ID: 6656553 doi:10.1249/00005768-198315060-00003

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43.

    Wallerstein LF, Tricoli V, Barroso R, et al. Effects of strength and power training on neuromuscular variables in older adults. J Aging Phys Act. 2012;20(2):171185. PubMed ID: 22472578 doi:10.1123/japa.20.2.171

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44.

    Hart JM, Pietrosimone B, Hertel J, Ingersoll CD. Quadriceps activation following knee injuries: a systematic review. J Athl Train. 2010;45(1):8797. PubMed ID: 20064053 doi:10.4085/1062-6050-45.1.87

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45.

    Aminaka N, Pietrosimone BG, Armstrong CW, Meszaros A, Gribble PA. Patellofemoral pain syndrome alters neuromuscular control and kinetics during stair ambulation. J Electromyogr Kinesiol. 2011;21(4):645651. PubMed ID: 21524921 doi:10.1016/j.jelekin.2011.03.007

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46.

    Mauntel TC, Begalle RL, Cram TR, et al. The effects of lower extremity muscle activation and passive range of motion on single leg squat performance. J Strength Cond Res. 2013;27(7):18131823. PubMed ID: 23096063 doi:10.1519/JSC.0b013e318276b886

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
All Time Past Year Past 30 Days
Abstract Views 14 14 0
Full Text Views 323 323 37
PDF Downloads 161 161 28