Journal of Bodywork & Movement Therapies (2017) 21, 554e564

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ORIGINAL RESEARCH

Comparison of ischemic compression and

lumbopelvic manipulation as trigger point
therapy for patellofemoral pain syndrome in
young adults: A double-blind randomized
clinical trial
Shabnam Behrangrad, MSD, PT a, Fahimeh Kamali, PhD, PT b,*

a
Physiotherapy Department, School of Rehabilitation, Shiraz University of Medical Sciences, Shiraz,
Iran
b
Rehabilitation Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

Received 20 June 2016; received in revised form 26 July 2016; accepted 14 August 2016

KEYWORDS Summary Objective: To compare the effectiveness of ischemic compression (IC) directly to
Patellofemoral pain the vastus medialis obliquus (VMO) versus lumbopelvic manipulation (LPM) in improving pain,
syndrome; functional status and sensitivity to mechanical stimulation of the VMO trigger point in patients
Ischemic with patellofemoral pain syndrome (PFPS).
compression; Participants: 40 patients with unilateral PFPS aged 20e30 years were selected randomly
Myofascial trigger among patients with unilateral PFPS referred to physical therapy clinics of Shiraz University
point; of Medical Sciences in Shiraz, Iran, between March 2014 and July 2014. 30 young adults partic-
Lumbopelvic ipated. Participants were blinded to treatment allocation, and 15 patients were allocated to
manipulation; either IC or LPM.
Rehabilitation Interventions: Patients in both groups were treated in three sessions per week. IC consisted of
three sets of continuous pressure applied for on the myofascial trigger point (MTrP) of VMO.
LPM consisted of supine rotational glide manipulation of the ipsilateral lumbopelvic region
of the involved knee.
Main outcome measures: Numeric pain rating scale (VAS) for pain intensity, Kujala question-
naire for functional status, and pressure pain threshold (PPT) for sensitivity to mechanical
stimulation. All three were recorded before treatment, 1 week, 1 month and 3 months after
the last session.
Results: Both groups showed significant improvement (p < 0.05, 95% confidence interval) in
pain, functional status and PPT values. However, the IC group showed greater improvements,

* Corresponding author. Shiraz University of Medical Sciences, Abivardi St, PO Box 71345-1733, Chamran Ave, Shiraz, Iran. Fax: þ98
7116272495.
E-mail address: fahimekamalii@gmail.com (F. Kamali).

http://dx.doi.org/10.1016/j.jbmt.2016.08.007
1360-8592/ª 2016 Elsevier Ltd. All rights reserved.
Ischemic compression efficacy in patellofemoral pain syndrome
and outcome measures remained significantly better than in the LPM group during post-
intervention follow-up.
Conclusions: Both groups showed improvements throughout the study and follow-up period.
However, the IC showed better short-term and long-term effectiveness than LPM for treating
PFPS.
ª 2016 Elsevier Ltd. All rights reserved.
Nomenclature
IC ischemic compression
MTrP myofascial trigger point
VAS visual analog scale
LPM lumbopelvic manipulation
PFPS patellofemoral pain syndrome
PPT pressure pain threshold
SIJ sacroiliac joint
VMO vastus medialis obliquus
VL vastus lateralis
Introduction
Patellofemoral pain syndrome (PFPS) is one of the most
frequent disorders among young individuals (McConnell,
1996) and may affect up to 30% of the population
(McConnell, 1996; Witvrouw et al., 2000a,b). This disorder
has been described as a syndrome causing pain in the
anterior or medial aspect of the knee (Travel and Simmons,
1983; Wood, 1998; Chaitow and DeLany, 2002) during active
overloading or activities that compress the patella, i.e.
prolonged sitting or stair climbing (Wood, 1998; Travel and
Simmons, 1983; Powers et al., 1996; Chaitow and DeLany,
2002). It can therefore affect several aspects of daily life
(Crossley et al., 2002; Crossley et al., 2004). Although the
exact causes of PFPS are not well understood (Witvrouw
et al., 2000a,b), repeated trauma (Davidson, 1993) and
extensor mechanism dysfunction are known to be the most
probable causes (Post, 1998; Juhn, 1999). People with PFPS
are more likely to have quadriceps weakness (Grindstaff
et al., 2012) and inhibition (Suter et al., 1999). In addi-
tion, abnormalities in neuromuscular factors (Powers et al.,
1996; Cowan et al., 2001; Crossley et al., 2002; Cowan
et al., 2002; Gilleard et al., 1998) such as a delayed onset
of vastus medialis obliquus (VMO) activity (Gilleard et al.,
1998; Cowan et al., 2001; Crossley et al., 2002; Cowan
et al., 2002) may alter patellar tracking and increase
patellofemoral joint contact pressure, leading to overload
of the retinaculum, subchondral bone and knee extensors.
This overload may also activate pain fibers in the bone,
synovium or retinaculum (Piva et al., 2005) and provide
nociceptive input into the dorsal horn of the spinal cord.
Pain can alter motor activation patterns by affecting
efferent signals to the extensor mechanism of the knee,
especially in the VMO, which is predominantly involved in
PFPS (Travel and Simmons, 1983; Powers, 1998; Wills et al.,
2004; Hillermann et al., 2006). The vicious cycle of pain-
555
dysfunction may be perpetuated in these patients, leading
to VMO insufficiency and weakness. As a result, the muscle
works harder to achieve better contraction and function,
which can lead to muscle overuse. This theory could explain
the development of latent myofascial trigger points (MTrP)
in the VMO in the overload phase of this condition (Davidson,
1993; Chaitow and DeLany, 2002; Simons, 2002; Colloca
et al., 2004; Chaitow et al., 2006).
Repeated trauma (Davidson, 1993) or overuse injuries
can also lead to PFPS. Trigger points appear as a result
of overuse or overload, so it is not uncommon to find
MTrP in patients with PFPS (Dippenaar, 2003; Crossley
et al., 2005). There is also evidence that MTrP in the
quadriceps femoris, particularly in the VMO (Dippenaar,
2003; Chaitow et al., 2006; Lucas, 2008), can result in a
combination of PFPS signs and symptoms.
Conventional treatments for PFPS usually focus on
balanced strengthening of the quadriceps (Witvrouw et al.,
2000a,b; Crossley et al., 2002; Fulkerson, 2002; Crossley
et al., 2005; Bolgla and Malone 2005; Grindstaff et al.,
2012), and may not fully address muscle inhibition (Mizner
et al., 2003; Pietro et al., 2011). Therefore, treatments
that focus directly on the patient’s pain and function
are needed. Although the use of different manual therapy
techniques such as manipulation or ischemic compression
(IC) (Hou et al., 2002; Rickards, 2006) is increasing, the
effectiveness of these methods in PFPS is a matter of
debate. Ischemic compression is claimed to be effective
by increasing local blood flow after transient blood
flow occlusion, thus facilitating tissue recovery and
normalizing impaired motor activation patterns in the
muscle (Chaitow 2006; Lucas, 2008; Kostopoulos et al.,
2008). In patients with PFPS, IC on the MTrP in the VMO
can improve VMO function, which is one of main factors in
the adequate cushioning of direct forces to the knee and in
VMO/vastus lateralis (VL) coordination. Ischemic compres-
sion can therefore improve patellar tracking (Powers, 1998;
Gilleard et al., 1998; Gotlin, 2000).
Lumbopelvic manipulation (LPM) is well established as a
treatment for PFPS (Suter et al., 1999; Grindstaff et al.,
2012). Joint manipulation can stimulate mechanorecep-
tors and nociceptors, which are primary receptors involved
in muscle inhibition, within and around the joint (Powers
et al., 1996; Dippenaar, 2003; Colloca et al., 2003;
Iverson et al., 2008; Grindstaff et al., 2012), and can thus
affect spinal efferent signals. Moreover, quadriceps inhibi-
tion may originate from structures in and around the knee
joint (Hillermann et al., 2006; Iverson et al., 2008;
Grindstaff et al., 2012). In addition, because of the com-
mon nerve root levels of the sacroiliac joint (SIJ) (L2-S3),
556
quadriceps (L2&L4) and knee (L2-S3), afferent information
from each structure might alter motor signals of the other
structures with similar nerve root innervations (Hillermann
et al., 2006; Iverson et al., 2008; Grindstaff et al., 2012).
At present, both LPM (Hillermann et al., 2006; Iverson
et al., 2008; Grindstaff et al., 2012) and IC (Simons, 2002;
Hou et al., 2002; Fryer and Hodgson, 2005; Chaitow
et al., 2006) are known to be effective treatments for
PFPS. However, to the best of our knowledge this study is
the first randomized clinical trial designed to compare the
short- and medium-term impact of IC and LPM on symptoms
in patients with PFPS.
Method
Forty young adults aged 20e30 years with a medical diag-
nosis of unilateral PFPS with asymptomatic SIJ dysfunction
were selected by simple random sampling among patients
referred to physical therapy clinics of Shiraz University of
Medical Sciences in Shiraz, Iran, between March 2014 and
July 2014. In the initial interview, an independent research
assistant not involved in the interventions or data collec-
tion screened volunteers for inclusion criteria. Thirty-three
patients met the inclusion criteria, and 3 patients declined
to participate in the trial. For volunteers who met all in-
clusion criteria and agreed to take part in the trial, an
assessor recorded baseline measures of weight, height,
pain, pressure pain threshold (PPT) and Kujala question-
naire score. All participants were blinded to treatment
allocation, and were randomly assigned with concealed
allocation to the LPM or IC group by an independent
research assistant. In this study our primary outcome was
clinical improvement, which was defined as a reduction of
20 mm on the VAS and a score of 10 on the Kujala
questionnaire.
Sample size was calculated with SPSS software as 13
patients in each group on the basis of information from
studies on the effects of LPM (Iverson et al., 2008) and
trigger point therapy on PFPS (Hains and Hains, 2010) (Z1-a/
2 Z 1.96 Z1-b Z 0.85 S Z 0.45 d Z 0.5). To compensate for
the loss of patients during the study, 15 patients were
initially included in each group. The trial was approved by
the institutional review board of Shiraz University of Med-
ical Sciences. Informed consent was obtained from all pa-
tients, and ethics approval and support were obtained from
the Office of the Vice-Chancellory for Research of Shiraz
University of Medical Sciences.
Participants
The inclusion criteria were: 1) reported pain of more than 6
weeks’ duration in at least two of the following situations:
patellar compression, squatting, prolonged sitting, walking,
stair climbing, isometric quadriceps contraction (Crossley
et al., 2002; Whittingham et al., 2004; Iverson et al.,
2008); 2) reported pain in one of the following tests:
vastus medialis coordination test, patellar apprehension
test, eccentric step test (Nijs et al., 2006); 3) presence of
at least one MTrP in the VMO of the symptomatic knee
(pressure applied to the VMO produced pain); 4) confirmed
asymptomatic SIJ dysfunction on the side of the
S. Behrangrad, F. Kamali
symptomatic knee in at least three of the following tests:
Yeoman’s test, Gaenslen’s sign, the FABER test (Patrick’s
sign), the compression test, resisted hip abduction or a
thigh thrust test (Kamali and Shokri, 2012); 5) Kujala
questionnaire score between 40 and 70, and visual analog
scale (VAS) score greater than 40.
Volunteers were excluded if they had a history of any of
the following: ligamentous insufficiency of the knee,
meniscus damage, patellar subluxation or dislocation,
nerve root compression, spine or lower extremity surgery,
any systemic, orthopedic or neurological disorder, or cur-
rent physical therapy (Iverson et al., 2008; Hains and Hains,
2010; Grindstaff et al., 2012).
Outcome measures
Visual analog scale
The VAS is an appropriate and sensitive scale for the clinical
and experimental evaluation of pain intensity (Williamson
and Hoggart, 2005). This score on this 100-point scale
ranges from 0 (no pain) to 100 (worst imaginable pain).
Participants were instructed to score their pain and circle
the appropriate number on the VAS form before and after
each treatment intervention (Price et al., 1998; Williamson
and Hoggart, 2005; Piva, 2006).
Anterior knee pain questionnaire (Kujala questionnaire)
The Kujala Patellofemoral Scale is a valid and reliable
questionnaire to evaluate functioning in patients with
PFPS, and has been translated into Persian. The reliability
and validity of the Persian version of this questionnaire
score have been verified (Negahban et al., 2012). The
scores range from a maximum of 100 to a minimum of 0,
with lower scores indicating greater pain and disability.
Digital algometry
Digital pressure algometry has shown high reliability and
validity for PPT measurements (Reeves et al., 1986). The
algometer used in this study consisted of a circular 0.86 cm2
pliance capacitance pressure sensor worn on the palpating
thumb, and connected to data collection hardware (pli-
ance, novel, Munich, Germany). This was the same set-up
as used by Price and colleagues (Williamson and Hoggart,
2005). The pressure sensor was calibrated according to
the manufacturer’s specifications before data collection.
Pressure pain threshold
Pain pressure threshold has been defined as the lowest-
intensity stimulus at which a person perceives pain (Reeves
et al., 1986; International Association for the Study of Pain,
1986). The high reliability, reproducibility and validity of
PPT have been demonstrated in many studies (Reeves
et al., 1986; International Association for the Study of
Pain, 1986). For each measurement we recorded three
PPT values and calculated the mean value for use in all
analyses.
Design
This double-blind randomized clinical study was conducted
at clinics affiliated with Shiraz University of Medical Sci-
ences in Shiraz, Iran. An independent research assistant
Ischemic compression efficacy in patellofemoral pain syndrome 557

Figure 1 Flow-chart of procedures.

managed group assignments with a block randomization
method based on a randomization table from a computer-
generated random number sequence. Eligible participants
were assigned in blocks of 4 participants, and group allo-
cation was done with sealed envelopes that contained slips
of paper labeled with a “I” or an “L”, signifying assignment
to the IC or LPM group, respectively. The 30 patients who
met the inclusion criteria were randomly assigned in either
the LPM (15 participants) or the IC group (15 participants).
Each group received 3 sessions of treatment per week. Main
outcome measures were recorded at baseline (before
treatment), 1 week, 1 month and 3 months after the last

Table 1 Demographic characteristics of the participants.

Characteristic Total Ischemic compression Lumbopelvic manipulation Test statistic p- value
t
Age (years) 24.3  1.9 24.3  1.9 24.3  1.9 0.000 1.00
Height (cm) 168.3  5 168.4  4.9 168.3  5.3 0.072 0.94
Weight (kg) 54.9  8.3 54.7  8.5 55  8.2 0.087 0.93
Body mass index 19.4  2.3 19.3  2.4 19.4  2.2 0.145 0.88
Gender (female) 12 (80%) 12 (80%) 12 (80%) Chi-square 1.00
0.000
All data are reported with 95% confidence intervals calculated with reference to baseline values.
The significance level for all statistical tests is set at p < 0.05.
558 S. Behrangrad, F. Kamali

session of treatment. During the trial, two physical thera-

value
4.171 0.00
8.563 0.00

0.00
pists attended all treatment sessions. The first therapist

p-
monitored the outcome measurements, and the second
therapist performed the interventions and was blinded as

7.027
to the outcome measurements being recorded. The flow

Lumbopelvic t
chart of the procedure is shown in Fig. 1, and participants’

value compression manipulation

characteristics are shown in Table 1.

30.7  1.3
75.9  5.6

3.83  0.2
Interventions

3 months after

4.232 0.00 13.3  1.4

0.00 4.46  0.2

Lumbopelvic manipulation

Ischemic

8.627 0.00 92.5  4

Lumbopelvic manipulation consists of applying rotational
glide forces to the ipsilateral lumbopelvic region of the
involved knee. Patients lay supine and the therapist stood
contralateral to the side which was to be manipulated.

p-
They were passively moved onto their side, toward the side

8.307
to be manipulated, and then interlocked their fingers
behind their head. The therapist passively rotated the pa-

Lumbopelvic t
-value compression manipulation
tient, and then delivered a quick thrust to the anterior

26.7  10.6
77.9  5.6

3.96  0.2
superior iliac spine in a posterior and inferior direction
(Suter et al., 1999; Iverson, 2008; Childs and Flynn, 2004).
Each patient received a maximum of two manipulations on
the same side as the symptomatic knee.

1 month after

11.3  9.2
92.1  3.5

4.53  0.2
Ischemic
Ischemic compression
Ischemic compression involves applying tolerably painful,
persistent manual pressure (usually with the thumb) against
the tissue barrier of the MTrP (Fulkerson, 2002; Gemmell

3.997 0.00
8.344 0.00

0.00
All data are reported with 95% confidence intervals calculated with reference to baseline values.
et al., 2008; Hains and Hains, 2010). Patients lay in the

p
supine position with their knee extended, and were

8.635
Mean outcome measures for NPRS, Kujala score and PPT in the two groups.

encouraged to relax as much as possible. The first examiner

monitored the PPT (N/cm2), and the second examiner
Lumbopelvic t
value compression manipulation
applied constant, gradually increasing pressure to the
25.7  0.3
78.7  5.2

3.98  0.2
identified MTrP while using a pain scale. When the pressure
reached 70 on the VAS, the second examiner sustained the
pressure for 90 s. If the patient reported a decrease in pain
to a value of 30 or 40, the second examiner slowly increased
1 week after

the pressure to restore perceived pain to the target value

0.335 0.74 11.7  8.8

0.462 0.64 4.56  0.2

Ischemic

0.591 0.56 91  3.5

of 70. Compression was performed three times in each

session, with a 30-s rest between applications (Fryer and
The significance level for all statistical tests is set at p < 0.05.

Hodgson, 2005; Hains and Hains, 2010). The exact loca-

tion of the MTrP was marked to ensure accurate relocation
p-

for IC and post-treatment PPT measurement.

Statistical analysis
Lumbopelvic t

All descriptive and statistical analyses were done with SPSS

compression manipulation

version 16.0. Each of the demographic characteristics was

65.7  8.6
63.1  1.3

3.34  0.1

compared between the two groups. Also clinical data were

compared between the two groups and within each group.
The one-sample KolmogoroveSmirnov test was used to
verify normal distribution of the values for variables in each
62.7  2.3

3.32  0.1

group. The two-independent samples t-test (for Quantita-

Ischemic

64.8  5
Baseline

tive variables) and chi-squared test (for Qualitative vari-

able) with alpha set at 0.05, were used to identify
differences in demographic data between groups and
questionnaire

repeated measures ANOVA were used for between-groups

and within-group comparisons of the changes in pain, PPT
value and Kujala scores at baseline, 1 week, 1 month and 3
Table 2

months of follow-up. All data are presented as the

Kujala
Group

NPRS

mean  standard deviation. Bonferroni post hoc test were

PPT

performed when significance was detected. The

 Ischemic compression efficacy in patellofemoral pain syndrome
Table 3 Mean outcome measures and p values in the ischemic compression group.
(I) (J) NPRS Kujala score PPT
b b
Mean p-value 95% CI for difference Mean p- 95% CI for difference Mean p- 95% CI for differenceb
differencea Lower Upper differencea value Lower Upper differencea value Lower Upper
(IeJ) bound bound (IeJ) bound bound (IeJ) bound bound
Before 1 week after 53.1 0.00 46.7 59.5 29.5 0.00 32.8 26.1 1.24 0.00 1.43 1.05
treatment treatment
1 month after 53.4 0.00 46.62 60.3 29.8 0.00 33 26.6 1.24 0.00 1.4 1.02
treatment
3 months after 51.5 0.00 42.8 60.1 28.4 0.00 32.1 24.7 1.14 0.00 1.35 0.93
treatment
1 week after Before treatment 53.1 0.00 59.5 46.8 29.5 0.00 26.1 32.8 1.24 0.00 1.05 1.43
treatment 1 month after 0.3 1 0.69 1.35 1.1 0.02 0.91 0.24 0.03 0.08 0.01 0.05
treatment
3 months after 1.7 0.81 4.9 1.56 1.06 0.01 0.22 2.35 0.09 0.01 0.02 0.17
treatment
1 month after Before treatment 53.4 0.00 60.3 46.6 29.8 0.00 26.6 33 1.24 0.00 1.02 1.4
treatment 1 week after 0.3 1 1.35 0.690 1.1 0.02 0.24 0.91 0.03 0.08 0.05 0.01
treatment
3 months after 2 0.32 4.9 0.919 1.4 0.03 0.07 2.7 0.07 0.03 0.00 0.13
treatment
3 months after Before treatment 51.5 0.00 60.1 42.8 28.4 0.00 24.7 32.1 1.14 0.00 0.93 1.35
treatment 1 week after 1.7 0.81 1.5 4.90 1.06 0.01 2.35 0.22 0.09 0.01 0.17 0.02
treatment
1 month after 2 0.3 0.92 4.92 1.4 0.03 2.7 0.07 0.07 0.03 0.13 0.00
treatment
All data are reported with 95% confidence intervals calculated with reference to baseline values.
The significance level for all statistical tests was set at p < 0.05.
a
Mean difference significant at the 0.05 level.
b
Adjustment for multiple comparisons were performed by Bonferroni correction.

559
560 S. Behrangrad, F. Kamali

significance level for all statistical tests was set at p < 0.05. patients with PFPS (Suter et al., 1999). Some studies have
Clinical significance of the effect sizes was determined with shown that the distal portion of the VMO has more latent
95% confidence intervals. trigger points in patients with PFPS than other parts of the
quadriceps (Dippenaar, 2003; Daly, 2005). Delayed VMO
Results activity is one of the main causes of pain and disability in
patients with PFPS (Powers et al., 1996; Gilleard et al.,
1998; Cowan et al., 2002). Many studies have reported
There were no significant differences among the 30
short- or long-term improvements in pain and function after
enrolled patients in demographic characteristics or other
manual therapy (Powers, 1998; Suter et al., 1999;
baseline measurements (Tables 1 and 2). The IC group
Fulkerson, 2002; Hou et al., 2002; Crossley et al., 2004;
showed significant greater improvements in pain at all
Daly, 2005; Hillermann et al., 2006; Brantingham et al.,
follow-up periods in comparison with the baseline mea-
2009; Khuman et al., 2012; Miller et al., 2013; Nambi,
surements. (P < 001) Between 1 week and 1 month there
2013). The purported aim of manual therapy is to in-
was some improvement in pain although the change was not
crease motor neuron pool activity, which can normalize
significant. There was a slight, nonsignificant increase in
VMO contraction timing and enhance patellar tracking
pain between 1 and 3 months. At 3 months’ follow-up, pain
realignment (Powers, 1998; Suter et al., 1999; Fulkerson,
was significantly lower than at baseline (Table 3 and Fig. 2).
2002; Hou et al., 2002; Crossley et al., 2004; Daly, 2005;
Patients in the LPM group had significant improvements
Hillermann et al., 2006; Brantingham et al., 2009;
in pain at all follow-up periods compared to baseline
Khuman et al., 2012; Miller et al., 2013; Nambi, 2013).
measurements. However, pain increased after 1 week, and
Evaluations of the effectiveness of IC applied directly to
was noticeably exacerbated 3 months after treatment
the peripatellar region suggest that PFPS may be success-
compared to 1 month and 1 week after treatment (Table 4
fully managed by IC (Fulkerson, 2002). In a study that
and Fig. 2).
evaluated the effectiveness of manipulation therapy by
On comparing the two groups, we found greater im-
comparing local knee manipulation and full kinetic chain
provements in pain at all follow-up periods in the IC group
manipulation, only the knee manipulation group demon-
(Table 2 and Fig. 2). This group also showed significantly
strated significant changes immediately after treatment.
greater functional improvement at all follow-up periods
After 2 months, both groups had remarkable functional
(Table 3 and Fig. 3). Patients in the LPM group showed
improvements and pain reduction (Brantingham et al.,
significant improvement at all follow-up periods, but we
2009). Also a comparison of tibiofemoral joint manipula-
noted a considerable decline in function from 1 week to 3
tion versus SIJ manipulation to increase quadriceps muscle
months after treatment (Table 4 and Fig. 3). The IC group
strength in patients with PFPS reported significant
showed significant functional improvement compared to
improvement only in the SIJ manipulation group
the LPM group at all follow-up periods (Table 2 and Fig. 3).
(Hillermann et al., 2006). Miller and colleagues compared
In both groups, PPT was significantly greater compared to
the effectiveness of gluteal muscle kinsiotaping versus LPM
the baseline value at 1 week, 1 month and 3 months after
as two indirect methods for decreasing muscle inhibition in
treatment. In both groups, PPT showed no significant
PFPS. Although the results in both treatment groups were
changes from 1 week to 1 month after treatment. At the end
significantly better than in the control group, the im-
of all follow-up sessions the improvement in PPT was greater
provements in the taping group were greater (Miller et al.,
in the IC group than the LPM group (Table 2 and Fig. 4).
2013). In a comparison of patellar mobilization versus tap-
ing as two direct methods of PFPS treatment, both methods
Discussion led to significant improvements. However, patellar taping
had greater effects on pain (Khuman et al., 2012). Another
This study aimed to evaluate the effect of IC and LPM on study compared 8 weeks of LPM as an indirect method
improving pain, function and PPT in patients with PFPS to versus patellar mobilization as a direct method in patients
determine which treatment was more effective. According with chronic PFPS. The LPM group showed greater changes
to the results, in both groups the clinical improvement has in pain intensity, patellar alignment and functional status
been achieved but the IC group showed higher rate of im- (Nambi, 2013). A comparison of tibiofemoral joint
provements. Our findings are consistent with earlier studies
of direct and indirect manual therapy to treat PFPS
(Powers, 1998; Suter et al., 1999; Fulkerson, 2002; Hou
et al., 2002; Crossley et al., 2004; Daly, 2005; Hillermann
et al., 2005; Brantingham et al., 2009; Khuman et al.,
2012; Miller et al., 2013; Nambi, 2013). However, straight-
forward comparisons with earlier studies are difficult
because no earlier studies, to our knowledge, have exam-
ined the presence of MTrP in the quadriceps and MTrP
sensitivity.
On examination, all participants had ipsilateral SIJ
dysfunction and at least one MTrP in the VMO of the
symptomatic knee, which produced pain. According to an
earlier study, LPM was associated with significant changes
in muscle activation, knee extensor torque and inhibition in Figure 2 Numeric pain rating scale scores in the two groups.
 Ischemic compression efficacy in patellofemoral pain syndrome
Table 4 Mean outcome measures and p values in the lumbopelvic manipulation group.
(I) (J) NPRS Kujala score PPT
b b
Mean p- 95% CI for difference Mean p- 95% CI for difference Mean p- 95% CI for differenceb
differencea value Lower Upper differencea value Lower Upper differencea value Lower Upper
(IeJ) bound bound (IeJ) bound bound (IeJ) bound bound
Before 1 week after 40 0.000 30.4 49.6 15.6 0.000 18.9 12.3 0.64 0.00 0.78 0.5
treatment treatment
1 month after 39 0.000 29.5 48.5 14.8 0.000 18.4 11.2 0.62 0.00 0.76 0.47
treatment
3 months after 35 0.000 25.5 44.5 12.9 0.000 16.5 9.2 0.5 0.00 0.67 0.31
treatment
1 week after Before treatment 40 0.00 49.6 30.4 15.6 0.000 12.3 18.9 0.64 0.00 0.5 0.78
treatment 1 month after 1 0.495 2.6 0.64 0.8 0.537 0.54 2.1 0.02 0.09 0.00 0.05
treatment
3 months after 5 0.003 8.3 1.6 2.7 0.000 1.5 3.9 0.15 0.00 0.05 0.24
treatment
1 month after Before treatment 39 0.000 48.5 29.5 14.8 0.000 11.2 18.4 0.62 0.00 0.47 0.76
treatment 1 week after 1 0.495 0.64 2.64 0.8 0.53 2.1 0.54 0.02 0.09 0.05 0.00
treatment
3 months after 4 0.008 7.1 0.93 1.93 0.002 0.65 3.2 0.12 0.00 0.03 0.21
treatment
3 months after Before treatment 35 0.000 44.4 25.5 12.9 0.000 9.2 16.5 0.5 0.00 0.31 0.67
treatment 1 week after 5 0.003 1.65 8.34 2.7 0.000 3.9 1.5 0.15 0.00 0.24 0.05
treatment
1 month after 4 0.008 0.931 7.07 1.9 0.002 3.2 0.65 0.12 0.00 0.21 0.03
treatment
All data are reported with 95% confidence intervals calculated with reference to baseline values.
a
Mean difference is significant at the 0.05 level.
b
Adjustment for multiple comparisons was performed by Bonferroni correction.

561
562
Figure 3 Kujala questionnaire scores in the two groups.
Figure 4 Pressure pain threshold in the two groups.
manipulation versus SIJ manipulation to increase quadri-
ceps muscle strength in patients with PFPS reported sig-
nificant improvement only in the SIJ manipulation group
(Hillermann et al., 2006).
Study limitations
Some patients had MTrP in other areas of the lower ex-
tremity in addition to the MTrP related to patellofemoral
joint during treatment. We did not treat these additional
areas of irritation, although they might have contributed to
knee pain in some participants. Also, we did not study the
effect of biomechanical and structural factors such as Q
angle and hip internal rotation on the outcomes reported
here. Because of the relatively small sample size, the val-
idity of our findings should be viewed with appropriate
caution. Moreover, because our participants were young,
the results may not be generalizable to all age groups.
Accordingly, studies with larger groups are needed to verify
our findings. Furthermore, the effects of sham IC should be
investigated in future clinical studies.
Conclusion
The findings of this double-blind randomized trial show that
although both direct and indirect techniques were helpful
in treating patients with PFPS, IC was more effective than
LPM and had longer-lasting effects on the patients’ symp-
toms. Referred pain or disturbed afferent feedback caused
by the dysfunctional SIJ and MTrP of the VMO might
S. Behrangrad, F. Kamali
contribute to the delayed onset of VMO activity and thus to
quadriceps inhibition. Because of the nonspecific nature
and vague criteria used to diagnose PFPS, many chronic
knee conditions are likely to be misdiagnosed as this syn-
drome. Future studies should examine postural alignment
of the thigh and VMO/VL activity ratio with valid, accurate
methods. This will provide additional information that
could be used to develop effective intervention programs
for patients with PFPS. Additional studies with more accu-
rate diagnostic methods such as X-ray are also needed.
Acknowledgments
This work was based on the MSc Dissertation of the first
author, Shabnam Behrangrad, presented at the School of
Rehabilitation, Shiraz University of Medical Sciences. The
authors are grateful for financial support from the Vice-
Chancellory for Research, Shiraz University of Medical Sci-
ences (92-6830). No commercial party had a direct financial
interest in the results of the research with which the au-
thors are associated. We thank K. Shashok (AuthorAID in the
Eastern Mediterranean) for improving the use of English in
the manuscript.
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