Effect of Proximal Stabilization on Recruitment of the Core &amp; Vasti in Patients with Patellofemoral Arthritis as They Descend Stairs: A Randomized Controlled Trial

doi:10.21203/rs.3.rs-4808004/v1

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Effect of Proximal Stabilization on Recruitment of the Core & Vasti in Patients with Patellofemoral Arthritis as They Descend Stairs: A Randomized Controlled Trial

https://doi.org/10.21203/rs.3.rs-4808004/v1

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Background: ‘‘The well-trained core is essential for optimal performance and injury prevention.’’ Despite the recurrence with which this statement is used in exercise science literature, the evidence to support it is lacking, contradictory, or taken out of context. This quadruple-blinded, randomised controlled trial examined the impact of proximal stabilization training program on kinesiophobia, and the recruitment of the core and vasti during stair descent in isolated patellofemoral osteoarthritis (PF OA).

Methods: Fifty females with PF OA were enlisted, and two groups, group A (n=25) and group B (n=25), were randomly assigned. Both groups of patients underwent standard physical therapy procedures, but group (B) also underwent additional proximal stabilization exercises. Prior to and after therapy, all patients had their kinesiophobia, and recruitment techniques assessed. During stair descent, quantitative electromyography was used to quantify the muscle recruitment methods (onset and duration) of the vastus medialis obliques (VMO), vastus lateralis (VL), transversus abdominus (TrA), gluteus Medius (GM), and multifidus.

Results: Among all tested dependent variables in this study, results were positive for kinesiophobia and Gluteus Medius onset in the proximal stabilization group post treatment compared to the pre-treatment state but comparing the tested variables between both groups revealed only positive findings for kinisiophobia in favor of the proximal stabilization group. Conclusion: adding proximal stabilization exercises to hip and quadriceps strengthening exercises might have a surplus effect in the management of isolated patellofemoral osteoarthritis, yet its long-term effect should be tested through future studies.

Trial registration: clinical trial registration code: NCT05597670

PF OA

proximal stabilization

Electromyography

kinesiophobia

The patellofemoral (PF) and tibiofemoral (TF) joints are both affected by osteoarthritis (OA) of the knee, although the tibiofemoral joint has received most of the attention in OA studies (1). PF OA is a substantial risk factor for the development of generalised knee OA (2–4) and at least 25% of population-based cohorts are impacted by it (5–7).

Structural and functional factors that alter joint loads can cause patellofemoral joint (PFJ) stress, resulting in discomfort and gradual joint deterioration(8). Mixtures of distal (ankle and foot), local (tibiofemoral and patellofemoral), and proximal (lumbo-pelvic-hip complex) variables are among the anatomical and functional factors increasing PFJ stress (9). The assumption underpinning the majority of PF OA treatment strategies is that it comes from aberrant patellar tracking, so they focus on quadriceps strengthening, patellar bracing and patellar taping. Over the last decade, there was a trend to pay attention to proximal factors leading to PF dysfunction based on the notion that co-contraction between transversus abdominis (TrA) and multifidus muscles controls excessive anterior pelvic tilt(10) which is associated with excessive femoral internal rotation and adduction causing dynamic knee valgus leading to increasing lateral patellar tilt. Thus, increasing pain at PFJ (11).

Most of the previous research have been performed to determine whether increasing the endurance of proximal stabilizers (lumbo-pelvic-hip complex) would improve rehabilitation outcomes for patients with patellofemoral pain (PFP) (12–15). In isolated patellofemoral osteoarthritis, there is a dearth of randomised clinical trials on the effectiveness of a lower limb muscle strengthening programme (16), but up to our knowledge, how proximal stabilization affects individuals with PF OA was examined in only one pilot study and it documented the importance of proximal stabilization exercises for this cohort (17) and a previous research suggested using electromyography (EMG) in assessing recruitment pattern of lumbo-pelvic-hip complex muscles for more objective results (13) and identifying the precise mechanism through which these exercises achieve improvement. Surface EMG data can be obtained during static postures or dynamic movements (18). However, measuring muscle activity during functional tasks reveals information regarding adaptive changes (19). Stair descent results in the highest patellofemoral load (20), which aggravates anterior knee pain (21).

There is mounting evidence that chronic musculoskeletal diseases elicit pain, and fear of motion known as kinesiophobia (22–24) and due to the chronic nature of patellofemoral osteoarthritis, kinesiophobia should be considered, but there is a dearth in literature on the impact of a proximal stabilization exercise routine on kinesiophobia in this cohort. As a result, it is worth investigating whether a proximal stabilization program can help restore proper temporal muscle activation along with kinesiophobia.

Therefore, this quadruple blinded randomized controlled trial aimed to investigate the effect of a 6-week proximal stabilization exercise program in females with isolated patellofemoral osteoarthritis. The hypotheses in this study were that; (a) proximal stabilization exercise will have a significant positive effect on kinesiophobia. (b) proximal stabilization exercise won’t have a substantial positive effect on recruitment strategies (onset and duration) of vasti, GM (Gluteus Medius), TrA (transversus abdominus), and multifidus during stair descent.

Design

This quadruple blinded, parallel arm, randomized controlled trial included 2 evaluation sessions (baseline, and post-treatment) and a six-week intervention (traditional knee rehabilitation program, or proximal stabilization added to the traditional program). The outcome measures were the kinesiophobia quantified using Tampa scale, and recruitment strategies of vasti, GM, TrA, and multifidus during stair descent measured by surface electromyography.

Participants

Of 153 females screened from Outpatient clinics of Kasr Alainy Medical School at Cairo University, the study's inclusion criteria were not met by 103 females; thus, they were excluded from participating in the trial while the study's details and objectives were explained to the fifty volunteers who met the criteria, and they consented to participate. After obtaining their written consent, they were randomized in a 1:1 ratio into one of two equal treatment groups; traditional knee rehabilitation group (the control group A) or proximal stabilization added to the traditional program (the experimental group B) by the physical therapist responsible for applying the allocated treatments through lottery. To do that, fifty pieces of paper were put into a box; half of them were labeled as (A) and the other half were labeled as (B). Each patient was asked to pick one piece of paper to know which group she would be assigned to. The enrolled participants were omitted from knowing whether the group to which they were randomized was the experimental or the control. This allocation was also concealed from the researchers involved in collecting data from patients pre and post treatment, Matlab analysis, and statistical analysis which made this trial a quadruple blinded trial.

Before undertaking this trial, ethical approval (No. P.T.REC/012/003438) was acquired from the Institutional Review Board of the Faculty of Physical Therapy of Cairo University, then it was registered prospectively (NCT05597670) at clinicaltrials.gov. The study was carried out between November 2022 and June 2024.

Eligibility Criteria

Females between 35 and 55 years old (25) with PF OA and body mass index below 32 were included if they experienced anterior or retro-patellar knee pain on most days during the previous month and rated at least four and over on the eleven-point numerical rating scale (NRS) during at least 2 activities that load the PFJ including stair negotiation, rising from a chair, and squatting (26). According to the Kellgren-Lawrence OA grading system, patients must have radiographic signs of PF osteoarthritis with a grade of less than 2 from the postero-anterior views to exclude any concomitant tibiofemoral arthritis (27).

Exclusion criteria included people who exercised more than 2 hours per day or every other day, those who experienced at least a three-month pain in lumbar spine, foot, or hip that needed treatment, those with a history of fractures or surgeries in lower limbs, spine, pelvis, hip, knee, or foot, those with a hip or patellar subluxation or dislocation, those with an injury to the meniscus or any of the supporting knee ligaments, those with fibromyalgia, or neurological conditions (8).

Assessment

All participants' baseline demographic data, including age, duration of illness, and body mass index (BMI), were collected before the EMG measurements.

Outcome Measures

The following variables were collected from all patients:

Kinesiophobia measured by the Arabic version of Tampa scale (28) which includes seventeen questions (29) and the response for each question ranges from 1 which is equivalent to strongly disagree to 4 which is equivalent to strongly agree and in order to calculate the overall score, the responses are combined together (24). The overall score ranges from 17 to 68 with 17, and 68 inferring no kinesiophobia, and severe kinesiophobia, respectively (24).
The recruitment strategies (onset and duration) of vasti, GM, TrA, and multifidus during stair descent. First, the activation of these muscles was measured using an eight-channel, high resolution wireless bio amplifier (WBA) surface electromyography from Biomation in Almonte, Canada. The recorded EMG data were sampled at 1000 Hz and an EMG amplifier (band-pass filtered between 50 and 200 Hz) was adjusted to optimize signal resolution. Thereafter, the sampled amplified data were stored in a personal laptop to detect the activation onset and duration by Matlab analysis.

Procedures For EMG Measurement and analysis

The subject's skin was cleansed with alcohol prior to the electrode implantation to lower impedance, and extra hair was shaved to prevent sliding of the electrodes if necessary. Three disposable bipolar Ag-AgCl surface electrodes (Better signal solution medical supply Co., limited, Zhongshan, China) were applied to each muscle; two electrodes were spaced roughly 30 mm apart in the direction of the muscle fibres (30), and the third electrode was applied over the nearest bony prominence as a ground electrode. Electrodes were installed for the multifidus muscle 2 cm laterally to the L5 spinous process (30, 31), whereas the electrodes were positioned 2 cm medial and inferior to anterior superior iliac spine for TrA, but this electrode placement to assess the transversus abdominus also depicts the activity of the internal obliques (IOs), because the two muscles cannot be distinguished functionally or anatomically using the surface EMG approach (32). Electrodes were positioned over the GM's muscle belly at a distance of one-third between both the iliac crest and greater trochanter (30). Approximately 5 cm medial to a location that is 25% of the distance between the superior portion of the patella to the anterior superior iliac spine is where electrodes for the vastus medialis obliques (VMO) were placed, while the electrodes were placed for the vastus lateralis (VL) lateral to the rectus femoris, midway between the lateral femoral epicondyle and greater trochanter (33).

The patients were instructed to descend 2 steps without handrails (each step measured 20 cm in height and 40 cm in breadth. First and second stairs were 30 cm and 40 cm deep, respectively) with their most painful limb (34) at their normal speed (35, 36) in response to a command barefooted with one foot on each step and they should keep their arms by their side all over the task. Each patient was instructed to perform one practice attempt of stair descent to be familiar with the test procedures before starting the actual data collection, then for data acquisition, each patient performed three attempts of the task they already became accustomed with, and they were given a break of thirty seconds after each attempt to avoid fatigue. The mean value of the data in the three attempts was used in further analysis.

All EMG data were processed by a custom software in Matlab (Math Works, Natick, Massachusetts, USA). For that, data were full wave rectified, then high-pass filtered using a fourth-order Butterworth filter (75 KHz). A computer algorithm was used to determine the onset and cessation of the EMG activity. Three hundred milliseconds before the beginning of each attempt were used to identify the baseline activation of muscles in standing. The point at which the EMG signal surpassed (for onset) or dropped below (for cessation) 3 standard deviations (SDs) of baseline for a minimum of 25 milliseconds was determined to be the threshold for muscle activity onset and cessation (37), then the duration of muscular activity was identified as the time from activation onset to cessation (38).

Treatment regime implemented for both groups.

Females in both groups whether the control or the experimental group received a multimodal regime in the form of exercises to stretch the calf, quadriceps, and hamstrings, transcutaneous electrical nerve stimulation (TENS) using two adhesive electrodes applied around the painful patella, not to mention clamshell exercise and mini squat used to strengthen muscles around hip and knee (39). The physical therapist responsible for applying the treatment regime (J.A.) used a universal goniometer to restrict patients from flexing their knees beyond 45^o while performing the mini squat exercise. Moreover, to execute the progressive resistance concept while performing the mini squat and clamshell exercises, the ten-repetition maximum was measured at fixed time intervals for each individual patient; the first, the 5th, and the 9th treatment sessions using color code elastic bands. The exercise was executed for a total of three sets of ten repetitions, with a one-minute rest interval between sets.

Protocol implemented to boost core stability.

Females randomly assigned to the experimental group received additional exercises that focused on activating the transversus abdominus, multifidus, and the abdominal oblique muscles to boost core stability. we substituted a more intense exercise for a less intense one according to the ability of the subject to hold and repeat the less intense exercise for a definite number of times.

Exercises that focused primarily on activating TrA arranged from the less intense to the more intense are 8-seconds hold abdominal drawing in maneuver repeated 30 times, 4-seconds hold abdominal drawing in maneuver with heel slide repeated 20 times for each leg, 4-seconds hold abdominal drawing in maneuver with leg lifts repeated 20 times for each leg, 8-seconds hold abdominal drawing in maneuver with bridging repeated 30 times, 6-seconds hold standing abdominal drawing in maneuver with row exercise repeated 30 times, and abdominal drawing in maneuver while walking (40).

Exercises that focused primarily on activating multifidus arranged from the less intense to the more intense are 8-seconds hold abdominal drawing in maneuver with quadruped arm lifts repeated 30 times on each side, 8-seconds hold abdominal drawing in maneuver with quadruped leg lifts repeated 30 times on each side, and 8-seconds hold abdominal drawing in maneuver with quadruped contralateral arm and leg lifts repeated 30 times on each side (40).

Exercises that focused primarily on activating abdominal oblique muscles arranged from the less intense to the more intense are 8-seconds hold abdominal drawing in maneuver with flexed knees-side plank repeated 30 times on each side, and 8-seconds hold abdominal drawing in maneuver with extended knees-side plank repeated 30 times on each side (40).

Statistical Analysis

A pilot study was conducted, including five participants in each group to predict the size of the needed sample. The sample size for this study was calculated using the G*power program 3.1.9 (G power program version 3.1, Heinrich-Heine-University, Düsseldorf, Germany). Sample size calculation based on F tests (MANOVA: Global effects), Type I error (α) = 0.05, power (1-α error probability) = 0.90, and effect size f2 (V) = 0.92 with 2 independent groups comparison for 11 major variable outcomes. The appropriate minimum sample size for this study was 36 participants (18 participants in each group as a minimum).

Statistical analysis for all reported data was performed using the 23-version of SPSS (Statistical Package for Social Sciences) for windows (SPSS, Inc., Chicago, IL). The EMG onset and duration of the VL, VMO, TrA, gluteus Medius, and multifidus muscles during stair descent, and kinesiophobia were among the eleven dependent variables in this study, while two independent variables were involved; The first one was the tested group which had two levels (Control group A received a traditional therapeutic knee rehabilitation program and experimental group B received additional proximal stabilization exercises) and the second one was the measuring periods which had two levels (pre-treatment, post-treatment). The 2x2 mixed design MANOVA (multivariate analysis of variance) was performed to compare the mean values of the 11 independent variables between patients in the control group and study group. The baseline demographic and clinical characteristics (age, duration of illness, and BMI) between patients in the control and study groups were compared using an independent t-test. The statistically significant level was defined as p < 0.05.

From November 2022 to June 2024, fifty participants were enrolled and received each treatment according to the treatment schedule without any dropout (Fig. 1). Patients in the control group (A) and the experimental group (B) showed no statistically significant difference in the mean values of any baseline clinical and demographic characteristics (age, duration of illness, and BMI), as the probability level was higher than the level of significance established for this investigation (Table 1).

The 2x2 mixed design MANOVA indicated non-significant effects of the tested group on the eleven tested dependent variables (F = 1.511, p = 0.211, Partial Eta square = 0.48). On the other hand, there were significant effects of the measuring periods on the twelve tested dependent variables (F = 4.668, p = 0.002, Partial Eta square = 0.74). Additionally, the interaction between the two independent variables was non-significant, which indicates that the effect of the tested group on the dependant variables was not influenced by the measuring periods (F = 1.998, p = 0.093, Partial Eta square = 0.55 ). Tables 2 and 3 present the descriptive statistic and the comparison tests for the eleven tested dependant variables, respectively.

Considering the effect of the measuring periods on the eleven tested dependant variables, post hoc tests conducted within the experimental group (B) revealed non-significant differences in the mean values of all tested dependant variables (P > 0.05) except kinesiophobia, and the EMG onset of GM muscle as they showed significant earlier activation of GM, and improvement of kinesiophobia post-treatment compared to pre-treatment (P < 0.05), whereas post hoc tests conducted within the control group (A) showed significant long activation duration of VL and short activation duration of GM muscle post-treatment compared to pre-treatment (P < 0.05). (Table 3).

Considering the effect of the tested group on the eleven tested dependant variables, post hoc tests yielded non-significant differences in the post-treatment mean values of the tested dependant variables between both groups except for kinesiophobia which indicated significant improvement (P = 0.001) (Table 3).

Table 1: The Baseline demographics of the enrolled patients

Table 1

The Baseline demographics of the enrolled patients
	Group (A) (n = 25)	Group (B) (n = 25)	p-value
Age (years)	46.10 ± 5.90	45.40 ± 6.60	0.78
Body mass(kg)	77.4 ± 7.83	78.16 ± 8.55	0.745
Height (cm)	166.92 ± 8.42	166.12 ± 7.59	0.726
BMI (Kg/m²)	27.8 ± 2.3	28.32 ± 2.54	0.451
Duration of Illness (years)	3.5 ± 1.92	4.3 ± 1.60	0.531

Data were expressed as mean ± SD. P-value, probability value. The statistically significant level was defined as p < 0.0

Table 2

Descriptive statistics for the eleven dependent variables pre-treatment and post-treatment.
Variables	Group A		Group B
Variables	Pre	Post	Pre	Post
Multifidus onset	1.48 ± 0.68	1.55 ± 0.66	1.85 ± 0.80	1.73 ± 0.43
Multifidus duration	0.26 ± 0.24	0.28 ± 0.19	0.24 ± 0.18	0.25 ± 0.18
TrA onset	1.31 ± 0.53	1.16 ± 0.69	1.65 ± 0.73	1.39 ± 0.48
TrA duration	0.23 ± 0.29	0.40 ± 0.30	0.24 ± 0.23	0.36 ± 0.31
GM onset	1.70 ± 0.39	1.47 ± 0.50	2.07 ± 0.78	1.48 ± 0.45
GM duration	0.44 ± 0.35	0.19 ± 0.18	0.26 ± 0.19	0.33 ± 0.25
VMO onset	1.56 ± 0.39	1.69 ± 0.37	1.99 ± 0.62	1.93 ± 0.38
VMO duration	0.24 ± 0.16	0.36 ± 0.30	0.33 ± 0.21	0.27 ± 0.18
VL onset	1.08 ± 0.74	1.62 ± 0.56	1.77 ± 1.00	1.49 ± 0.75
VL duration	0.22 ± 0.25	0.45 ± 0.32	0.30 ± 0.26	0.28 ± 0.15
Kinesiophobia	51 ± 4.98	47.69 ± 3.32	48.94 ± 5.29	41.58 ± 5.07

Data were expressed as mean ± SD. VMO, vastus medialis obliques. VL, vastus lateralis. GM, gluteus Medius. TrA, transversus abdominus.

Table 3

Comparison tests for the 11 tested dependent variables at both groups.
Variables	Within group (pre vs post)		Between groups (Group A vs. Group B)
Variables	Group A	Group B	Pre	Post
Multifidus onset	P = 0.686	P = 0.44	P = 0.193	P = 0.394
Multifidus duration	P = 0.782	P = 0.86	P = 0.743	P = 0.631
TrA onset	P = 0.569	P = 0.244	P = 0.17	P = 0.306
TrA duration	P = 0.139	P = 0.205	P = 0.893	P = 0.791
GM onset	P = 0.277	P = 0.004*	P = 0.135	P = 0.937
GM duration	P = 0.012*	P = 0.401	P = 0.08	P = 0.147
VMO onset	P = 0.393	P = 0.638	P = 0.051	P = 0.102
VMO duration	P = 0.175	P = 0.463	P = 0.187	P = 0.366
VL onset	P = 0.082	P = 0.293	P = 0.051	P = 0.606
VL duration	P = 0.016*	P = 0.813	P = 0.426	P = 0.061
Kinesiophobia	P = 0.098	P = 0.0001*	P = 0.289	P = 0.001*

P, Probability value. VMO, vastus medialis obliques. VL, vastus lateralis. GM, gluteus Medius. TrA, transversus abdominus. The statistically significant level was defined as p < 0.05.

This quadruple blinded randomized controlled trial showed that among all tested dependent variables in this study, results were positive for kinesiophobia and Gluteus Medius onset in the proximal stabilization group post treatment compared to the pre-treatment state but comparing the tested variables between both groups revealed only positive findings for kinisiophobia in favor of the proximal stabilization group.

In line with our initial hypothesis, patients who underwent additional proximal stabilization exercises experienced a significant reduction in kinesiophobia post treatment compared to pretreatment and even when compared with those who received a traditional program only. This could be because proximal stabilization exercises focus on neutralizing the spinal posture, activating the deep multifidus and TrA muscles while minimizing superficial muscle activity, and employing activities of low load that enhance muscle coordination (41) and according to a previous study, there was a positive correlation between trunk stiffness and kinesiophobia in patients with low back pain (42). A recent systematic review investigated interventions that might address kinesiophobia in patients with anterior knee pain whether they were specifically targeting kinesiophobia (e.g., cognitive behavior therapy) or not (43), but proximal stabilization exercises were not among of them and to our knowledge there is a dearth of literature in this regard thus it should be addressed in future studies.

In this study, it was hypothesized that proximal stabilization exercises will not have a significant positive effect on EMG onset and duration of VMO (Vastus Medialis Obliques), VL (Vastus Lateralis), GM, TrA, and multifidus during stair descent. Our results were in line with the tested hypothesis except for the activation onset of gluteus Medius, as proximal stabilization did not significantly affect any of the other tested variables but resulted in significantly earlier activation of gluteus Medius post treatment compared to the pretreatment state. According to previous research, a change of 5.5 points on the Tampa Scale is required to define a clinically meaningful difference (44) and as long as the Tampa scale in our study showed a 7.36-point reduction in kinesiophobia post the 6-week proximal stabilization exercise program, it might be the premise behind the earlier onset of gluteus Medius during stair descent. In addition, the proximal stabilization program used in this study included gluteal bridge exercises and a previous observational study considered gluteal bridges the optimal for enhancing gluteal Medius muscle (45). Hence, it could be another explanation for this finding.

It is worth noting that patients in group (A) who performed the traditional program without proximal stabilization exercises displayed significant longer activation duration of GM and shorter activation duration of VL muscle post treatment compared to pretreatment which we consider unfavorable result as the shorter activation duration of GM muscle which reflects lack of control over this important proximal stabilizer might lead to increased dynamic knee valgus leading to increased lateral patellar tracking which might be the reason behind longer activation duration of VL muscle. A future study that integrates kinematic analysis with EMG measurements is needed to confirm this assumption.

Comparing EMG onset and duration of vasti, GM, TrA, and multifidus during stair descent between the proximal stabilization group and the other group received traditional exercise program yielded a non-significant difference. To our knowledge, only one case report investigated if a two-week proximal stabilization exercise program would alter the amplitude of rectus abdominus muscle, erector spinae, rectus femoris, and vastus lateralis during walking in a 47-year-old-male with grade IV knee osteoarthritis and found greater amplitude for the rectus abdominus and erector spinae muscles and lesser amplitude for rectus femoris and vastus lateralis muscles (46) and as long as the functional task and the cohort are different from those used in our study, it would be inappropriate to compare their findings with ours.

There are some important limitations that should be addressed since they could have contributed to the study's non-significant findings: First, patients were included in the trial if they had a minimum of one month of pain chronicity; however, upper bounds for pain chronicity were not set. Another limitation of this study was the short duration of the intervention (twelve sessions) and missing follow up. Additionally, A placebo-controlled group was not enrolled in this study. Moreover, the results of this study should not be extrapolated to other populations suffering from anterior knee pain as males, athletes, and younger patients with patellofemoral pain syndrome. Furthermore, we were unable to acquire kinematic data because the laboratory we worked in lacked a motion analysis system. Lastly, we did not investigate bilateral transversus abdominus and multifidus responses or muscle activity amplitude. We can determine spinal stability through bilateral muscle activation as the micromotion of the lumbar vertebrae might be minimized if the onset and amplitude of trunk muscles (TrA and multifidus) on the affected side are similar to their counterparts on the other side (47).

Adding proximal stabilization exercises to the traditional program implemented for PF OA resulted in significant reduction in kinesiophobia compared to the traditional program alone after six weeks of treatment in females with PF OA, but future studies are needed to investigate the long-term effect of proximal stabilization exercise program on this cohort and whether there is a correlation between kinesiophobia and recruitment strategies of TrA, multifidus, GM, VMO, and VL during stair descent.

PF OA patellofemoral osteoarthritis

VMO vastus medialis obliques

VL vastus lateralis

GM gluteus Medius

TrA transversus abdominus

PF patellofemoral

TF tibiofemoral

OA osteoarthritis

PFJ patellofemoral joint

PFP patellofemoral pain syndrome

EMG electromyography

NRS numerical rating scale

BMI body mass index

WBA wireless bio amplifier

MANOVA multivariate analysis of variance

IOs internal obliques

TENS transcutaneous electrical nerve stimulation

SPSS Statistical Package for Social Sciences

P-value probability value

Author contributions

All authors took part in the concept and design of the study. JA contributed to applying each treatment according to the treatment schedule. HH participated in the acquisition of data, statistical analysis, and interpretation of the data. AB and JA collaborated on writing and editing.

Funding

There was no external funding for this research.

Data availability

No datasets were generated or analyzed during the current study.

Ethical approval

The Research Ethics Committee of the Faculty of Physical Therapy at Cairo University examined and approved the studies involving human subjects (No. P.T.REC/012/003438). The subjects gave written, informed consent to take part in this investigation.

Competing interests

The authors declare no competing interests

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Effect of Proximal Stabilization on Recruitment of the Core & Vasti in Patients with Patellofemoral Arthritis as They Descend Stairs: A Randomized Controlled Trial

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