Authors
Study design
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Patient sample size & characteristics
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Description of interventions and setting
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Comparator exercise and setting
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Follow-up duration & outcome measures
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Effect size & summary
of key findings
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Avraham et al. (2007)
Single-blinded randomised clinical trial
(A pilot trial)
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N=30; Patients with a confirmed diagnosis of PFP
Ratio of male: female not indicated
Mean age: 35 yrs.
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Hip group (N=10)
Participants underwent an exercise program targeting strengthening of hip external rotators
3-week exercise protocol with supervision involved: 90o knee flexion/extension exercise, hamstring/iliotibial band stretches coupled with electrotherapy 2 times per week.
Hip/quadriceps group (N=10)
Participants received exercise targeting hip and quadriceps musculature. This was coupled with electrotherapy 2 times per week
Setting: Rehabilitation facility.
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Quadriceps group (N=10)
Participants received quadriceps strengthening exercise involving: straight leg raise (SLR), single-leg squats coupled with electrotherapy 2 times per week
Setting: rehabilitation facility.
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Pain assessed by numeric visual analogue scale (VAS)
Function assessed by Patello-Femoral Joint Evaluation Scale (PFJES)
Measured at baseline and 3 wks. post-intervention
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All groups exhibited significant improvements in VAS and PFJES scores (p<0.0001).
Between-group differences in pain and function were not statistically significant (p>0.05).
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Nakagawa et al. (2008)
Prospective, single-blinded randomised controlled design
(A pilot trial)
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N=14; (10 females and 4 males)
Patients with a confirmed diagnosis of PFP
Age range: 17–40 yrs. [mean ± SD 23.6±5.9 yrs.]
Hip/quadriceps group (n=7)- Group characteristics not defined
Quadriceps group (n=7)- Group characteristics not defined
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Hip/quadriceps group
(N=7)
Hip/quadriceps protocol involved strengthening of hip abductors, lateral rotators and transverse abdominis coupled with quadriceps protocol.
Exercise performed once a week under supervisions and 4-times a week at home under no supervision for 6 weeks.
Setting: rehabilitation facility with a home programme
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Quadriceps group (N=7)
Quadriceps protocol involved patellar mobilization, stretching of the quadriceps, gastrocnemius, hamstrings and iliotibial band coupled with open and closed kinetic chain exercises for quadriceps strengthening.
Exercise performed once a week under supervisions and 4-times a week at home under no supervision for 6 weeks.
Setting: rehabilitation facility with a home programme
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Perceived pain symptoms during functional activities assessed by VAS
Measured at baseline and 6 wks. post-intervention
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The hip/quadriceps group exhibited significant improvement in pain symptoms (p=0.02–0.04) except during prolonged sitting:
Mean difference (at 6 weeks-baseline) in usual pain –3.6±2.6 (p=0.03*), worst pain –2.6±2.5 (p=0.03*),
Stair climbing –3.0±3.2 (p=0.04*),
Descending stair –4.1±2.9 (p=0.03*), and Squatting –5.4±3.0 (p=0.02*) significant, but not prolonged sitting –1.9±2.9 (p=0.14).
No significant pain improvement in the quadriceps group (P>0.05).
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Song et al. (2009)
Randomised controlled trial
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N=89; (69 females and 20 males)
with a confirmed diagnosis of PFP
Mean age: 41 yrs.
Hip adduction/leg-press Exercise (LPHA) group: (N=29) - (8 men; 21 women); Mean ±SD age: 38.6 ±10.8 yrs.
Mean ±SD duration of symptoms: 41.8 ±36.1 months
Leg-press Exercise only (LP) group (N=30) - (8 men; 22 women); Mean ±SD age: 40.2 ±9.9 yrs.
Mean ±SD duration of symptoms: 38.3 ±34.2 months
No Exercise group (N= 30) - (4 men; 26 women); Mean ±SD age: 43.9 ±9.8 yrs.
Mean ±SD duration of symptoms: 27.7 ±41.0 months
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LPHA group (N=29)
50-N isometric hip adduction/abduction for strengthening hip abductors coupled with leg-press exercise for quadriceps strengthening.
3 weekly sessions for 8 wks. with full supervision
Setting: Clinical (kinesiology laboratory)
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LP group (N=30)
Leg-press exercise performed unilaterally from 45o of knee flexion to full extension assisted by an EN-Dynamic Track machine.
3 weekly sessions for 8 wks. with full supervision
Setting: Clinical (kinesiology laboratory)
No exercise group: (N=30)
Given health educational materials on PFP self-efficacy
Advised not to enrol in any exercise program during the study period
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Worst pain in the previous week rated on a 10-cm visual analogue scale (VAS-W). Knee function evaluated by Tegner Lysholm Knee Scoring Scale
Follow-up: Immediately and at 8 wks. post-intervention
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The LPHA group:
Exhibited significant improvements in VAS-W ratings (p<0.005) with mean difference of 2.18 (3.17-1.19; 95% CI) and Tegner Lysholm (p<0.005) with a mean score difference of 10.93 (7.27 to 14.59; 95% CI)
LP group:
Significant improvements in VAS-W ratings (p<0.005) with mean difference of 2.58 (3.56-1.61) and Tegner Lysholm scale (p<0.005) with a mean score difference of 10.93 (7.27-14.59; 95% CI).
Non-exercise group had no significant pain improvements (p = 0.714-0.715)
Effect difference between LPHA and LP was not significant in VAS-W ratings (p=0.577) and TLKSS (p=0.776), respectively
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Fukuda et al. (2010)
Randomised controlled clinical trial
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N=54 (females) Sedentary women
with a confirmed diagnosis of PFP
Age range:
20-40 yrs.
Knee and hip Exercise (KHE) group (N=25);
Mean ±SD age: 22 ±3 yrs.
Mean ±SD duration of symptoms: 23.2 ±19.0 months
Knee
Exercise (KE) group (N=24); Mean ±SD age: 23±3 yrs.
Mean ±SD duration of symptoms: 21.0 ±17.7 months
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KHE group (N= 25)
Knee exercise coupled with hip abductor and lateral rotator strengthening
Exercise protocol included hip abduction against elastic band while standing or with weights in the side-lying position.
Hip lateral rotation against elastic band while seated and hip extension.
It was coupled with knee exercise for the KE group.
3 sessions per week for 4 weeks
Setting: Rehabilitation facility.
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KE group (N=24)
Hamstrings/plantar flexors/quadriceps/ iliotibial band stretches.
Knee extension at an angle of 90° to 45°,
Leg presses and squats at an angle of 0° to 45°, single-leg calf raises, and prone knee flexion
3 sessions per week for 4 weeks
Setting: Rehabilitation facility.
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Pain assessed by 11-point NPRS during ascending and descending stairs
Knee function assessed by LEFS and AKPS
Follow-up:
at 3, 6, and 12
months post-intervention
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Within KHE group change in mean NPRS scores:
For ascending stairs at 3, 6 and 12 months post-treatment were –5.0 ±1.5 (95% CI: –5.6, –4.4), –4.5 ±1.4 (95% CI: –5.0, –4.0) and –3.3 ±1.1 (95% CI: –3.7, –2.9), respectively; (p<.05).
For descending stairs at 3, 6 and 12 months post-treatment were –4.2 ±1.7 (95% CI: –4.9, –3.5), –3.8 ±1.4 (95% CI: –4.4, –3 2), and –3.3 ±1.1 (95% CI: –3.7, –2 9), respectively: (p<.05).
Within KE group change in mean NPRS scores:
For ascending stairs at 3, 6 and 12 months post-treatment were –1.3 ±1.2 (95% CI: –2.9, 0.3), –1.1 ±1.1 (95% CI: –1.6, –0.6) and –0.1 ±1.0 (95% CI: –0.7, 0.5), respectively: (p<.05).
For descending stairs at 3, 6 and 12 months post-treatment were –1.4 ±0.9 (95% CI: –1.7, –1.1), –0.8 ±0.9 (95% CI: –1.2, –0.4), and 0.0 ±0.9 (95% CI: –0.3, 0.3), respectively.
Within KHE group change in mean LEFS scores: at 3, 6 and 12 months post-treatment were 22.4 ±10.5 (95% CI: 18.4, 26.4), 20.7 ±11.0 (95% CI: 16.5, 24.9), and 17.9 ±9.7 (95% CI: 14.2, 21.6), respectively: (p<.05).
Within KE group change in mean LEFS scores: at 3, 6 and 12 months post-treatment were 0.4 ±5.2 (–1.7, 2.5) –1.3 ±5.3 (–3.4, 2.1) –2.9 ±4.9 (–4.9, –0.9), respectively.
For descending stairs at 3, 6 and 12 months post-treatment were –1.4 ±0.9 (95% CI: –1.7, –1.1), –0.8 ±0.9 (95% CI: –1.2, –0.4), and 0.0 ±0.9 (95% CI: –0.3, 0.3), respectively: (p<.05).
Within KHE group change in mean AKPS scores: at 3, 6 and 12 months post-treatment were 19.8 ±9.1 (95% CI: 16.2, 23.4), 15.8 ±8.1 (95% CI: 12.6, 19.0) and 13.1±8.3 (95% CI: 9.8, 16.4), respectively: (p<.05).
Within KE group change in mean AKPS scores: at 3, 6 and 12 months post-treatment were 2.8 ±8.9 (95% CI: –0.7, 6.3) 0.2 ±8.4 (95% CI: –3.2, 3.6), and –1.8 ±8.4 (95% CI: –5.1, 1.5), respectively: (p<.05).
*Overall KHE outcomes were superior over those of the KE group (p<.05).
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Dolak et al. (2011)
Randomised Clinical Trial
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N=33; Females with a confirmed diagnosis of PFP.
Age range: 16-35 yrs.
Hip group (N=17) Mean age: 25±5 yrs.
Mean ±SD duration of symptoms: 36 ±34 months
Quadriceps group (n=16) Mean age: 26±6 yrs.
Mean ±SD duration of symptoms: 27±34 months
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Hip group (n=17)
Hip protocol involved combined hip abduction and external rotation in side-lying and standing positions coupled with seated hip external rotation.
Participants supervised during 1 session and unsupervised during 2 weekly home-based sessions for 4 weeks.
Setting: Rehabilitation facility and home
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Quadriceps group (n=16)
Quadriceps protocol involved quad sets, short-arc quads, straight leg raises and terminal knee extensions
This protocol performed for 4 consecutive weeks with full supervision.
Setting: Rehabilitation facility and home.
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Pain: VAS-W
Function: LEFS, AKPS
Follow-up: Immediately
Outcome measured at baseline and 4 weeks post-intervention
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Hip group exhibited significant improvements in pain: 47.9% (p<0.001) and knee function: 18.7% (p<0.001).
Quadriceps group exhibited significant improvements in knee function (9.3%; p<0.001) but not pain (p=0.88)
Pain significantly reduced in the hip group compared to the quadriceps group with a mean difference of 1.7 (p=0.035)
No significant difference in knee function (p>0.05) between the two groups at the end of the study.
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Fukuda et al. (2012)
Randomised controlled trial with 1-year follow-up.
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N=49; Sedentary females with a confirmed diagnosis of PFP
Age range
20-40 yrs.
Hip/quadriceps group (n=25) Mean ±SD age: 22.0 ±3.0 yrs.
Mean ±SD duration of symptoms: 23.2 ±19.0 months
Quadriceps group (n=24) Mean ±SD age: 23.0 ±3.0 yrs.
Mean ±SD duration of symptoms: 21.0 ±17.7 months
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Hip/quadriceps group (N=25)
Hip abductor and external rotators coupled with quadriceps strengthening/ stretching knee exercise: seated knee extension, leg press, squatting, stretching of hamstrings, quadriceps, ankle plantar flexors and iliotibial band
3 sessions per week for 4 weeks
Setting: Rehabilitation facility.
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Quadriceps group (N=24)
Quadriceps strengthening/stretching knee exercise; seated knee extension, leg press, squatting, stretching of hamstrings, quadriceps, ankle, plantar flexors and iliotibial band
Setting: Rehabilitation facility.
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Pain: 11-point NPRS during
ascending and descending stairs
Function: LEFS, AKPS
At baseline
Follow-up: immediately and post-intervention at 3, 6, and 12 months.
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For interventional group:
Pain during upstairs gait reduced to 80.7% (p <0.05) at 3 months, 73.2% (p <0.05) at 6 months and 53.2 % (p <0.05) at 12 months
Pain during downstairs gait reduced to 72.4 % (p <0.05) at 3 months, 65.5 % (p <0.05) at 6 months and 56.9 % (p <0.05) at 12 months
Knee function score on AKPS improved to 30.1 % (p <0.05) at 3 months, 20.4 % (p <0.05) at 6 months and 19.9 % (p <0.05) at 12 months
For comparator group:
Pain during downstairs gait reduced to 21.9% (p <0.05) at 3 months, 12.5% (p <0.05) at 6 months.
At 6 months pain during upstairs gait reduced to 16.7% (p <0.05)
No significant change in both AKPS and LEFS scores at 3, 6 and 12 months.
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Khayambashi et al. (2012)
Randomised controlled trial.
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N= 28; Sedentary females with patellofemoral pain (PFP)
Hip exercise group (n=14); Mean ±SD age: 28.9±5.8 yrs.
Duration of symptoms: not indicated
Non-exercise group (N=14); Mean ±SD age: 30.5 4.8 ±3.2 yrs.
Duration of symptoms: not indicated
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Hip exercise group (n=14)
Supervised isolated hip abductor strengthening to 30o in standing position.
Supervised isolated hip external rotator strengthening to 30o in the seated position.
Exercise protocol performed 3 times per week for 8 weeks.
Setting: Rehabilitation facility.
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Non-exercise group (n=14)
Participants also prescribed 1000 mg of Omega-3 and 400 mg of calcium daily for 8 weeks.
Setting: home
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Worst pain in the previous week assessed by VAS
Self-reported health status assessed by the Western Ontario and McMaster Universities (WOMAC) questionnaire.
VAS and WOMAC scores recorded at baseline (pre-intervention), week 8 (post-intervention), and 6 months post-intervention.
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For hip exercise group:
Exhibited significant improvements in VAS score (p <0.001):
Mean VAS score difference from baseline (7.9 ±1.7) to 8 wk. post-intervention (1.4 ±1.9) was –6.4 ±2.7; 95% CI: –7.9, –4.9 (p <0.001).
Mean VAS score difference from baseline (7.9±1.7) to 6 months post-intervention (1.7±2.7) was –6.2 ±1.4; 95% CI: –7.9, –4.3 (p <0.001).
Significant improvements were seen in WOMAC score (p <0.001):
Mean WOMAC score difference from baseline (54.0±18.1) to 8 wk. post-intervention (10.7±16.1) was –43.3 ±20.1; 95% CI: –54.9, –31.7 (p<0.001).
Mean WOMAC score difference from baseline (54.0±18.1) to 6 months post-intervention (10.8 ±17.7) was –43.2 ±7.7; 95% CI: –55.9, –30.0 (p <0.001).
Non-exercise group:
No noticeable improvements in VAS and WOMAC scores (p >0.05).
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Ismail et al. (2013)
Prospective randomised controlled trial
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N=32; (23 females 9 males); with a confirmed diagnosis of PFP
Age range 18-30 yrs.
Closed kinetic chain (CKC) + hip exercise (CKCH) group (n=16); (11 women, 5 men)
Mean ±SD age: 20.8 ±2.7 yrs.
Mean ±SD duration of symptoms: not indicated
CKC group (n=16); (12 women, 4 men)
Mean ±SD age: 21.2 ±3.2 yrs.
Mean ±SD duration of symptoms: not indicated
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CKCH group (n=16)
Hip abductors and lateral rotators strengthening exercise coupled with CKC exercises for hip/quadriceps strengthening
Hip abductor strengthening performed in a side-lying position on the non-affected side.
Lateral rotators strengthening performed while seated and hip flexed to 90o
Training sessions: 3 times per week for 6 weeks
Setting: Rehabilitation facility.
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CKC group (n=16)
Closed kinetic chain exercises for quadriceps strengthening
Protocol involved stretching of hamstrings, iliotibial band and gastrocnemius.
Also involved mini wall squats, forward/lateral step-ups and terminal knee extensions.
Training sessions: 3 times per week for 6 weeks
Setting: Rehabilitation facility.
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Worst pain in the previous week assessed by VAS
Knee function assessed by AKPS
Follow-up: Immediately
Outcome measured at baseline and 6 weeks post-intervention
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For CKCH group:
Significant improvements in VAS and Kujala scores (p <0.05).
Mean VAS score difference from baseline (5.3 ±1.6) to 6 wk. (2.0 ±1.1) post-intervention 3.2 ±0.9.
Mean Kujala score difference from baseline (71.5 ±7.8) to 6 wk. (85.1 ±6.2) post-intervention 13.7 ±5.5
For CKC group:
Significant improvements in VAS and Kujala scores p <0.05)
Mean VAS score difference from baseline (4.5 ±1.8) to 6 wk. (2.3 ±1.1) post-intervention 2.26 ±1.3.
Mean Kujala score difference from baseline (76.4 ±10.4) to 6 wk. (85.0 ±6.7) post-intervention 8.6 ±7.3
*Overall pain and function outcome in the CKCH group was superior to the CKC group (p <0.05)
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Baldon et al. (2014)
Randomised, comparative-controlled single-blinded study
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N=31 (Females); with a confirmed diagnosis of PFP
Age range: 18-30 yrs.
Hip exercise group (n=15); Mean ±SD age:27.7±3.2 yrs.:
Mean duration of symptoms: not indicated
Quadriceps group (n=16); Mean ±SD age:21.3±2.6 yrs.:
Mean duration of symptoms: not indicated
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Hip exercise group (n=15)
Hip extension/lateral rotation in prone, side-lying, standing
Isometric hip abduction/ lateral rotation in standing knee and hip flexion in side-lying
Pelvic drop in standing
Hip lateral rotation in closed kinetic chain
Plus the standard knee exercise
Sessions performed 3 times a week for 8 wks.)
Sessions lasted between 90 to 120 minutes with supervision by a physical therapist
Setting: Laboratory of Intervention and Orthopaedics and Traumatology laboratory
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Quadriceps group (n=16)
Quadriceps strengthening and lateral retinaculum stretches
Hamstrings, soleus, gastrocnemius, and iliotibial band stretches
Sessions performed 3 times a week for 8 wks.)
Sessions lasted between 75 to 90 minutes with supervision by a physical therapist
Setting: Laboratory of Intervention and Orthopaedics and Traumatology laboratory
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Worst-pain in the previous week rated on 10cm- VAS
Knee function: LEFS
Baseline, immediately and 3-month post-intervention
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For Hip exercise group:
Mean differences in VAS score at end of intervention (–5.2 ±1.6) and 3-months post-intervention (-5.7 ±2.3) were significant (p<0.05*). Pain reduced.
Mean difference in LEFS at end of intervention (–18.9 ±12.5) and 3-months post-intervention –19.5 ±11.9) were significant (p <0.05*). Knee function improved
For quadriceps group:
Pain improved significantly (p <0.05), but not knee function (p >0.05).
Mean difference in VAS at the end of intervention (–3.0 ± 2.4) and 3-months post-intervention (– 3.6 ±3.3) were significant (p <0.05).
Mean difference in LEFS score at the end of intervention (–12.9 ±7.5) and 3-months post-intervention (–12.7 ±6.2) was not significant (p >0.05).
Between-group difference in VAS scores only significant at 3-months post-intervention (p <0.05).
Between-group differences not significant in VAS at any time-point
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Khayambashi et al. (2014)
Comparative control trial
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N=36 (18 men, 18 women); with clinical diagnosis of PFP
Hip exercise group (n=18); (9 men and 9 women); Mean ±SD age: 28.2 ±7.9 yrs.
Mean duration of symptoms: not indicated
Quadriceps group (n=18); (9 men and 9 women); Mean ±SD age: 27.3 ±6.7yrs
Mean duration of symptoms: not indicated
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Hip exercise group (n=18)
Underwent supervised exercise programs targeting hip muscles strengthening.
Hip exercise protocol included hip abductor and external rotator strengthening exercises in side-lying and knee flexed to 90o while seated, respectively.
Quadriceps protocols include knee flexion to 30ocoupled with partial squats.
3 times a week for 8 wks.
Setting: Rehabilitation facility
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Quadriceps group (n=18)
Received supervised quadriceps strengthening exercises (3 times a week for 8wks).
Quadriceps protocols included knee flexion to 30o coupled with partial squats.
Setting: Rehabilitation facility
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Worst pain in the previous week assessed by VAS
Self-reported health status assessed using the WOMAC questionnaire.
VAS and WOMAC scores recorded at baseline (pre-intervention), week 8 (post-intervention), and 6 months post-intervention.
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For Hip exercise group:
Significant improvements in VAS and WOMAC scores (p <0.001):
Mean VAS score difference from baseline (7.63 ±1.79) to 8 wk. (2.11 ±1.6) and 6 months (2.00 ±1.97) post-intervention was –5.53 ±1.60; 95% CI and –5.64 ±1.99; 95% CI, respectively (p <0.001).
Mean WOMAC score difference from baseline (46.83 ±21.86) to 8 wk. (6.22 ±3.87) and 6 months (6.94 ±5.70) post-intervention was –40.61 ±20.68; 95% CI and –39.89 ±21.35; 95% CI, respectively (p <0.001).
For Quadriceps group:
Significant improvements in VAS and WOMAC scores (p <0.001):
Mean VAS score difference from baseline (6.91 ±1.94) to 8 wk. (3.27 ±2.19) and 6 months (4.00 ±2.44) post-intervention was –3.64 ±1.39; 95% CI and –2.92 ±1.72; 95% CI, respectively (p <0.001).
Mean WOMAC score difference from baseline (44.11 ±22.05) to 8 wk. (21.89 ±16.55) and 6 months (23.16 ±14.15) post-intervention was –22.22 ±10.59; 95% CI and –20.94 ±14.30; 95% CI, respectively (p <0.001).
*Between-group difference was statistically significant p ≤0.05, where outcomes in the hip group were superior over the quadriceps group.
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