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Follow-up: The details of that strength training protocol that didn’t work for knee pain

 •  • by Paul Ingraham
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I recently blogged some bad news about strengthening as a treatment for anterior knee pain — strength failed a fair test. Before the virtual ink was dry, I regretted omitting a description of exactly what exercise was on trial, because readers started scoffing at the protocol, without even knowing it: “Must have been shite! Only possible explanation!”

And I couldn’t reply, because I lost my PDF of the paper! Awkward.🎵 I got another copy (you can usually just ask the authors), but it took a few days.

So, what did Hansen et al. ask people to do? Was it one-size-fits-all training? Was it incompetent? Was it lame?

No. The exercise protocol was not shite. In fact, I was pleasantly surprised by how thoughtfully conceived and thoroughly reported it was.

Amusingly, these authors have another paper about the lousy reporting of exercise protocols in 38 similar trials: “the level of exercise prescription detail was low” they say. And they seemed keen not to make the same mistake! They clearly wanted to do it right and “show their work.” Bravo.

Flow chart time! I will describe it nicely for you. First cell says: new study published. Second cell: does it confirm my beliefs? If yes… must be a GOOD study. If no… must be a BAD study, so nitpick and find flaws, bad study confirmed! And then both pathways then ultimately lead to the inevitable conclusion: “I was right all along!”

This might be my all-time favourite flowchart.

The strength training

It was exactly what patients can expect from competent physical therapists in the wild, neither fancy nor shoddy. And the subjects got stronger! By a respectable 10%.

They got there with twelve weeks of regular workouts at home, each one 3 sets of 8-12 repetitions. The knee exercises were:

  • sitting knee extension
  • squat
  • forward lunge

And the hip exercises were:

  • hip external rotation (clam shell)
  • side-lying/standing hip abduction
  • prone/standing hip extension

Patients were trained at an initial session with an “experienced” physiotherapist, and they were directed to adjust their repetitions to their ability; there were monthly follow-up visits with review and emphasis of progression principles.

Would a perfect protocol work?

Maybe! But this was not a test of ideal strength training and nor should it have been. Such ambitious trials are rarely done; it’s difficult and dubious to chase after an ideal that’s out of reach for most people. This test reflected clinical reality.

Hypothetically, there’s only one obvious major improvement anyway:

“… although personalisation of exercise interventions to individual patients or subgroup of patients may be a useful strategy that can ultimately lead to improved outcomes for patients, such strategy remains to be supported by research evidence — preferably from prospective randomised trials.”

In other words: fancier strengthening for knee pain hasn’t been studied … and someone should do that someday … but today is not that day.

PainSci Member Login » Submit your email to unlock member content. If you can’t remember/access your registration email, please contact me. ~ Paul Ingraham, PainSci Publisher