Stabilization exercise compared to general exercises or manual therapy for the management of low back pain: A systematic review and meta-analysis

Mansueto Gomes-Neto, Jordana Moura Lopes, Cristiano Sena Conceição, Anderson Araujo, Alécio Brasileiro e, Camila Sousa, Vitor Oliveira Carvalho e Fabio Luciano Arcanjo.

1. Background: Low back pain (LBP) is a multifactorial disorder with a high prevalence; most people experience back pain at some point in their life and it has a significant impact on individuals, their families, and the healthcare systems. This disorder causes disability, participation restriction, a career burden, the use of health-care resources, and a financial burden. In addition to medical treatment, musculoskeletal physiotherapy (exercise therapy and manual therapy) is the most common method of conservative intervention for LBP (Amit, Manish, & Taruna, 2013; Hoy, Brooks, Blyth, & Buchbinder, 2010; Smith et al., 2014). The European Guidelines for Management of Chronic Non-Specific Low Back Pain (Airaksinen et al., 2006) recommend supervised exercise therapy as the first-line treatment. Stabilization exercise programs have become widely used for low back rehabilitation because of its effectiveness in some aspects related to pain and disability (Ferreira, Ferreira, Maher, Herbert, & Refshauge, 2006; Liddle, David Baxter, & Gracey, 2009). Stabilization exercise are exercise interventions that aim to improve function of specific trunk muscles thought to control inter-segmental movement of the spine and enable the patient to regain control and coordination of the spine and pelvis using principles of motor learning such as segmentation and simplification (Hodges and Richardson, 1996; Richardson, Jull, Hides, & Hodges, 1999). Although stabilization exercises have become the major focus in spinal rehabilitation, as well as in prophylactic care, the therapeutic evidence using pain and disability control variables as outcomes remains controversial. Most therapeutic studies have compared stabilization exercise, general exercise, and manual therapy. Systematic reviews to date that have evaluated the effectiveness of exercise therapies have concluded that there is no evidence to support the superiority of one form of exercise over another (Ferreira et al., 2006; Macedo et al., 2010). In a recent review, Wang et al. (Wang et al., 2012) showed that stability exercise is more effective for decreasing pain than general exercise, and it may improve physical function in patients with chronic LBP. However, the efficacy of stability exercise was not compared with manual therapy. After reviews on this topic were published (Ferreira et al., 2006; Macedo et al., 2010; Wang et al., 2012), new randomized controlled trials (RCTs) have been released (Amit et al., 2013; Inani and Selkar, 2013; Macedo et al., 2012; Sung, 2013). The Cochrane Collaboration recommends that systematic reviews be updated biannually (Higgins and Green, 2006). Moreover, as far as we know, no meta-analysis has been performed on studies comparing segmental stabilization exercise with manual therapy. The meta-analysis technique minimizes subjectivity by standardizing treatment effects of relevant studies into effect sizes (ESs), pooling, and analyzing data to draw conclusions. The aim of this systematic review with meta-analysis was to analyze published RCTs that investigated the efficacy of stabilization exercises versus general exercises or manual therapy in patients with LBP.

2. Methods: This review was planned and performed in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines (Moher et al., 2009).

2.1. Eligibility criteria: This systematic review included all RCTs that investigated the efficacy of stabilization exercises in patients with non-specific LBP. Studies that compared a stabilization exercises group with a general exercises group or a stabilization exercises group with a manual therapy group were included. Studies were considered for inclusion regardless of publication status, language, or size. Trials that enrolled patients with chronic non-specific LBP were included in this meta-analysis. For this study was considered the chronic nonspecific LBP as low back pain (>3 months’ duration) without leg pain. The studies that enrolled patients with acute LBP in association with neurologic diseases were excluded from this systematic review. The main outcomes of interest were pain (assessed using visual analog scale, numerical rating scale, or any other instrument or scale) with scores ranging from 0 to 10, disability, and function assessed by any questionnaire. To be eligible, the RCTs should have randomized patients with chronic LBP to at least one group of stabilization exercises. For this review, stabilization exercises was considered as prescribed exercises aimed at improving function of specific trunk muscles that control inter-segmental movement of the spine, including the transversus abdominis, multifidus, diaphragm, and pelvic floor muscles (Hodges and Richardson, 1996; Richardson et al., 1999). General exercise were prescribed exercises that included strengthening and/or stretching exercises for the main muscle groups of the body as well as exercises for cardiovascular fitness. Manual therapy comprised physiotherapy based on manual techniques (joint mobilization or manipulation techniques).

2.2. Search methods for identification of studies: We searched for studies on MEDLINE, LILACS, EMBASE, SciELO, Cumulative Index to Nursing and Allied Health (CINAHL), PEDro, and the Cochrane Library, up to November 2014, without language restrictions. A standard protocol for this search was developed and whenever possible, a controlled vocabulary was used (Mesh terms for MEDLINE and Cochrane; EMTREE for EMBASE). Keywords and their synonyms were used to sensitize the search. For identification of RCTs in PUBMED, the optimally sensitive strategy developed for the Cochrane Collaboration was used (Higgins and Green, 2006). For identification of RCTs in EMBASE, a search strategy using similar terms was adopted. In the search strategy, there were four groups of keywords: study design, participants, interventions, and outcome measures. We analyzed the reference lists of all eligible articles in order to detect other potentially eligible studies. For ongoing studies or when any data was to be confirmed or additional information was needed, the authors were contacted by e-mail. The previously described search strategy was used to obtain titles and abstracts of studies that were relevant for this review. Each identified abstract was independently evaluated by two authors. If at least one of the authors considered one reference eligible, the full text was obtained for complete assessment. Two reviewers independently assessed the full text of selected articles to verify if they met the criteria for inclusion or exclusion. In case of any disagreement, the authors discussed the reasons for their decisions and a consensus was reached. Two authors, independently blinded, extracted descriptive and outcome data from the included studies using a standardized form developed by the authors and adapted from the Cochrane Collaboration’s (Higgins and Green, 2006) model for data extraction. We considered: 1) aspects of the study population, such as the average age and sex; 2) aspects of the intervention performed (sample size, type of stabilization exercise performed, presence of supervision, frequency, and duration of each session); 3) follow-up (if the patients included were analyzed); 4) loss to follow-up (if there was a loss in the sample); 5) outcome measures; and 6) presented results. Another author resolved disagreements. Any additional information required from the original author was requested by e-mail. The risk of bias of included studies was assessed independently by two authors using The Cochrane Collaboration’s “Risk of bias” tool (Higgins and Green, 2006). The following criteria were assessed: Random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, intention-to-treat analysis, and completeness of follow-up. The quality of evidence was independently scored by two researchers based on the PEDro scale (Olivo et al., 2008) that consisted of 11 items based on a Delphi list (Verhagen et al., 1998). The PEDro scale is a useful tool for assessing the quality of physical therapy and rehabilitation trials (Olivo et al., 2008). One item on the PEDro scale (eligibility criteria) is related to external validity and is generally not used to calculate the method score, leaving a score range of 0e10 (Maher, Sherrington, Herbert, Moseley, & Elkins, 2003).

2.3. Statistical assessment: Pooled-effect estimates were obtained by comparing the least square mean percentage change from the baseline to the study end for each group, and were expressed as the weighted mean difference between groups. Calculations were performed using a random-effects model. Two comparisons were made: stabilization exercises group versus general exercises group and stabilization exercises group versus manual therapy group. An a value of 0.05 was considered significant. Statistical heterogeneity of the treatment effect among studies was assessed using Cochran’s Q-test and the inconsistency I (Hoy et al., 2010) test, in which values between 25% and 50% were considered indicative of moderate heterogeneity, and values > 50% were considered indicative of high heterogeneity (Higgins, Thompson, Deeks, & Altman, 2003). All analyses were conducted using Review Manager Version 5.0 (Cochrane Collaboration). (CollaborationAvailab).

3. Results: The initial search led to the identification of 653 abstracts, from which 24 studies were considered as potentially relevant and were retrieved for detailed analysis. After complete reading of 24 articles, 13 were excluded. Finally, 11 papers (Akbari, Khorashadizadeh, & Abdi, 2008; Amit et al., 2013; Ferreira et al., 2007; França, Burke, Hanada, & Marques, 2010, 2012; Goldby, Moore, & Doust, 2006; Inani and Selkar, 2013; Macedo et al., 2012; Rasmussen-Barr, Nilsson-Wikmar, & Arvidsson, 2003; Sung, 2013; Unsgaard-Tøndel, Fladmark, Salvesen, & Vasseljen, 2010) met the eligibility criteria. Fig. 1 shows the PRISMA flow diagram of studies for this review. Each of the papers was scored using the PEDro scale. Table 1 presents the results of individual assessment by the PEDro scale. The final sample ranged from 30 to 172 participants, and the mean age ranged from 59 to 67 years. All studies analyzed in this review included outpatients with documented LBP. The parameters used in the application of stabilization exercises have been reported, and all studies described the progressive nature of the programs. The duration of stabilization exercises programs ranged from 4 to 12 weeks. The duration of sessions varied from 20 to 60 min in the studies. The frequency of sessions ranged from one to three times per week. Table 2 summarizes the characteristics of included studies.

3.1. Pain intensity: In total, eight trials assessed pain intensity (Akbari et al., 2008; Amit et al., 2013; Ferreira et al., 2007; França et al., 2010; Goldby et al., 2006; Macedo et al., 2012; Rasmussen-Barr et al., 2003; Sung, 2013). The meta-analyses showed (Fig. 2) a significant improvement in pain of 1.03 (95% CI: 1.79 to 0.27, N ¼ 603) for participants in the stabilization exercises group compared to the general exercises group. Three studies compared stabilization exercise to manual therapy (Ferreira et al., 2007; Goldby et al., 2006; Rasmussen-Barr et al., 2003). A non-significant difference in pain of 0.38 (95% CI: 0.98 to 0.22, N ¼ 358; Fig. 3) was noted for participants in the stabilization exercises group compared to the manual therapy group. Age mean.




3.2. Disability: Seven trials assessed disability (Ferreira et al., 2007; França et al., 2010, 2012; Inani and Selkar, 2013; Macedo et al., 2012; Sung, 2013; Unsgaard-Tøndel et al., 2010). Five of these studies measured disability using the Oswestry Disability Index (França et al., 2010, 2012; Inani and Selkar, 2013; Sung, 2013; Unsgaard- Tøndel et al., 2010), and two assessed disability using the Roland-Morris Disability Questionnaire (Ferreira et al., 2007; Macedo et al., 2012). In four individual trials, significant improvements were found in the stabilization exercises group compared to the general exercises group as measured by the Oswestry Disability Index. The meta-analyses showed a significant improvement in disability of 5.41 (95% CI: 8.34 to 2.49, N ¼ 209; Fig. 4) for participants in the stabilization exercises group compared to the general exercises group. As assessed using the Roland-Morris Disability Questionnaire, the non-significant difference in disability of 0.75 (95% CI: 2.26 to 0.75, N ¼ 310; Fig. 5) was noted for participants in the stabilization exercises group compared to the general exercises group. Three studies compared stabilization exercise to manual therapy (Ferreira et al., 2007; Goldby et al., 2006; Rasmussen-Barr et al., 2003). A non-significant difference in disability of 0.17 (95% CI: 0.38 to 0.03, N ¼ 358) was found for participants in the stabilization exercises group compared with manual therapy (Ferreira et al., 2007; Goldby et al., 2006; Rasmussen-Barr et al., 2003). (Fig. 6) Owing to the differences between instruments used to measure disability (stabilization exercises group versus manual therapy group), a meta-analysis was performed using the standardized mean difference. All studies included patients of both genders, but there was an overall predominance of female. The mean age ranged from 38 (Rasmussen-Barr et al., 2003) to 53 (Ferreira et al., 2007) years. All studies analyzed in this review included outpatients with documented chronic nonspecific LBP (pain duration > 12 weeks). The parameters used in the application of manual therapy have been reported. The duration of manual therapy programs ranged from 8 (Ferreira et al., 2007) to 12 (Goldby et al., 2006; Rasmussen-Barr et al., 2003) weeks. The duration of sessions varied from 45 (Rasmussen-Barr et al., 2003) to 60 (Ferreira et al., 2007; Goldby et al., 2006) min in the studies. The frequency of sessions ranged from one (Rasmussen-Barr et al., 2003) to two (Ferreira et al., 2007) times per week. Table 2 summarizes the other characteristics of included studies.

3.3. Function: Two trials assessed function using the Patient-Specific Functional Scale (Macedo et al., 2012; Verhagen et al., 1998). The nonsignificant difference in function of 0.01 (95% CI: 1.18 to 1.21, N ¼ 310) (Fig. 7); was noted for participants in the stabilization exercises group compared with the general exercises group.

3.4. Risk of bias in the included studies: The studies did not have enough detail for assessing the potential risk of bias. Details regarding the generation and concealment of the random allocation sequence were poorly reported. Six studies presented objective evidence of the random allocation characteristics. The studies presented objective evidence of balance in baseline characteristics. Only three studies stated that the measurements were blinded.

4. Discussion: In the present systematic review, a meta-analysis of 8 studies indicated that stabilization exercises were more effective than general exercises in reducing pain. Five studies demonstrated a significant improvement in disability between patients treated with stabilization exercises compared with those treated with general exercises. Moreover, the meta-analysis of three studies demonstrated that stabilization exercises were as efficacious as manual therapy in decreasing pain and disability. In our meta-analysis the mean of pain in the analyzed studies was 6.01 at baseline, being 2.1 at the end of the stabilization exercises on a 0e10 pain scale. Specifically, the WMD in pain was 1.03 favoring stabilization exercises, what represents an improvement of 39% in pain. Considering pain, for patients with subacute or chronic LBP, the minimally clinically important change for pain on a visual analog scale (0e10) should at least be 20%. If a numerical rating scale (0e10) is used it seems reasonable to suggest that the minimally clinically important change should at least be 25% for patients with chronic LBP (Ostelo and de Vet, 2005). The results of this review are consistent with the findings of a previous systematic review (Ferreira et al., 2006; Macedo et al., 2010) on the effects of stabilization exercise on nonspecific LBP. Our meta-analysis indicated that stabilization exercise can be more effective than general exercise in improving pain and disability in the short term, but it was not superior to manual therapy. In another systematic review by Pereira et al. (Pereira et al., 2012), stabilization exercise and Pilates offered no significant improvement in functionality. Previously, two other meta-analyses (Rackwitz et al., 2006; Wang et al., 2012) reported that specific stabilization exercises was better than ordinary medical care provided by a general practitioner to reduce pain over the short and intermediate terms. However, in a recent meta-analysis, Macedo et al. (Macedo, Maher, Latimer, & McAuley, 2009) demonstrated that stabilization exercises were superior to minimal intervention, but not more effective than manual therapy. Macedo and coworkers’ results are in agreement with those of our meta-analysis (Macedo et al., 2009). Contrary to our results, the meta-analysis by Macedo et al. (Macedo et al., 2009) also demonstrated that stabilization exercises were not more effective than other forms of exercise.



This disagreement can be explained by several different approaches currently in use for stabilization exercise to treat LBP. A standard protocol and definition for stabilization exercises is yet to be established. Therefore, there is a wide variation among studies in how the exercises were named and implemented (Lewis et al., 2005). Nevertheless, multiple studies have shown that not all subjects with LBP benefit equally from stabilization exercise (Hicks, Fritz, Delitto, & McGill, 2005). A recent review of studies has shown that therapy that is specifically directed at well-defined subgroups leads to improved effectiveness of interventions (Karayannis, Jull, & Hodges, 2012). The identification of predictive factors in patients with LBP should allow the prescription of the most appropriate treatment intervention, maximizing the likelihood of a favorable clinical outcome (Brennan et al., 2006; Fersum et al., 2010). In the present review, the included studies did not report concealment allocation or randomization in an appropriate manner. Thus, the effectiveness of stabilization exercises may be even lower in studies with proper randomization and concealment allocation. Our meta-analysis showed that stabilization exercise was as efficient as manual therapy for improving in pain and disability. However, the total number of patients involved in the meta-analysis was too small to identify relatively small disparities between the effects of stabilization exercise and manual therapy. It is difficult to make a definitive and pragmatic recommendation regarding stabilization exercise for patients with LBP. There was a variation in the duration of exercise programs, progression criteria, muscle activation, and type of feedback used during the interventions. However, with the exception of the study of Ferreira et al. (Ferreira et al., 2007) did not inform which protocol was used for stabilization, the protocol used in the studies were based on the protocol proposed by Richardson & Hodges (Hodges and Richardson, 1996; Richardson et al., 1999). Caution is warranted when interpreting the present results given the significant heterogeneity found in primary analyses. The use of different instruments for assessment and intervention programs (session time and duration of intervention) can compromise the comparisons. The studies used different scales and time periods to measure pain intensity (e.g., pain in last 24 h, pain in the last months) and disability (e.g. the Roland Morris Disability Index and the Oswestry Disability Index) and the duration of intervention and the time points of follow-up were different. Despite the differences in frequency and duration, stabilization exercise using the principles proposed by Richardson & Hodges (Hodges and Richardson, 1996; Richardson et al., 1999). were superior to general exercise that prioritizes exercise of superficial muscles. One of the limitations of this review was that the findings were based on relatively low quality data that led to a high risk of bias. Additional research is required to ascertain the positive effects of stabilization exercise over time and to determine their essential attributes, such as mode, intensity, frequency, duration, and timing. New RCTs testing different stabilization exercise for LBP should be conducted to determine the optimal treatment approach. Additionally, it will be important to match exercise prescription to clinical/treatment characteristics of a patient subgroup or individual patient.

5. Conclusion: Stabilization exercises and/or manual therapy can be encouraged as part of musculoskeletal rehabilitation for patients with LBP. However, the best prescription program, needs to be determined by new RCTs.

Hydrotherapy on exercise capacity, muscle strength and quality of life in patients with heart failure: A meta-analysis

Mansueto Gomes Neto, Cristiano Sena Conceição, Fabio Luciano Arcanjo de Jesus , Vitor Oliveira Carvalho

Heart failure (HF) is clinically characterized by exercise intolerance, poor health related quality of life (HRQOL) and high mortality. Exercise training is a well-established method to improve exercise intolerance and to restore HRQOL in patients with HF. However, the most efficient modality is unknown. In this context, hydrotherapy (i.e. exercise in warm water) has been proposed as an alternative tool in the rehabilitation of patients with HF. There is no meta-analysis of the efficacy of this intervention in HF patients. The aim of this systematic review with meta-analysis was to analyze the published randomized controlled trials (RCTs) that investigated the effects of hydrotherapy on exercise capacity and HRQOL in HF patients. This review was planned and conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We searched for references on MEDLINE, EMBASE, CINAHL, PEDro, and the Cochrane Library up to May 2014 without language restrictions. This systematic review included all RCTs that studied the effects of hydrotherapy in aerobic capacity, muscle strength and/or HRQOL of the HF patients. Two authors independently evaluated and extracted data from the published reports. Methodological quality was also independently assessed by two researchers. Studies were scored on the PEDro scale a useful tool for assessing the quality of physical therapy trials based on a Delphi list that consisted of 11 items with a score range of 0 to 10.



Pooled-effect estimates were obtained by comparing the least square mean percentage change from baseline to study end for each group. Two comparisons were made: hydrotherapy versus control group (non exercise) and hydrotherapy versus aerobic exercise group. All analyses were conducted using Review Manager Version 5.0 (Cochrane Collaboration). Six papers met the eligibility criteria. Fig. 1 shows the PRISMA flow diagram of studies in this review. The results of the assessment of the PEDro scale are presented individually in Table 1. The final sample size for the selected studies ranged from 14 to 25 and mean age of participants ranged from 51 to 75 years. All studies analyzed in this review included outpatients with documented HF and New York Heart Association (NYHA) classes II–III. Table 2 summarizes the characteristics. Hydrotherapy was considered as aerobic and strength exercises in warm water and the duration of the programs ranged from 3 to 24 weeks. Regarding the time of the session, there was a variation from 30  to 90 minutes. The frequency of sessions was three times per week in three studies and five times per week in others. Four studies assessed peak VO2 as an outcome, two compared hydrotherapy versus no exercise [10,11] and two hydrotherapy versus conventional aerobic exercise in land. The meta-analyses showed a significant improvement in peak VO2 of 2.97 mL·kg−1 ·min−1 (95% CI: 1.99, 3.94, N = 42) for participants in the hydrotherapy group compared with the no exercise group (Fig. 2A). A non significant change in peak VO2 of −0.66 mL·kg−1 ·min−1 (95% CI: −2.05, 0.72, N = 48) was found for participants in the hydrotherapy group compared with conventional aerobic exercises (Fig. 2B). Three studies assessed the 6-minute walk test (6WMT) as an outcome [10,11,14], two compared hydrotherapy versus no exercise and one hydrotherapy versus aerobic exercises in land. Significant improvements were found when comparing hydrotherapy with no exercise controls. The meta-analyses showed (Fig. 3) a significant improvement in 6WMT of 43.8 m (95% CI: 7.36, 80.16, N = 42) for participants in the hydrotherapy group compared with the no exercise group. Three studies assessed muscle strength as an outcome, two compared hydrotherapy versus no exercise and one hydrotherapy versus aerobic exercise in land. Significant improvements were found when comparing hydrotherapy with no exercise controls. The meta-analyses showed (Fig. 4) a significant improvement in muscle strength of 23.7 Nm (95% CI: 4.49, 42.89, N = 42) for participants in the hydrotherapy group compared with the no exercise group. Two studies measured HRQOL. The meta-analyses showed non significant improvement in HRQOL of −4.5 (95% CI: −14.40, 5.49, N = 42) for participants in the hydrotherapy group compared with the no exercise group (Fig. 5). Meta-analysis demonstrated a significant difference in peak VO2, distance in the six-minute walking test, muscle strength and DBP between patients with HF submitted to hydrotherapy and controls. Moreover, hydrotherapy was as efficient as conventional aerobic exercise in land for peak VO2. It is now known that cardiac function actually improves during water immersion due to the increase in early diastolic filling and decrease in heart rate, resulting in improvements in stroke volume and ejection fraction. These data created a positive scenario to discuss hydrotherapy as a potential tool in cardiovascular rehabilitation. This systematic review with meta-analysis is important because it analyzes the hydrotherapy as a potential co-adjutant modality in the rehabilitation of patients with HF. The mean of peak VO2 in the analyzed studies was 17.05 at the beginning and 18.3 mL·kg−1 ·min−1 at the end of the intervention. It has been demonstrated that improvements above 10% after a cardiovascular rehabilitation program represent a good prognosis in patients with HF. It has also been demonstrated that a minimum VO2 peak of 15 mL·kg−1 ·min−1 in women and 18 mL·kg−1 ·min−1 in men aged 55–86 years seems to be necessary for full and independent living. Thus the improvement generated by the hydrotherapy program can contribute to those patients with CHF to have better conditions to carry out their everyday activities.




Quadriceps mass and strength are related to maximal exercise capacity in HF. Moreover, changes in muscle performance with exercise training have been demonstrated to be related to changes in physical function and quality of life. In the present systematic review, our meta-analysis demonstrated a significant difference in muscle strength between patients with HF submitted to hydrotherapy and sedentary controls. Despite the fact that hydrotherapy was shown to be efficient in improving peak VO2 and muscle strength, it is not possible to conclude about the benefits of hydrotherapy compared to no exercise in HRQOL. Considering the available data, our meta-analysis showed that hydrotherapy was efficient to improve exercise capacity in patients with HF. Well controlled RCTs are needed to understand the potential bene- fits of hydrotherapy in patients with HF.

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Idosos com osteoartrite de joelho obesos e não obesos

Durante o processo de envelhecimento, ocorrem perdas funcionais que se acentuam devido à falta de atividade do sistema neuromuscular e à redução da força muscular e do condicionamento físico. Além da redução da funcionalidade, o idoso perde de maneira mais acentuada a capacidade de reter água e de produzir proteoglicanos, o que causa alterações degenerativas articulares, como a osteoartrite (OA). Um dos fatores de risco para a OA é a obesidade. Além de ser um fator de risco para a OA, a associação entre OA e obesidade pode aumentar a intensidade da dor e das limitações funcionais, devido a uma maior descarga de peso na articulação acometida, com estreitamento do espaço intra‐articular, que pode aumentar a dor articular, rigidez e atrofia muscular. Numa recente metanálise que avaliou o risco para o inicio da OA, reportam que pessoas obesas têm três vezes mais risco de desenvolver OA em relação a indivíduos sem sobrepeso.

O peso excessivo aumenta tanto a pressão quanto a força sobre a articulação, ativa mecanismos de degradação da cartilagem articular, esclerose do osso subcondral e formação de osteófitos e leva ao agravamento da AO. Esses fatores podem influenciar negativamente na qualidade de vida (QV) de idosos obesos acometidos pela doença. A OA por si só ou em conjunto com a obesidade está associada a um maior risco de morbimortalidade e pode reduzir a QV do idoso. Um atributo essencial na saúde do idoso é a sua capacidade funcional, um componente chave para avaliação global da saúde. Além de ser fator de risco para a AO, a obesidade pode agravar sintomas e aumentar o declínio funcional de idosos com OA. Compreender fatores que interferem na capacidade funcional e QV de idosos com AO pode contribuir na formulação de estratégias de prevenção e tratamento. Diante disso, este estudo teve como objetivo comparar a capacidade funcional e a QV de idosos com OA de joelho, obesos e não obesos.

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Mansueto Gomes-Neto, Anderson Delano Araujo, Isabel Dayanne Almeida Junqueira, Diego Oliveira, Alécio Brasileiro, Fabio Luciano Arcanjo

Comparative study of functional capacity and quality of life among obese and non-obese elderly people with knee osteoarthritis

Revista Brasileira de Reumatologia (English Edition), Volume 56, Issue 2, March–April 2016, Pages 126-130

Vamos falar sobre o Aparelho Isocinético

O Aparelho Isocinético é um equipamento conectado a um computador que capta informações de movimento. Leia mais

Condromalácia patelar

Condromalácia patelar é o amolecimento e degeneração da cartilagem da patela, decorrente do uso excessivo, trauma direto ou indireto decorrente de alteração biomecânica da articulação patelo femoral, representando uma causa comum de dor anterior no joelho.

O tratamento visa o fortalecimento do músculo que está em desequilíbrio, a fim de melhorar a disfunção e o reequilíbrio muscular. Assim, o paciente passa por tratamentos e medidas que fortaleçam a musculatura do joelho e quadril. O trabalho da AF Fisioterapia é realizar junto com o paciente exercícios para a região, com o objetivo de melhorar a função e encorajar o paciente ao retorno da prática esportiva.

Síndrome femoropatelar, via Instituto Trata

O que é?

A Síndrome da Dor Femoropatelar (SDFP) é ocasionada por um desequilíbrio biomecânico, que atinge a articulação do joelho, mais especificamente a articulação entre o fêmur e a patela. Acomete até 25% da população, sendo mais comum em mulheres sedentárias e indivíduos com grau de treinamento elevado.

Diversas causas podem estar relacionadas com a SDFP como: largura excessiva da pelve, joelho valgo, fraqueza muscular dos músculos do quadril e da coxa, patela alta, insuficiência ligamentar, dentre outros.


Dor na região anterior do joelho, ao subir e descer escadas, ao agachar e saltar, após longo período sentado (sinal do cinema), estalos ao andar e correr, sensação de areia dentro da articulação.

Diagnóstico e exames

Um exame físico deve ser realizado pelo fisioterapeuta especializado ou médico a fim de avaliar prováveis insuficiências de partes moles, acometimento de estruturas articulares, além de fatores que afetem as força e o alinhamento articular.

O tratamento depende da causa da dor no joelho, sendo geralmente conservador, baseado em técnicas de Fisioterapia. A fisioterapia específica visa melhorar o deslizamento da patela sobre o sulco troclear no fêmur, utilizando exercícios de fortalecimento muscular e correção biomecânica. Os resultados das sessões de fisioterapia vão depender das características individuais de cada paciente.

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The Stabilizing System of the Spine. Part I. Function, Dysfunction, Adaptation, and Enhancement

Panjabi MM1

Presented here is the conceptual basis for the assertion that the spinal stabilizing system consists of three subsystems. The vertebrae, discs, and ligaments constitute the passive subsystem. All muscles and tendons surrounding the spinal column that can apply forces to the spinal column constitute the active subsystem. The nerves and central nervous system comprise the neural subsystem, which determines the requirements for spinal stability by monitoring the various transducer signals, and directs the active subsystem to provide the needed stability. A dysfunction of a component of any one of the subsystems may lead to one or more of the following three possibilities: (a) an immediate response from other subsystems to successfully compensate, (b) a long-term adaptation response of one or more subsystems, and (c) an injury to one or more components of any subsystem. It is conceptualized that the first response results in normal function, the second results in normal function but with an altered spinal stabilizing system, and the third leads to overall system dysfunction, producing, for example, low back pain. In situations where additional loads or complex postures are anticipated, the neural control unit may alter the muscle recruitment strategy, with the temporary goal of enhancing the spine stability beyond the normal requirements.

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The Stabilizing System of the Spine. Part I. Function, Dysfunction, Adaptation, and Enhancement

Tecnologias que ajudam os corredores na prática de exercícios

A tecnologia acompanha os atletas. A avaliação isocinética consegue avaliar o modo como cada pessoa corre. “A ciência nos mostra que a gente precisa trabalhar a musculatura do atleta como um todo para que ele corra do jeito que ele se sinta mais confortável. […] Se a pessoa corre com o tronco mais para a frente ela consegue estirar mais a musculatura posterior e consequentemente a musculatura vai trabalhar melhor. Fique bem para correr.” Fabio Arcanjo. Confira a matéria que saiu na Rede Bahia:


Treatment of shoulder pain in spastic hemiplegia by reducing spasticity of the subscapular muscle: a randomised, double blind, placebo controlled study of botulinum toxin A

Alain P Yelnik, Florence M Colle, Isabelle V Bonan and Eric Vicaut

J. Neurol. Neurosurg. Psychiatry; originally published online 6 Nov 2006;

Pain and spastic shoulder are frequent in hemiplegia following a stroke. Shoulder pain is a major problem for these patients, interfering with physiotherapy, sleep and daily activities. It is usually due to local causes: algoneurodystrophy (shoulder–hand syndrome), capsulitis, glenohumeral subluxation and also spasticity because of the prolonged muscular contracture and possible tendinopathies. These causes can be associated, especially spasticity and algoneurodystrophy in severe hemiplegia, and patients exhibit the typical arm posture: adduction and medial rotation of the shoulder, and flexion of the elbow, wrist and finger. Different approaches are used for treatment of pain in such patients, depending on the mechanism involved. Oral medications for pain, as those for spasticity, are usually ineffective or insufficient. Treatment of algoneurodystrophy and capsulitis mainly consists of corticosteroids, systemic treatment being more effective than local administration. To treat spasticity or its consequences, transection of the subscapularis tendon or subcapularis nerve block has been reported, but these treatments are not in common use. Botulinum toxin A has been shown to be effective in reducing spasticity and increasing the passive range of motion of the spastic upper limb in hemiplegic patients with a real functional benefit. The effect of botulinum toxin A on shoulder pain after a stroke has not been systematically studied. However, improvement of pain by the toxin has been reported in a placebo controlled study, although pain was not the main objective of the study. A beneficial effect has also been observed in an open study. Other controlled studies in which upper limb pain was assessed failed to show a significant reduction in pain. No specific treatment of the spastic shoulder muscles has been studied. Suprasupinator and infrasupinator muscles are not involved in painful contracted shoulder, and among the muscles implicated in medial rotation, the subscapularis and pectoralis muscles undoubtedly play a major role, with apparent pre-eminence of the subscapularis muscle. In a recent study of three cases, injection of botulinum toxin A into the subscapularis muscle was shown to reduce pain and improve the passive range of motion. Based on these observations, we formed the hypothesis that shoulder pain occurring in patients with spastic hemiplegia, even with limited range of motion compatible with capsulitis, can be relieved by reducing the spasticity of the main medial rotator muscle (ie, the subscapularis muscle). Therefore, we conducted the present study to further assess the beneficial effect of injection of botulinum toxin A (Dysport) into the subscapularis muscle on shoulder pain. An improvement in the passive range of motion was expected as a parameter of the efficacy of botulinum toxin on spasticity and as a possible secondary benefit.

Study design and patients

The study was conducted according to a randomised, double blind, placebo controlled, parallel group design in hemiplegic patients of either sex presenting with upper limb spasticity related to cerebral stroke. Patients were included whatever the post-stroke stage. Spasticity was characterised by a score of at least 1+ on the Modified Ashworth Scale (MAS)20 for the medial rotators and elbow flexors, with limited range of passive motion of the shoulder: external rotation 10°or ,30°related to the opposite side. Patients gave written informed consent before entering the study. The following criteria excluded patients from selection: previous traumatic or neurological disease of the hemiplegic shoulder; retraction of at least one muscle of the elbow, wrist or fingers in the hemiplegic upper limb; previous treatment with botulinum toxin A or alcohol in the subscapularis muscle of the hemiplegic shoulder; neuromuscular disease such as myasthenia gravis; pregnant or lactating female patients; other common exclusion criteria for clinical trials. Concomitant treatment with drugs affecting muscle tone was allowed when initiated at least 2 weeks before inclusion, and without changes in the doses; it was then continued through the follow-up post-injection period without any change. Five patients (one in the toxin group, four in the placebo group) were previously treated with botulinum toxin A for upper (never in the shoulder muscles) or lower limb spasticity, always with Dysport, and at least 3 months ago. The study was conducted in accordance with the guidelines of the Declaration of Helsinki and prevailing amendments, and was formally approved by the Ethics Committee of Saint-Louis Hospital (Paris, France).


Treatment was allocated by computerised randomisation. Patients were seated on the edge of their bed, with the arm against the trunk, the shoulder being slightly pushed backward
by an assistant to produce as much winging of the scapula as possible. An 0.8 mm diameter, 100 mm needle coated with Teflon, except for the tip, was inserted in the medial scapular border, slightly below the level of the spine of the scapula, along its anterior face, pointing at the acromion, as previously described. Before the intramuscular injection, the needle was used as a stimulation electrode to detect the motor point here minimal stimulation induces maximum internal rotation, and then botulinum toxin A (Dysport, 500 Speywood units) or placebo (all constituents of Dysport solvent) was injected while pulling back the needle by 1–2 cm. In addition, all patients received after treatment, on weekdays—non-standardised physical therapy for stretching, spasticity inhibition and increasing active motion when possible.

Methods of assessment

Pain was assessed using a 10 point verbal scale or, for aphasic patients only (one in the placebo group, three in the toxin group), a visual analogue scale. Subscapularis muscle spasticity was assessed, with the patient sitting, by a range of motion inducing a strong resistance after slow stretching in passive lateral rotation and abduction measured in degrees. Assessment of the spasticity of the whole upper limb was carried out, with the patient sitting, using the MAS for shoulder medial rotators, elbow flexors, wrist flexors and fingers flexors. These assessments were carried out at baseline and at weeks 1, 2 and 4. In addition to the assessments of pain, consumption of analgesics at baseline and at week 4 was recorded. The change from baseline in pain associated with spasticity, as assessed by the patient, was calculated at each visit. The change in consumption of analgesics between baseline and week 4 was coded by the investigator as increased (increasing the dosage or changing to another analgesic), no change or decreased. The change in shoulder range of motion was assessed by the change from baseline in lateral rotation and in abduction values at week 1, week 2 and week 4 visits. Changes from baseline in MAS scores for each muscle group were calculated at each visit.

Statistical analyses

As the statistical distributions of the pain and range of motion parameters were a priori not Gaussian, non-parametric tests were used. As calculated according to the method of Noether, the population required to detect a difference in the distribution of values between the two groups with an 80% power and a two sided 5% confidence level was 24 patients (ie, 12 per group). Characteristics of the patients in the two groups at baseline were compared using exact 95% confidence intervals (CI). Covariance analyses adjusted on values at baseline were used to compare pain reduction and change in range of motion between the two groups at each visit.22 A x2 test was used for comparisons of differences in MAS scores.

Patient characteristics at baseline

Twenty patients, 10 in each group, were recruited and completed the study. This population fell short of the planned 24 patients because of the difficulty in recruitment, as explained in the discussion. The characteristics of the patients are shown in table 1. As determined from exact 95% CI, there were no statistically significant differences between groups for age or sex. The same was true for all parameters of disease history and for the time elapsed since cerebral stroke.


Clinical efficacy

Median pain scores and quartiles in the two treatment groups at baseline and at the post-treatment time points are summarised in table 2. There was no statistically significant difference in baseline pain scores between the two groups. As shown by the mean changes from baseline (fig 1), pain improvement was observed throughout the observation period following Dysport, while minimal post-treatment changes were observed after placebo administration. Pain improvement appeared as early as week 1 and was significantly different from baseline (4 points vs 1 point in the placebo group; p=0.025) at week 4. Consumption of analgesics in the Dysport group was unchanged in 5/6 patients and increased in only 1/6 patients. In the placebo group, it was unchanged in 2/5 patients and increased in 3/5 patients. However, the difference in consumption between the two groups was not statistically significant. Values for lateral rotation and abduction of the hemiplegic spastic shoulder are summarised by time point in table 2. Median baseline values for the two parameters were similar at baseline and showed wide individual variations. In the Dysport group, the amplitude of external rotation was improved as early as week 1, showing a change from a median of 0°at baseline to 10°. Change from baseline in external rotation became statistically significant compared with placebo at week 2 (p=0.05) and even more so at week 4 (p=0.018). Improvement in abduction was less marked and was not statistically significant compared with placebo (table 3). Compared with baseline MAS scores, there was a general decrease in the spasticity of the upper limb muscles, especially the elbow flexors, wrist flexors and finger flexors. However, differences in changes from baseline between the groups were statistically significant only for finger flexors at week 4: MAS score decreased by 2 points in 2/10 patients, by 1 point in 5/10 patients and did not change in 3/10 patients, whereas in the placebo group no change was observed in 8/10 patients and an increase of 1 point was observed in 1/10 patients (p=0.025). As time elapsed after stroke was different between the groups (although this was not significant), a post hoc analysis was conducted to confirm that the observed effect in the Dysport group was not caused by previous subscapularis muscle treatment in that group. However, it appeared that the longer the time after stroke, the better was the effect. Thus taking into account the time elapsed since the cerebral lesion, covariance analysis22 showed stronger statistical results, with pain being significantly reduced at week 2 (p=0.042) and at week 4 (p=0.007), and improvement in lateral rotation being significant at week 2 (p=0.019) and at week 4 (p=0.002).


During the 4 week study period, three patients of the Dysport group experienced treatment unrelated adverse events: moderate orchitis, mild influenza and vasovagal syncope. In the placebo group, one patient experienced severe injection pain  and pain thereafter, probably related to the injection process rather than to the placebo itself; another patient experienced somnolence.


Twenty patients were included in this randomised, double blind, placebo controlled study with the objective of assessing the efficacy of a single injection of botulinum toxin A into the subscapularis muscle to reduce pain associated with shoulder spasticity after stroke. The main finding was improvement in pain. A clinically significant improvement in passive lateral rotation was concurrently observed, resulting from a decrease in local spasticity. External rotation improved markedly, more than abduction, which is not surprising because the subscapularis muscle is a strong internal rotator with limited impact on abduction. At the same time as the improvement in shoulder pain and range of motion, spasticity of the upper limb muscles appeared to be reduced. The improvement was statistically significant for the finger flexors. This confirms clinical experience, suggesting that part of the spasticity of these muscles remote from the injection point is related to shoulder pain. Another interesting point is that, contrary to what would have been expected, the longer the time after stroke, the better were the results. This suggests that algoneurodystrophy and capsulitis, often associated with spasticity in severe hemiplegia but for which botulinum toxin is not a treatment, mainly occurred during the first months after the stroke, whereas pain remaining for longer was primarily caused by spasticity and thus could be treated by relieving spasticity with botulinum toxin A. The population size may have hindered the evaluation of the efficacy of botulinum toxin A on the range of motion of the spastic shoulder. Sample size estimation was 24 patients based on an expected large effect size. However, the difficulty in recruitment limited the study population to 20. This difficulty was mainly because of the impossibility, in the time frame of this study, to concurrently treat other spastic muscle groups, whichwas difficult to accept, as spasticity in hemiplegic patients is not usually limited to the shoulder. Despite the reduced population, the results retained a sufficient statistical power. The injection technique used was derived from that described for subscapular motor point block8 but patient position was modified, as previously proposed.18 In our experience, keeping the patient seated makes the injection easier, as the scapula is maintained separated from the thorax by an assistant standing in front of the patient and pushing back the shoulder. In this position, the subscapularis muscle is usually not difficult to find. The best response to electrostimulation is usually obtained between 6 and 8 cm from the edge of the scapula. Nevertheless, in the present study, one patient (on placebo) suffered severe pain on injection because of the conflict of the needle and the anterior face of the scapula. The reduction in pain by subscapular injection of botulinum toxin A, with a concurrent improvement in shoulder range of motion observed in the present study, confirms the role of spasticity in hemiplegic shoulder pain. Currently, the treatment of hemiplegic shoulder pain focuses on algoneurodystrophy or capsulitis, often considered the main causes of pain. Yet, the contribution of spasticity deserves to be systematically considered because pain is more frequent in spastic patients than in flaccid patients.1 4 The possible efficacy of triamcinolone injection to relieve pain supposedly related to capsulitis in hemiplegic patients with a limited range of motion, as reported by some authors,23 has not been confirmed in a randomised, placebo controlled trial.5 Moreover, our results confirm that the limited range of passive lateral rotation and limited abduction, the usual criteria of capsulitis, can be due to spasticity in hemiplegic patients. Surprisingly, the effect of botulinum toxin A in relieving pain of the shoulder or the upper limb after stroke has not been systematically studied. The present study is the first to focus specifically on pain related to spasticity in poststroke hemiplegic patients, with specific treatment of the shoulder muscles. Our results confirm those observed in three previously published cases.



Injection of botulinum toxin A (Dysport) into the subscapularis muscle appears to be of value in themanagement of shoulder pain in spastic hemiplegic patients. The results confirm the role of spasticity in post-stroke shoulder pain, which deserves to be systematically considered. However, injection of the subscapularis muscle only, as conducted here for medical research purposes, cannot be recommended. In the management of spasticity in hemiplegic stroke patients, treatment of all of the muscles involved has to be discussed while keeping in mind that, among them, the subscapularis muscle can be injected with success.

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Suspected Mechanisms in the Cause of Overuse Running Injuries: A Clinical Review

Reed Ferber, PhD, Alan Hreljac, PhD, and Karen D Kendall, MKin

Context: Various epidemiological studies have estimated that up to 70% of runners sustain an overuse running injury each year. Although few overuse running injuries have an established cause, more than 80% of running-related injuries occur at or below the knee, which suggests that some common mechanisms may be at work. The question then becomes, are there common mechanisms related to overuse running injuries?

Evidence Acquisition: Research studies were identified via the following electronic databases: MEDLINE, EMBASE PsycInfo, and CINAHL (1980–July 2008). Inclusion was based on evaluation of risk factors for overuse running injuries. Results: A majority of the risk factors that have been researched over the past few years can be generally categorized into 2 groups: atypical foot pronation mechanics and inadequate hip muscle stabilization.

Conclusion: Based on the review of literature, there is no definitive link between atypical foot mechanics and running injury mechanisms. The lack of normative data and a definition of typical foot structure has hampered progress. In contrast, a large and growing body of literature suggests that weakness of hip-stabilizing muscles leads to atypical lower extremity mechanics and increased forces within the lower extremity while running.

Although runners often sustain acute injuries such as ankle sprains and muscle strains, a majority of running injuries can be classified as cumulative micro-trauma injuries (ie, overuse injuries). Running is one of the most widespread activities during which overuse injuries of the lower extremity occur. Various epidemiological studies have estimated that anywhere from 27% to 70% of recreational and competitive distance runners sustain an overuse running injury during any 1-year period. The runners in these studies vary considerably in their running experience and training habits, but they generally run at least 20 to 30 km per week and have been running consistently for at least 1 to 3 years. The knee is the most common site of overuse running injuries, accounting for close to 50% of all injuries.  A recent systematic review and meta-analysis reported that the knee was the most common site of musculoskeletal injury for runners. According to a clinical study of more than 2000 injured runners, the most common knee condition is patellofemoral pain syndrome (PFPS), followed by iliotibial band syndrome (ITBS), meniscal injuries, and patellar tendinitis. Injuries to the foot, ankle, and lower leg—such as plantar fasciitis, Achilles tendinitis, and medial tibial stress syndrome (also known as shin splints)—account for almost 40% of the remaining injuries, whereas less than 20% of the running injuries occur superior to the knee. Although few overuse running injuries have an established cause more than 80% of these injuries occur at or below the knee, thus suggesting that some common mechanisms may be involved. The cause of these injuries is multifactorial and diverse and several identifiable factors may predict who is at risk.


For the purpose of this clinical review, research studies were identified via the following electronic databases: MEDLINE, EMBASE, PsycInfo, and CINAHL (1980–July 2008). Included studies were directly related to risk factors for overuse. The following keywords were used: running, injury, mechanics, and knee (resulting in 283 articles). Criteria for screening included  running injuries in long-distance runners,  a minimum of 20 km per week, (3) recreational or competitive runners but not elite, and epidemiology (prevalence, incidence) or etiology (determinants). Two reviewers categorized the studies to determine whether a majority identified common risk factors. As such, risk factors were generally categorized into 2 groups: atypical foot pronation mechanics and inadequate hip muscle stabilization.


Pronation is a combination of ankle dorsiflexion, rearfoot eversion, and forefoot abduction, and it occurs during the first half of the stance phase in running. Excessive rearfoot frontal plane motion (eversion) influences lower extremity mechanics via tibial rotation. During the first half of the stance phase, the calcaneus everts and the head of the talus internally rotates. The tibia internally rotates with the talus, owing to the tight articulation of the ankle joint mortise. In weightbearing activities such as running, there is a direct relationship between degree of pronation and internal tibial rotation (ie, for runners who exhibit a heel-toe footfall pattern). Pronation is a necessary and protective mechanism during running; it allows impact forces to be attenuated over a long period. Researchers have suggested that a higher level of pronation is favorable during running, if it falls within normal physiological limits and does not continue beyond midstance. After midstance, it is necessary for the foot to become more rigid and supinate in preparation of toe-off (ie, the tibia and talus externally rotate and the calcaneus inverts). As such, the rearfoot inverts and the tibia externally rotates. Severe overpronators, or runners who exhibit prolonged pronation, may be at an increased risk of injury because of the potentially large torques generated within the lower extremity and the subsequent increase in internal tibial rotation. Specifically, the tibialis posterior and soleus muscles function to minimize these torsional forces within the shank and ankle complex. If these forces are experienced within the knee or hip joints, then the hamstring and deep external rotator muscles must concomitantly contract to control the subsequent torsional forces, respectively. Excessive pronation, pronation velocity, and time to maximum pronation have often been implicated as contributing factors to overuse running injuries. In many studies, a static evaluation of pronation was conducted on injured runners, with the results suggesting that injured runners were more often overpronators when compared to uninjured runners. However, minimal and conflicting experimental evidence supports excessive foot pronation as a contributing factor in the cause of injuries. The majority of these studies were cross-sectional. One study partially supported the speculation regarding a cause-and-effect relationship between foot pronation and injury; it reported that groups of injured runners, when compared to a control group comprising uninjured runners, exhibited greater maximum pronation angles and had greater maximum pronation velocities. The results were evident in a group who had medial tibial stress syndrome. Viitasalo and Kvist reported similar results when comparing runners with medial tibial stress syndrome to an uninjured control group during barefoot running. However, contradictory results were found in a study in which runners who had never sustained an overuse injury exhibited greater pronation velocity and greater touchdown supination angle when compared to runners who had sustained an overuse injury. Messier et al compared runners with PFPS to an uninjured control group and found no differences in any rearfoot variables. Thus, the relationship between rearfoot position and running injury susceptibility is not clear given these retrospective cross-sectional design studies. Unfortunately, only 2 prospective studies have been conducted to investigate the link between foot mechanics and overuse injuries. Willems et al evaluated lower leg pain in a group of 400 physically active young individuals. Plantar pressure measurements and 3-dimensional rearfoot kinematic data were collected, and participants were followed for 1 academic year. Seventy-five injured runners were identified, and their data were compared to those of 167 noninjured runners. The injured runners exhibited significantly prolonged rearfoot pronation, increased medial foot pressure, and accelerated reinversion when compared to controls, thus suggesting that atypical foot pronation is a contributing factor in the cause of running-related injuries. In contrast, Thijs et al, using plantar pressure measurements, examined gait-related risk factors for patellofemoral pain in a group of 84 officer cadets over the course of a 6-week basic military training period. Thirty-six cadets developed patellofemoral pain and were therefore compared to the remaining 48. Compared with the control group, the injured group exhibited a supinated heel strike position and reduced pronation (greater lateral contact pressure). Thus, the only 2 prospective studies conducted to date provide conflicting results: one suggests that excessive foot pronation mechanics are related to injury development, whereas the other suggests that reduced foot pronation mechanics are the culprit. Based on these data and the contradictory results derived from the various retrospective cross-sectional studies outlined previously, no definitive answer can be put forth regarding potential running-related injury mechanisms and excessive foot pronation.


The range of physiological foot pronation has not been established. Several investigators have based selection of participants on relatively arbitrary criteria. Mündermann et alclassified 20 runners as overpronators on the basis of a 2- dimensional standing rearfoot-shank angle greater than 13° (see Figure 1). This value was based on work by Clarke et al, who averaged the maximum pronation angle from 9 studies conducted between 1978 and 1983. The average angle when running was 9.4° (± 3.5°), with a maximum pronation of 13° or greater labeled excessive.


Figure 1: Right, markings to bisect the long axis of the shank and rearfoot; left, goniometric measurement of standing rearfoot-shank angle (left foot shown).
McClay and Manal investigated lower extremity mechanics for a group of 20 recreational runners exhibiting normal rearfoot mechanics. Participants for this study were selected using a dynamic assessment of 2-dimensional peak rearfoot-shank angle between 8° and 15° while running on a treadmill. Cheung and Ng identified 22 overpronators on the basis of a dynamic 3-dimensional rearfoot angle greater than 6° while running. Genova and Gross classified 8 overpronators on the basis of a standing rearfoot-shank angle greater than 10°. Cornwall and McPoil reported a measure of 6.3° (± 4.0°) for static rearfoot-shank angle from 82 participants. Sobel et al reported a similar measure of 6.07° (± 2.71°) for 88 adults, whereas Kendall et al reported an average angle of 6.10° (± 2.58°) in 221 runners. Based on these large samples, a static rearfoot-shank angle of 6.00° (± 3.00°) could be considered normal and thus an appropriate measure for screening.
The ability to dynamically stabilize the lower extremity during running may play a role in the cause of running-related injuries. For example, the gluteus medius muscle eccentrically controls hip adduction during the stance phase of gait, and the posterolateral fibers assist in eccentric control of hip internal rotation. The deep external rotators of the hip (piriformis, quadratus femoris, etc) play a critical role in hip stabilization and primarily function to eccentrically control internal rotation of the hip during the stance phase of gait. Ireland et al investigated the hypothesis of reduced hip muscle strength as a contributor to injuries and reported that, when compared to matched controls, female PFPS patients demonstrated 26% less hip abductor and 36% less hip external rotator strength. In addition, runners with ITBS exhibited significantly weaker hip abductor muscle strength in the affected limb, when compared to the unaffected limb and to healthy controls. Ten patients with PFPS exhibited 27% less hip abduction and 30% less hip external rotation strength on the injured limb, when compared to the contralateral limbs and to controls. Injured runners also demonstrated significantly weaker hip abductor and hip flexor muscles, as compared to the noninjured limb and to the control group. Cichanowski et al reported significantly reduced hip abductor and external rotator muscle strength for a group of 13 PFPS patients, compared to the noninjured limbs and to controls. Finally, Kendall et al investigated the influence of proximal and distal clinical measures between 60 runners with PFPS and 52 who served as noninjured controls. As such, 90% of the patients in the PFPS group exhibited significantly reduced hip external rotator, abductor, and flexor strength. These studies suggest a relationship among hip muscle weakness, side-to-side strength imbalances, and running-related overuse injuries. Unfortunately, the relationship between hip mechanics and running-related injuries is not well understood. Noehren et al examined differences in hip mechanics between runners who had sustained ITBS and those who had no knee-related running injuries. Compared to the control group, the ITBS group exhibited a significantly greater peak hip adduction angle and significantly greater frontal plane knee joint moments. Weakness of the hip abductor muscles may result in greater hip adduction, which may necessitate greater passive restraint from the iliotibial band and so result in the greater frontal plane knee joint moments while running. In support of Noehren et al, Ferber et al retrospectively evaluated 35 runners with a history of ITBS, who demonstrated significantly greater peak knee internal rotation angle and peak hip adduction angle when compared to 35 controls. Several studies link common clinical variables, such as muscle strength, anatomical alignment, and the development of running-related injuries. Ferber et al compared differences in kinematic and kinetic patterns of the hip and knee in 20 male and female recreational runners. Compared to men, women exhibited significantly greater peak hip adduction angle and hip frontal plane negative work, which may be the result of a greater pelvis width–femoral length ratio in women. Female runners also demonstrated a significantly greater peak knee abduction angle and were in a more abducted knee position throughout stance. Malinzak et al showed that female runners exhibit a significantly greater knee abduction angle throughout the stance phase of running, greater peak hip adduction, and hip internal rotation angle. The combination of greater hip adduction and knee abduction may be related to greater genu valgum and increased Q angle in women. Fredericson et al reported on the importance of hip abductor strengthening for participants experiencing ITBS. After participating in a 6-week intervention, 22 of 24 runners experienced a significant decrease in pain and a 35% to 51% increase in hip abductor strength. At a 6-month follow-up, there were no reports of ITBS recurrence. Ferber and Kendall evaluated 284 consecutive patients with various musculoskeletal running injuries. Patients were asked to report the average amount of pain they were experiencing while running, using a 10-cm visual analogue scale. A rehabilitation program was prescribed to improve hip abductor, flexor, and external rotator muscle strength. After 4 to 6 weeks of rehabilitation, 165 patients (58%) returned for follow-up assessment, among whom 89% reported at least a 50% improvement in pain. These results suggest that a hip strengthening rehabilitation program can be effective. The current treatment of PFPS is usually not effective, and research has revealed that patients remain at risk for recurring bouts of pain. Nimon et al reported that 25% of PFPS patients continued to have significant knee pain over a 20-year period. Features were not identified that predicted which patients would not improve. Stathopulu and Baildam found that 91% of PFPS patients continued to exhibit varying intensity of daily symptoms, 45% experienced pain at 4- and 18-year follow-up, and 36% stated that the pain restricted their physical activities. A study of 250 PFPS patients, who were surveyed an average 5.7 years after initial treatment, showed that 73% still experienced knee pain, 35% saw no change in symptoms, and 13% experienced increased pain.


Various epidemiological studies have estimated that up to 70% of runners sustain an overuse running injury each year. The knee is the most common site, accounting for approximately 50% of all running injuries. Risk factors can be categorized into 2 groups: atypical foot pronation and inadequate hip muscle stabilization.

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