Experience from work in my thesis.

Jaap Jansen

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Theoretical framework considering groin pain Practice! Fundamental (explanatory) theory Recommendations

Consistent terminology during symposium: longstanding adductor-related groin pain (LAGP)

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Symptom of pain during forceful adduction

Similar as in patients with post partum pelvic pain. (Mens et al., 2006) Similar as in patients with post partum pelvic pain.

(Mens et al., 2006)

Active Straight Leg Raise test (ASLR) sometimes positive Wearing a pelvic belt decreases both symptoms
(Mens et al.,

2006) Similar as patients with post partum pelvic pain.

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2002)

Transversus abdominus (TA) as stabilizer of the pelvis

(Richardson

TA recruitment is delayed in athletes with LAGP (Cowan et al., 2004)

thickness in patients compared with controls Rest ASLR Hip adduction

Ultrasonography of deep abdominal muscle

TA resting thickness decreased in patients with LAGP

What are the effects of physical therapy with specific abdominal exercises compared to physical therapy with general hip-trunk stabilizing and strengthening exercises in athletes with LAGP? 1. Randomized controlled trial - Ultrasonographic measures - Sports related outcomes 2. Identification of prognostic factors associated with recovery

Control treatment Information on injury insight Mobilization/ manipulation hip, sacroiliac joints/lumbar spine

4 5

Intervention treatment Information on injury insight Mobilization/ manipulation hip, sacroiliac joints/lumbar spine Motor control training for TA function Low intensity cardiovascular exercise Low intensity cardiovascular exercise (bike, swimming) (bike, swimming) Low load hip adduction/ abduction training. Low load hip adduction/ abduction Straight/ oblique sit up training training with TA contraction. Straight/ oblique sit up training Bridging exercises while maintaining TA contraction Continuation of adduction/ abduction Continuation of adduction/ abduction exercises; increased load. Balance exercises with TA contraction and exercises using Swiss ball/ wobble board. avoidance of Valsalva maneuver; Return to running starting with 5 minutes increased load. Balance exercises jogging. Increase one minute per run using Swiss ball/ wobble board. Return to running starting with 5 minutes jogging; focus on breathing pattern. Increase one minute per run Sport specific exercises (kicking, sprinting, turning); gradual increase in intensity Return to sports at own club, starting with training and gradual progress to match

Baseline C (n=9) I (n=22)

14 weeks follow up C (n=9) I (n=22)

P-values from ANOVA Main effect time Interaction effect

TA Resting thickness (mm) Relative thickness ASLR (%) 15.1 (12.8) Relative thickness adduction (%) OI Resting thickness (mm) Relative thickness ASLR (%) 4.9 (9.9) Relative thickness adduction (%) 28.6 (27.2) 27.6 (24.5) 33.9 (22.4) 30.8 (24.7) 0.44 0.85 3.9 (8.4) 4.6 (7.4) 4.7 (9.2) 0.88 0.80 11.9 (3,0) 11.4 (1.6) 12.1 (2.9) 11.75 (2.0) 0.41 0.81 56.6 (45.6) 53.8 (41.4) 54.0 (38.8) 69.5 (55.2) 0.59 0.45 2.9 (12.1) 2.9 (15.2) 4.3 (14.5) 0.14 0.067 4.1 (1.0) 4.1 (0,8) 4.6 (1.2) 4.5 (0.87) 0.006 0.83

Sports restriction at follow up (numeric Likert scale 0-10) 0 1 2 3 4 5 6 7 8 9 10

N =35 (100%)

7 (20%) 9 (25.7%) 8 (22.8%) 1 (2.9%) 0 (0%) 3 (8.6%) 2 (5.7) 0 (0%) 3 (8.6%) 2 (5.7%) 0 (0%)

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* *

control intervention

self reported sports restriction

before intervention

after intervention

Return to sports yes Control (n=12) Intervention (n=23) 16 7 6 no 6

Odds ratio

Confidence interval

0.44

0.104 -1.84

No significant differences between control & intervention groups on abdominal and sportsrelated outcome measures!

Unstandardized coefficient Beta back pain (presence =1) ASLR test score Duration of complaints

Standardized P= coefficient Beta 0.47 -0,35 0.31 0.002 0.022 0.049

2.76 -0.934 0.016

A positive value for Beta indicates that a higher score is associated with more sports restriction at follow up i.e. poorer prognosis. Presence of back pain is associated with poorer prognosis.

Both general exercise and specific exercise programs are equally (in-)effective in changing abdominal muscle thickness (behavior) as measured with ultrasonography
Poor sensitivty of ultrasonography to detect small changes in muscle activity No measurements of changes in timing

Both general exercise and specific exercise programs are equally effective for athletes with LAGP in the short term! } Indications that low back pain, ASLR test score and duration of complaints are relevant predictors!
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Limitation: underpowered!

Does pain itself affect abdominal muscle recruitment? } 14 volunteers to study the effects of experimental groin pain using electrostimulation! } Ultrasonography
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Pain anticipation leads to adaptions in deep abdominal muscle recruitment } Pelvic instability not required to alter abdominal muscle behaviour (Jansen et al. Clin J Pain 2010)
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Might explain lack of difference between groups No need for specific stabilization!

Effects on hip/ groin proprioception } Repositioning error measured by a pulley apparatus using video analysis
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With and without painful electrostimulation Verbal estimate of the magnitude and direction of the error

15 healthy volunteers } No significant difference between repostioning error with (14.0 (5.9) or without pain (13.2 (5,69)) pixels (p=0.56). } Pain affects association between verbal estimate of error and true error
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Correlation verbal estimate-true error Verbal estimate-true error pain condition Rho=0,29 Rho=-0,01 P-value 0,05 0,995

Pain

Proprioception

Memory

Signal integration Motor output

Previous muscle activity

Specific exercises for deep abdominals

Only data on short term follow up!

Efficacy at long term follow up? } Altered recruitment of TA may not change without specific exercise potential risk factor for recurrence!
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Patients: } Dont wait too long consulting a sports medical expert on groin pain! } Strengthen your back muscles! A. Weir, PhD Therapists: } Use the ASLR test to prognose effectiveness of exercise therapy } Strengthen the hip flexion kinetic chain } Graded activity or pain contingent approach for exercise in LAGP?
Given the effects of pain on muscle recruitment patterns and its possible influence on proprioception, pain should not be ignored!

Thank you!