Effects of rehabilitation approaches for runners with patellofemoral pain: protocol of a randomised clinical trial addressing specific underlying mechanisms.
ABSTRACT: Patellofemoral pain (PFP) is highly prevalent in runners, and often leads to functional limitations and cessation of running. Training errors as well as decreased lower limb strength and control during running have all been associated with PFP. While strengthening and gait retraining are commonly used by clinicians, no randomised clinical trial has compared these modalities in runners with PFP. The primary objective of this randomised clinical trial will be to compare the effects of three rehabilitation programs targeting different key factors on symptoms and functional limitations of runners with PFP. The secondary objective will be to explore the factors leading to clinical improvement.We will conduct a single-blind randomised clinical trial to compare three different 8 week rehabilitation programs: Group 1 will receive education on symptoms management based on training modifications; Group 2 will receive an exercise program targeting lower limb strengthening and control in addition to the education component of Group 1; Group 3 will receive running gait retraining advice as well as the education component of Group 1. Sixty-nine runners with PFP will be recruited and will be seen by independent physiotherapists on five visits through 8 weeks. The primary outcome measure will be symptoms and functional limitations measured by the Knee Outcome Survey - Activities of Daily Living Scale questionnaire at baseline, and at the four, eight and 20 weeks follow-up. Secondary outcomes will include pain level measured using visual analog scales, and running mileage. Lower limb kinematics and kinetics during running, and isometric strength will also be evaluated at baseline and 8 weeks follow-up. The effects of rehabilitation programs on measures of symptoms and functional limitations will be assessed using a 2-way ANOVA (Groups x Time). Regression analyses will be used to identify if changes in running mechanics or strength are determinants of clinical success.Studies with a high level of evidence are needed to determine the best rehabilitation interventions for runners with PFP. This randomised clinical trial will be the first to compare programs targeting different key factors linked with PFP. Results may guide clinicians and improve their clinical outcomes when treating runners with PFP.ClinicalTrials.gov: NCT02352909. Registered on December 3, 2014.
Project description:BACKGROUND:Aberrant frontal-plane hip and pelvis kinematics have been frequently observed in runners with patellofemoral pain (PFP). Gait retaining interventions have been shown to improve running kinematics and may therefore be beneficial in runners with PFP. PURPOSE:To investigate whether a 10% increase in the running step rate influences frontal-plane kinematics of the hip and pelvis as well as clinical outcomes in runners with PFP. STUDY DESIGN:Case series; Level of evidence, 4. METHODS:Runners with PFP underwent a 3-dimensional gait analysis to confirm the presence of aberrant frontal-plane hip and/or pelvis kinematics at baseline. A total of 12 participants with frontal-plane hip and/or pelvis kinematics 1 standard deviation above a reference database were invited to undergo the gait retraining intervention. Running kinematics along with clinical outcomes of pain and functional outcomes were recorded at baseline, 4 weeks after retraining, and 3 months. Gait retraining consisted of a single session where step rate was increased by 10% using an audible metronome. Participants were asked to continue their normal running while self-monitoring their step rate using a global positioning system smartwatch and audible metronome. RESULTS:After gait retraining, significant improvements in running kinematics and clinical outcomes were observed at 4-week and 3-month follow-up. Repeated-measures analysis of variance with post hoc Bonferroni correction (P < .016) showed significant reductions in peak contralateral pelvic drop (mean difference [MD], 3.12° [95% CI, 1.88°-4.37°]), hip adduction (MD, 3.99° [95% CI, 2.01°-5.96°]), and knee flexion (MD, 4.09° [95% CI, 0.04°-8.15°]) as well as significant increases in self-reported weekly running volume (MD, 13.78 km [95% CI, 4.62-22.93 km]) and longest run pain-free (MD, 6.84 km [95% CI, 3.05-10.62 km]). Friedman test with a post hoc Wilcoxon signed-rank test showed significant improvements on a numerical rating scale for worst pain in the past week and the Lower Extremity Functional Scale. CONCLUSION:A single session of gait retraining using a 10% increase in step rate resulted in significant improvements in running kinematics, pain, and function in runners with PFP. These improvements were maintained at 3-month follow-up. It is important to assess for aberrant running kinematics at baseline to ensure that gait interventions are targeted appropriately. REGISTRATION:NCT03067545 (ClinicalTrials.gov identifier).
Project description:PURPOSE:The purpose of the present study was to describe the incidence proportion of different types of running-related injuries (RRI) among recreational runners and to determine their time to recovery. METHODS:A sub-analysis of the injured runners included in the 839-person, 24-week randomized trial named Run Clever. During follow-up, the participants reported levels of pain in different anatomical areas on a weekly basis. In case injured, runners attended a clinical examination at a physiotherapist, who provided a diagnosis, e.g., medial tibial stress syndrome (MTSS), Achilles tendinopathy (AT), patellofemoral pain (PFP), iliotibial band syndrome (ITBS) and plantar fasciopathy (PF). The diagnose-specific injury proportions (IP) and 95% confidence intervals (CI) were calculated using descriptive statistics. The time to recovery was defined as the time from the first registration of pain until total pain relief in the same anatomical area. It was reported as medians and interquartile range (IQR) if possible. RESULTS:A total of 140 runners were injured at least once leading to a 24-week cumulative injury proportion of 32% [95% CI: 26%; 37%]. The diagnoses with the highest incidence proportion were MTSS (IP = 16% [95% CI: 9.3%; 22.9%], AT (IP = 8.9% [95% CI: 3.6%; 14.2%], PFP (IP = 8% [95% CI: 3.0%; 13.1%]. The median time to recovery for all types of injuries was 56 days (IQR = 70 days). Diagnose-specific time-to-recoveries included 70 days (IQR = 89 days) for MTSS, 56 days (IQR = 165 days) for AT, 49 days (IQR = 63 days) for PFP. CONCLUSION:The most common running injuries among recreational runners were MTSS followed by AT, PFP, ITBS and PF. In total, 77 injured participants recovered their RRI and the median time to recovery for all types of injuries was 56 days and MTSS was the diagnosis with the longest median time to recovery, 70 days.
Project description:<h4>Background</h4>Excessive impact peak forces and vertical load rates are associated with running injuries and have been targeted in gait retraining studies. This study aimed to determine the effects of 12-week cadence retraining on impact peak, vertical load rates and lower extremity biomechanics during running.<h4>Methods</h4>Twenty-four healthy male recreational runners were randomised into either a 12-week cadence retraining group (<i>n</i> = 12), which included those who ran with a 7.5% increase in preferred cadence, or a control group (<i>n</i> = 12), which included those who ran without any changes in cadence. Kinematics and ground reaction forces were recorded simultaneously to quantify impact force variables and lower extremity kinematics and kinetics.<h4>Results</h4>Significantly decreased impact peak (1.86 ± 0.30 BW vs. 1.67 ± 0.27 BW, <i>P</i> = 0.003), vertical average load rates (91.59 ± 18.91 BW/s vs. 77.31 ± 15.12 BW/s, <i>P</i> = 0.001) and vertical instantaneous load rates (108.8 ± 24.5 BW/s vs. 92.8 ± 18.5 BW/s, <i>P</i> = 0.001) were observed in the cadence retraining group, while no significant differences were observed in the control group. Foot angles (18.27° ± 5.59° vs. 13.74° ± 2.82°, <i>P</i> = 0.003) and vertical velocities of the centre of gravity (CoG) (0.706 ± 0.115 m/s vs. 0.652 ± 0.091 m/s, <i>P</i> = 0.002) significantly decreased in the cadence retraining group at initial contact, but not in the control group. In addition, vertical excursions of the CoG (0.077 ± 0.01 m vs. 0.069 ± 0.008 m, <i>P</i> = 0.002) and peak knee flexion angles (38.6° ± 5.0° vs. 36.5° ± 5.5°, <i>P</i> < 0.001) significantly decreased whilst lower extremity stiffness significantly increased (34.34 ± 7.08 kN/m vs. 38.61 ± 6.51 kN/m, <i>P</i> = 0.048) in the cadence retraining group. However, no significant differences were observed for those variables in the control group.<h4>Conclusion</h4>Twelve-week cadence retraining significantly increased the cadence of the cadence retraining group by 5.7%. This increased cadence effectively reduced impact peak and vertical average/instantaneous load rates. Given the close relationship between impact force variables and running injuries, increasing the cadence as a retraining method may potentially reduce the risk of impact-related running injuries.
Project description:Determine if a change in internal knee abduction angular impulse (KAAI) is related to pain reduction for runners with patellofemoral pain (PFP) by comparing lateral and medial wedge insole interventions, and increased KAAI and decreased KAAI groups.Randomized controlled clinical trial (ClinicalTrials.gov ID# NCT01332110).Biomechanics laboratory and community.Thirty-six runners with physician-diagnosed PFP enrolled in the trial, and 27 were analyzed.Runners with PFP were randomly assigned to either an experimental 3 mm lateral wedge or control 6 mm medial wedge group. Participants completed a biomechanical gait analysis to quantify KAAIs with their assigned insole, and then used their assigned insole for six-weeks during their regular runs. Usual pain during running was measured at baseline and at six-week follow-up using a visual analog scale. Statistical tests were performed to identify differences between wedge types, differences between biomechanical response types (i.e. increase or decrease KAAI), as well as predictors of pain reduction.Percent change in KAAI relative to neutral, and % change in pain over six weeks.Clinically meaningful reductions in pain (>33%) were measured for both footwear groups; however, no significant differences between footwear groups were found (p = 0.697). When participants were regrouped based on KAAI change (i.e., increase or decrease), again, no significant differences in pain reduction were noted (p = 0.146). Interestingly, when evaluating absolute change in KAAI, a significant relationship between absolute % change in KAAI and % pain reduction was observed (R2 = 0.21; p = 0.030), after adjusting for baseline pain levels.The greater the absolute % change in KAAI during running, the greater the % reduction in pain over six weeks, regardless of wedge type, and whether KAAIs increased or decreased. Lateral and medial wedge insoles were similar in effectiveness for treatment of PFP.Altering KAAI should be a focus of future PFP research. Lateral wedges should be studied further as an alternative therapy to medial wedges for management of PFP.ClinicalTrials.gov NCT01332110.
Project description:<h4>Objective</h4>To determine profiles of urban runners based on socio-demographic, health, motivational, training characteristics and running-related beliefs and behaviours.<h4>Methods</h4>Mixed, exploratory, sequential study with two stages: 1) quantitative, using an online survey; and 2) qualitative, using semi-structured interviews with runners from the previous stage. Participants were recruited via: running routes commonly attended by runners, eight races, previous databases and social media networks. The survey collected information on six dimensions: (1) socio-demographic; (2) health; (3) motivations; (4) training characteristics; (5) running-related behaviour; and (6) beliefs and perceptions about health. Profiles were identified using a two-step hierarchical clustering analysis. Subsequently, 15 interviews were conducted with participating runners across each of the identified profiles. Qualitative analysis complemented the profiles characterization, explaining motivations to start and continue running, beliefs about risk factors and injury prevention, and the physical therapist's role in rehabilitation. Statistical analysis from stage one was conducted using SPSS 22 with a confidence level of 5%. Qualitative data were analysed using thematic and content analyses.<h4>Results</h4>A total of 821 surveys were analysed (46% female), mean aged 36.6±10.0 years. Cluster analysis delineated four profiles (n = 752) according to years of running experience, weekly running volume and hours of weekly training. Profiles were named "Beginner" (n = 163); "Basic" (n = 164); "Middle" (n = 160) and "Advanced" (n = 265). Profiles were statistically different according to sex, age, years of running experience, training characteristics, previous injuries and use of technological devices (p<0.05). There were identified motivations to start and continue running. Beliefs about risk factors vary among stretching, footwear, training surface and overload. Runners identified the physical therapist as a specialist, involved in the rehabilitation process and showing empathy towards the patient. The identification of these profiles allows the generation of future prospective studies and clinical trials to evaluate risk and prognostic factors targeting specific populations of runners, with the ultimate aim of reducing running-related injury.
Project description:Purpose:To explore the changes in knee sagittal angle and moment and patellofemoral joint (PFJ) force and stress before and after 12-week gait retraining. Methods:A total of 30 healthy male recreational runners were randomized into a control group (n = 15) who ran in their original strike pattern using minimalist shoes or experimental group (n = 15) who ran in a forefoot strike pattern using minimalist shoes during the 12-week gait retraining. The kinematic and kinetic data of the dominant leg of the participants during the 12?km/h running were collected by 3D motion capture systems and 3D force platforms. Besides, the biomechanical property of the PFJ was calculated on the basis of the joint force model and the regression equation of the contact area. Results:After the 12-week gait retraining, 78% of the rearfoot strikers turned into forefoot strikers. Peak knee extension moment and peak PFJ stress decreased by 13.8% and 13.3% without altering the running speed, respectively. Meanwhile, no changes in maximum knee flexion angle/extension moment and PFJ force/stress were observed for the control group. Conclusion:The 12-week gait retraining effectively reduced the PFJ stress, thereby providing a potential means of reducing the risk of patellofemoral pain syndrome while running.
Project description:Running practice could generate musculoskeletal adaptations that modify the body mechanics and generate different biomechanical patterns for individuals with distinct levels of experience. Therefore, the aim of this study was to investigate whether foot-ankle kinetic and kinematic patterns can be used to discriminate different levels of experience in running practice of recreational runners using a machine learning approach. Seventy-eight long-distance runners (40.7 ± 7.0 years) were classified into less experienced (n = 24), moderately experienced (n = 23), or experienced (n = 31) runners using a fuzzy classification system, based on training frequency, volume, competitions and practice time. Three-dimensional kinematics of the foot-ankle and ground reaction forces (GRF) were acquired while the subjects ran on an instrumented treadmill at a self-selected speed (9.5-10.5 km/h). The foot-ankle kinematic and kinetic time series underwent a principal component analysis for data reduction, and combined with the discrete GRF variables to serve as inputs in a support vector machine (SVM), to determine if the groups could be distinguished between them in a one-vs.-all approach. The SVM models successfully classified all experience groups with significant crossvalidated accuracy rates and strong to very strong Matthew's correlation coefficients, based on features from the input data. Overall, foot mechanics was different according to running experience level. The main distinguishing kinematic factors for the less experienced group were a greater dorsiflexion of the first metatarsophalangeal joint and a larger plantarflexion angles between the calcaneus and metatarsals, whereas the experienced runners displayed the opposite pattern for the same joints. As for the moderately experienced runners, although they were successfully classified, they did not present a visually identifiable running pattern, and seem to be an intermediate group between the less and more experienced runners. The results of this study have the potential to assist the development of training programs targeting improvement in performance and rehabilitation protocols for preventing injuries.
Project description:Overall performance, particularly in a very popular sports activity such as running, is typically influenced by the status of the musculoskeletal system and the level of training and conditioning of the biological structures. Any change in the musculoskeletal system's biomechanics, especially in the feet and ankles, will strongly influence the biomechanics of runners, possibly predisposing them to injuries. A thorough understanding of the effects of a therapeutic approach focused on feet biomechanics, on strength and functionality of lower limb muscles will contribute to the adoption of more effective therapeutic and preventive strategies for runners.A randomized, prospective controlled and parallel trial with blind assessment is designed to study the effects of a "ground-up" therapeutic approach focused on the foot-ankle complex as it relates to the incidence of running-related injuries in the lower limbs. One hundred and eleven (111) healthy long-distance runners will be randomly assigned to either a control (CG) or intervention (IG) group. IG runners will participate in a therapeutic exercise protocol for the foot-ankle for 8 weeks, with 1 directly supervised session and 3 remotely supervised sessions per week. After the 8-week period, IG runners will keep exercising for the remaining 10 months of the study, supervised only by web-enabled software three times a week. At baseline, 2 months, 4 months and 12 months, all runners will be assessed for running-related injuries (primary outcome), time for the occurrence of the first injury, foot health and functionality, muscle trophism, intrinsic foot muscle strength, dynamic foot arch strain and lower-limb biomechanics during walking and running (secondary outcomes).This is the first randomized clinical trial protocol to assess the effect of an exercise protocol that was designed specifically for the foot-and-ankle complex on running-related injuries to the lower limbs of long-distance runners. We intend to show that the proposed protocol is an innovative and effective approach to decreasing the incidence of injuries. We also expect a lengthening in the time of occurrence of the first injury, an improvement in foot function, an increase in foot muscle mass and strength and beneficial biomechanical changes while running and walking after a year of exercising.Clinicaltrials.gov Identifier NCT02306148 (November 28, 2014) under the name "Effects of Foot Strengthening on the Prevalence of Injuries in Long Distance Runners". Committee of Ethics in Research of the School of Medicine of the University of Sao Paulo (18/03/2015, Protocol # 031/15).
Project description:Many patients with primary brain tumors experience cognitive deficits. Cognitive rehabilitation programs focus on alleviating these deficits, but availability of such programs is limited. Our large randomized controlled trial (RCT) demonstrated positive effects of the cognitive rehabilitation program developed by our group. We converted the program into the iPad-based cognitive rehabilitation program ReMind, to increase its accessibility. The app incorporates psychoeducation, strategy training and retraining. This pilot study in patients with primary brain tumors evaluates the feasibility of the use of the ReMind-app in a clinical (research) setting in terms of accrual, attrition, adherence and patient satisfaction. The intervention commenced 3 months after resective surgery and patients were advised to spend 3 h per week on the program for 10 weeks. Of 28 eligible patients, 15 patients with presumed low-grade glioma or meningioma provided informed consent. Most important reason for decline was that patients (7) experienced no cognitive complaints. Participants completed on average 71% of the strategy training and 76% of the retraining. Some patients evaluated the retraining as too easy. Overall, 85% of the patients evaluated the intervention as "good" or "excellent". All patients indicated that they would recommend the program to other patients with brain tumors. The ReMind-app is the first evidence-based cognitive telerehabilitation program for adult patients with brain tumors and this pilot study suggests that postoperative cognitive rehabilitation via this app is feasible. Based on patients' feedback, we have expanded the retraining with more difficult exercises. We will evaluate the efficacy of ReMind in an RCT.
Project description:AbstractThis is a protocol for a Cochrane Review (Intervention). The objectives are as follows:To assess the effects (benefits and harms) of running shoes for preventing lower?limb running injuries in adult runners.