Does a Hip Muscle Activation Home Exercise Program Change Patient Performance on the Forward Step-Down Test? A Single-Arm Clinical Trail
Phase: NA
Conditions: Movement, Abnormal, Lower Extremity Problem
Sponsor: Louisiana State University Health Sciences Center Shreveport

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PROTOCOL TITLE: 
Does a Hip Muscle Activation Home Exercise Program Change Patient Performance on 
the Forward Step-Down Test? 
 
PRINCIPAL INVESTIGATOR: 
Daniel W. Flowers, PT, DPT, PhD 
Assistant Professor of Physical Therapy 
318-813-2958 
daniel.flowers@lsuhs.edu 
 
VERSION NUMBER: 
1 
DATE: 
10/31/22 
 

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Table of Contents 
1.0 
Objectives* .................................................................................................................................... 3 
2.0 
Background* ................................................................................................................................ 4 
3.0 
Inclusion and Exclusion Criteria* ........................................................................................ 6 
4.0 
Study-Wide Number of Subjects* ........................................................................................ 6 
5.0 
Study-Wide Recruitment Methods* .................................................................................... 6 
6.0 
Multi-Site Research* ................................................................................................................. 6 
7.0 
Study Timelines* ........................................................................................................................ 6 
8.0 
Study Endpoints* ....................................................................................................................... 7 
9.0 
Procedures Involved* ............................................................................................................... 7 
10.0 Data and Specimen Banking* ............................................................................................. 10 
11.0 Data Management* ................................................................................................................. 10 
12.0 Provisions to Monitor the Data to Ensure the Safety of Subjects* ....................... 11 
13.0 Withdrawal of Subjects* ...................................................................................................... 11 
14.0 Risks to Subjects* .................................................................................................................... 12 
15.0 Potential Benefits to Subjects* .......................................................................................... 12 
16.0 Vulnerable Populations* ...................................................................................................... 12 
17.0 Community-Based Participatory Research* ................................................................ 12 
18.0 Sharing of Results with Subjects* ..................................................................................... 12 
19.0 Setting ......................................................................................................................................... 12 
20.0 Resources Available ............................................................................................................... 13 
21.0 Prior Approvals ....................................................................................................................... 13 
22.0 Recruitment Methods............................................................................................................ 13 
23.0 Local Number of Subjects .................................................................................................... 14 
24.0 Confidentiality .............................................................. Error! Bookmark not defined. 
25.0 Provisions to Protect the Privacy Interests of Subjects ........................................... 14 
26.0 Compensation for Research-Related Injury ................................................................. 14 
27.0 Economic Burden to Subjects ............................................................................................ 14 
28.0 Consent Process ...................................................................................................................... 14 
29.0 Process to Document Consent in Writing...................................................................... 15 
30.0 Drugs or Devices ..................................................................................................................... 15 
 

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1.0 
Objectives* 
1.1 The purpose of this study is to determine if activation training of the 
hip musculature affects muscle activation and frontal plane 
mechanics in healthy individuals.  
Specific Aim 1: Determine whether performance on the forward 
step-down test (FSDT) changes after an eight-week home exercise 
program (HEP) focused on hip musculature activation in healthy 
individuals.  
Specific Aim 2: Determine whether surface electromyography 
(sEMG) hip musculature changes following an eight-week HEP 
focused on hip musculature activation in healthy individuals. 
Specific Aim 3: Determine whether a dose-response relationship 
exists between compliance on the HEP and changes in FSDT 
scores in healthy individuals. 
Specific Aim 4: Determine whether a dose-response relationship 
exists between compliance on the HEP and sEMG changes in hip 
musculature activation in healthy individuals.  
1.2 Specific Aim 1:  
H0: There will be no significant change in FSDT scores 
after an eight-week hip musculature activation HEP in 
healthy individuals.  
H1: There will be a significant change in FSDT scores after 
an eight-week hip musculature activation HEP in healthy 
individuals.  
Specific Aim 2:  
H0: There will be no significant change in sEMG data of hip 
musculature after an eight-week hip musculature activation 
HEP in healthy individuals.  
H1: There will be a significant change in sEMG data of hip 
musculature after an eight-week hip musculature activation 
HEP in healthy individuals.  
Specific Aim 3:  
H0: There will be no significant dose-response relationship 
between HEP compliance and FSDT scores in healthy 
individuals. 
H1: There will be a significant dose-response relationship 
between HEP compliance and the FSDT scores in healthy 
individuals. 
 

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Specific Aim 4:  
H0: There will be no significant dose-response relationship 
between HEP compliance and sEMG data of hip 
musculature in healthy individuals. 
H1: There will be a significant dose-response relationship 
between HEP compliance and sEMG data of hip 
musculature in healthy individuals. 
2.0 
Background*  
2.1 Over the past 10 years, there has been a shift in the literature 
regarding treatment for individuals with frontal plane abnormalities 
and altered lower extremity biomechanics, especially in the case of 
individuals with patellofemoral pain syndrome (PFPS). Originally, 
the treatment focused on the knee joint itself and strengthening the 
quadriceps musculature.1 Current literature suggests that the focus of 
treatment for individuals with PFPS should be on the proximal hip 
joint.2–5 There is evidence that pain is reduced in individuals with 
PFPS after hip and knee muscle strengthening compared with knee 
muscle strengthening alone.3 While it is necessary to rule out true 
tibiofemoral and patellofemoral joint issues in individuals with 
PFPS, it is important to not neglect the transverse and frontal plane 
movements of the hip and ankle joints.5 Women are more likely to 
suffer from PFPS syndrome because they have a lower rate of torque 
development in the hip extensors, leading to an earlier activation of 
the hip and knee extensors6, emphasizing the importance of focusing 
treatment on the proximal hip joint and surrounding musculature. It 
is important to remember that the muscles of the lower extremity are 
all connected via the lumbo-pelvic hip complex, which is why the 
recent literature focuses on more proximal musculature rehabilitation 
while treating more distal pathologies. 
Weakness of the hip abductors, external rotators, and extensors has 
been shown to lead to increased frontal and transverse plane motions 
at the hip.3 There is evidence to suggest that there are improvements 
in pain and overall function after a hip abductor and external rotation 
strengthening program.5 However, strength training has been unable 
to generate movement changes in women with PFP.3 In a case report 
on two separate patients with patellofemoral pain, muscle 
recruitment exercises, endurance training exercises, and core 
stability exercises were used to treat their pain, function, strength, 
gait, and biomechanical abnormalities. A combination of hip muscle 
activation and strengthening decreased the symptoms in these 
patients and improved their overall function, including stair 
navigation.2 In other areas of the body, activation training vs strength 
training has been compared to see what yields better outcomes.7 
There is a current hole in the literature regarding whether activation 

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training alone of the hip musculature can alter frontal plane 
movements of the lower extremity.  There is evidence to support that 
activation training of certain muscles may lead to better 
performances of the muscle during more advanced training 
programs.8 Increasing core activation during exercises focused on 
the hip musculature, such as clam shells, side-lying hip abduction, 
and prone hip extension, was shown to overall increase muscle 
activation of the LE.9 As for dosing of these exercises, one minute 
isometric holds have been shown to improve recruitment of the hip 
muscles during weight bearing activities.10 Hip muscle activation 
training is an area of treatment which needs more research to see the 
overall benefits, but it has been explored in core musculature11, so 
we hope to examine if similar results will occur at the hip joint.  
2.2 Our participants will execute the hip activation intervention via an 8 
week home exercise program (HEP). This is the first study on this 
topic by the authors; however, two of the authors have previously 
published work using the FSDT as an outcome measure, using the 
same procedures for assessment as in this investigation.12 The study 
will evaluate the effects of a hip activation training program via HEP 
on the FSDT, as well as compliance measures of the HEP to analyze 
a dose-response predictive relationship. 
2.3 The FSDT is a relevant outcome measure for people with altered 
frontal plane movements after an activation training program 
because activation training has been shown to alter corticomotor 
excitability of the gluteus maximus and hip biomechanics.13 The 
FSDT has been shown to assess neuromusculoskeletal control of the 
hip14, because treating the proximal musculature has been shown to 
be beneficial for outcomes.15,16 Intrarater reliability has been 
established for the FSDT in individuals with PFPS and has been 
shown to relate to changes in pain levels.17 Interrater reliability for 
the FSDT has also been established with good agreement of the 
quality and distinguishing of movements between raters.12,18 Validity 
has been established for the use of the FSDT on individuals with 
altered frontal plane mechanics.14 
Compliance measurements of the intervention sessions and the 
amount of change in the dependent variable pre- and post- 
intervention have been shown as a reliable way to predict a dose-
response relationship.11 In this study, the authors aim to analyze a 
dose-response predictive relationship between compliance of the 
intervention sessions and altered FSDT scores, as well as change in 
gluteus medius and maximus activation via sEMG data.  
We are aiming to determine if a hip musculature activation training 
HEP has any affect on FSDT scores and sEMG measures of 
activation and to see how compliance affects the FSDT and muscle 
activation.  

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3.0 
Inclusion and Exclusion Criteria* 
3.1 Screening will be done concurrently with the written informed 
consent process through a self-reported assessment. 
3.2 Inclusion: Participants must be current first or second year Doctor of 
Physical Therapy (DPT) students in the School of Allied Health 
Professions (SAHP) at LSU Health Shreveport (LSUHS).  
Exclusion: current knee pain or pathology in the dominant leg, and 
women with known pregnancy. 
3.3 Regarding the inclusion of persons at increased risk:  
• 
Adults unable to consent: excluded due to not meeting 
inclusion criteria 
• 
Individuals who are not yet adults (infants, children, 
teenagers): excluded because this is not our target population 
• 
Pregnant women: excluded due to creating greater than 
minimal risk 
• 
Prisoners: excluded due to not meeting our inclusion criteria 
4.0 
Study-Wide Number of Subjects* 
4.1 N/A, not multi-institutional. 
5.0 
Study-Wide Recruitment Methods* 
5.1 N/A, not multi-institutional 
5.2 N/A, not multi-institutional 
5.3 N/A, not multi-institutional 
6.0 
Multi-Site Research* 
6.1 N/A, not multi-institutional 
6.2 N/A, not multi-institutional 
6.3 N/A, not multi-institutional 
7.0 
Study Timelines* 
7.1 The duration of an individual subject’s participation in the study is 
220 minutes or 3.66 hours. It will take 30 minutes to measure and 
record anthropometrics, sEMG, FSDT, and teach the HEP. The 
FSDT and sEMG measurements will be taken again at the end of the 
intervention program. The HEP should take a maximum of 10 
minutes a session, therefore 20 minutes total are allotted each week. 
The duration anticipated to enroll all study subjects is 15 minutes. 
The estimated completion date for the study is August 2023.  
 

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8.0 
Study Endpoints* 
8.1 The primary and secondary study endpoints are the completion of 
data collection and intervention for all participants, which will be 
completed by May 2023. 
8.2 Refer to 8.1. 
9.0 
Procedures Involved*  
9.1 The study will utilize a repeated-measures design, where all 
participants will perform the FSDT for assessment pre- and post-
intervention via an HEP while sEMG data is being collected from 
the gluteus medius and gluteus maximus. All of the activities listed 
above will be performed on the dominant LE. The HEP will be a 
combination of hip musculature activation exercises used by 
previous researchers that show an increase in hip muscle 
recruitment.2,10,19,20 Core activation via a side plank will be added to 
the clam exercise and the side-lying hip abduction exercise.9In this 
design the dependent variables are the scores on the FSDT pre- and 
post-HEP, sEMG pre-and post-HEP, and compliance with the HEP. 
The independent variable is the performance of the eight-week HEP. 
Two physical therapist students will perform the FSDT assessments 
and sEMG data collection (CH and MS). Two faculty members will 
also assist with data collection (DF and EM). Prior to data collection 
and assessments, the two students (CH and MS) will be educated by 
the primary investigator (DF), who is a board-certified orthopedic 
clinical specialist physical therapist with ten years of experience, on 
the FSDT protocol. Scoring guidelines of the FSDT will be reviewed 
according to the study by Park et al18 and practiced prior to data 
collection. The sEMG electrode placement will come from The ABC 
of EMG.21 The procedure for collection of the maximum volitional 
isometric contraction (MVIC) of the gluteus medius will follow the 
protocol used in a study by Harput et al.22 The MVIC of the gluteus 
maximus will follow the protocol used in a study by Selkowitz et al, 
with the knee flexed to 90o in prone.19 The same methodology will 
be used from McCallister and Flowers for scoring and reporting of 
the FSDT scores.12 
9.2 One investigator (CH) will inform one PT cohort in room 1-117 
inside the SAHP at LSUHS via word of mouth. During this time, the 
investigators will obtain informed consent. If the required number of 
participants is not met (N = 35), the other investigator (MS) will 
recruit students from the other PT cohort via word-of- mouth about 
the investigation and obtain informed consent until the required 
number of participants are enrolled. Each participant will be given a 
random number to ensure patient confidentiality. After enrollment, 
each participant will sign up with their participant number for a time 

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to attend an initial data collection session in the rehabilitation faculty 
clinic and the motion analysis lab 2-217 in the SAHP at LSUHS. 
Participants will meet in the rehabilitation faculty clinic and age, sex, 
height, weight, BMI, and dominant lower extremity (LE) will be 
recorded by DF or EM. The dominant LE is defined as the leg that 
they usually use to kick a soccer ball.7 Participants will take the 
elevator to the second floor and report to 2-217 for sEMG and FSDT 
data collection. During this time, sEMG electrodes will be applied to 
the gluteus maximus and medius of the dominant leg, following the 
placement criteria from The ABC of EMG21 by EM (for female 
participants) or DF (for male participants) and an MVIC for each 
muscle will be performed and recorded, with resistance by CH.19,22 
Participants will be instructed on the procedure for the FSDT by CH 
prior to completing the test. The FSDT consists of five consecutive 
repetitions of a forward step down from a 20cm step, with one score 
given for the whole set of five repetitions.18 The two student 
investigators (CH and MS) will both score and average the number 
between the two scores.12 sEMG data and FSDT scores will be 
collected before and after the 8 week HEP. After the initial FSDT is 
completed, the participant will be educated on the HEP and the 
compliance chart by MS. The HEP will be a combination of hip 
musculature activation exercises used by previous researchers that 
show an increase in hip muscle recruitment.2,10,19,20 Core activation 
via a side plank will be added to the clam exercise and the side-lying 
hip abduction exercise.9 The HEP consists of five hip activation 
exercises, clams, clams with trunk activation via side-plank, side-
lying hip abduction, side-lying hip abduction with trunk activation 
via side-plank, and hydrants. The participants will perform isometric 
contractions of these exercises for up to one minute on the LE used 
for testing.10 Once the participant is able to hold all of these 
exercises for one minute without a break, the participant will 
advance to the next step, adding a yellow theraband and completing 
the same exercises. If the participant is able to isometrically hold 
these five exercises for one minute with a yellow theraband, the 
participant will progress to a red theraband and repeat the process of 
working towards one minute holds of each exercise. Each participant 
will demonstrate the exercises of the HEP to ensure proper form and 
be informed on the proper progression of the exercises. A 
compliance chart will be given to the participants to track every time 
they perform the HEP. Previous authors have used compliance charts 
to measure this variable in preparation for a dose-response analysis 
for activation programs.11 The participants will take home their HEP, 
a compliance chart, and a yellow and red theraband. The participants 
will complete the HEP two days a week for eight weeks, with at least 
two rest days between sessions, and document the completion of the 
session on the compliance chart. At the end of the 8 week period, 

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each participant will be scheduled to return to the motion analysis 
lab to turn in their compliance sheet and perform a follow-up sEMG 
and FSDT using the same procedures as before. 
9.3 Table of events that lists each procedure or test and how often the 
procedure or test will occur: 
 
Written informed consent 
1 
Eligibility screening 
1 
Anthropometric assessment (height, weight, BMI) 
1 
FSDT 
2 
sEMG 
2 
HEP education 
1 
Compliance chart education 
1 
HEP 
16 
Compliance chart documentation 
16 
 
9.4 To reduce the risk of loss of confidentiality, participants will be 
assigned numbers. All hardcopy data will be stored in DF office 
(locked), room 2-234 in the SAHP at LSUHS in a locked drawer. All 
electronic data will be stored using Sharepoint connected to school 
email addresses with a password.  
To reduce the risk of muscle soreness, participants will be educated 
on proper performance of the exercises, to space sessions at least two 
days apart, and to add a band or progress to a yellow theraband once 
they can perform all exercises for one consecutive minute on the 
dominant LE. An informed consent document with participant 
identification numbers will be used to obtain consent from the 
participants. A participant identification number key will be made to 
match the participant name to their assigned number to maintain 
confidentiality. A sign up for the anthropometric data collection and 
pre- and post-HEP sEMG and FSDT data collection will be created, 
allowing the participants to sign up with their identification number. 
An excel sheet to collect data will be used by the investigators. A 
compliance chart for the participants to track their exercise sessions 
will be created. A paper copy of the HEP will be given to the 
participants.  

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9.5 Data collected will consist of participant age, height, weight, BMI, 
all at the first visit, in addition to the following pre- and post-
intervention: FSDT, sEMG from gluteus medius and maximus, 
recorded FSDT video. The data from the compliance chart will only 
be collected post-intervention. 
9.6 N/A 
 
10.0 Data and Specimen Banking* 
10.1 N/A 
10.2 N/A 
10.3 N/A 
11.0 Data Management* and Confidentiality 
11.1 FSDT 
 
Due to the ordinal nature of the FSDT data, a non-
parametric repeated-measures analysis will be performed to 
analyze the data. Therefore, a Wilcoxon signed-rank test 
will be performed. For the sEMG data, a repeated measures 
t-test or appropriate nonparametric twin via the Wilcoxon 
signed-rank test if assumptions are not met for parametric 
analysis will be used. Descriptive statistics will be provided 
for the demographic data.  
sEMG 
Data processing: Raw sEMG signals will be bandpass 
filtered between 10-500 Hz. The signal will be rectified, 
then smoothed using the Root Mean Square method with a 
50ms window. The signal will be normalized to the MVIC 
obtained during the MVIC testing.  
Data analysis: Following MVIC normalization, the mean 
EMG activation and peak EMG activation for each trial 
will be recorded. Each step-down repetition will be 
analyzed as a separate trial, and an average taken of all 5 
trials to provide the data for each muscle pre- and post-test.  
11.2 G*power (Heinrich-Heine-University Düsseldorf, Düsseldorf, 
Germany) software was used to perform an a priori power analysis to 
determine the required N for this investigation. Data was obtained 
from McCallister and Flowers (2020), which showed a significant 
within-groups difference pre-exertion and five minutes post-exertion 
change on the FSDT (r = .27). Pearson’s coefficient was converted to 
Cohen's d (d = .56). An N of 29 was calculated to achieve significant 
results, with beta = .80 and alpha = .05 for a two-tailed hypothesis 
from a repeated-measures design within groups analysis. We 

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assumed an attrition rate of 20% given the repeated-measures design 
of the investigation. Therefore, a final N of 35 will be recruited for 
the successful completion of this study. 
11.3 See 9.4 
11.4 The student investigators (CH and MS) will be educated on the 
proper procedures of the FSDT, sEMG data collection, and the HEP 
by the primary investigator (DF) and co-investigator (EM). The 
FSDT will be analyzed and scored by the two student investigators 
(CH and MS). The student investigators (CH and MS) will record 
and average their scores following the completion of five repetitions 
to improve the quality of the data.12 The sEMG electrodes will be 
placed on the female participants by EM and on the male participants 
by DF. CH will provide the pressure for the MVIC and explain the 
FSDT procedure to every participant. MS will explain the HEP and 
the compliance chart to the participants. The primary investigator 
(DF) is a board-certified orthopedic physical therapist with 10 years 
of experience, who has published research on this test.12 The co-
investigator (EM) is also a board-certified orthopedic physical 
therapist with 5 years of experience, who also published research on 
this test with the primary investigator.12  
11.5 The data that will be collected during the entire study includes: 
participant number, height, weight, BMI, sex, leg dominance, FSDT 
pre and post HEP, recorded FSDT video, sEMG from gluteus 
medius and maximus on the dominant leg during FSDT pre and post 
HEP, and compliance. Data storage will follow the guidelines in 
section 9.4. The data will be stored for the duration of the study and 
throughout the following semester while analyzing and finalizing 
data for presentation. The data will be kept up to one year after the 
completion of the data analysis in event that the research wants to be 
continued. The only people to have access to this information will be 
the primary investigators, student investigators, and the co-
investigator (DF, EM, CH, MS). All investigators are responsible for 
the receipt and transmission of the data. Data will be manually 
transported to DF office room 2-234 in the SAHP at LSUHS. 
Electronic data will remain on Sharepoint. 
12.0 Provisions to Monitor the Data to Ensure the Safety of Subjects* 
12.1 N/A 
13.0 Withdrawal of Subjects* 
13.1 Non-study related injury that affects ability to complete HEP or 
FSDT post intervention. 
13.2 After the participant has notified any investigator that they wish no 
longer to continue or no longer meet the inclusion/exclusion criteria, 
the investigators will notify the participant that they have been 

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withdrawn from the study and document the nature for withdrawal 
and date. The participant will return the compliance sheet to the 
investigators. 
13.3 N/A 
 
14.0 Risks to Subjects* 
14.1 Muscle soreness is a potential side effect that may occur with 
exercise.  
This will be minimized via the progression principles previously outlined 
in section 9.4.   
Participant loss of confidentiality is always a risk; however, this will be 
minimized via the procedures enumerated in section 9.4. 
14.2 N/A 
14.3 N/A 
14.4 N/A 
15.0 Potential Benefits to Subjects* 
15.1 The potential benefits that an individual may experience from taking 
part in this investigation are improved frontal plane trunk and LE 
mechanics and improved gluteus medius and maximus activation. 
15.2 N/A 
16.0 Vulnerable Populations* 
16.1 N/A 
17.0 Community-Based Participatory Research* 
17.1 N/A 
18.0 Sharing of Results with Subjects* 
18.1 Participants will not receive their individual results. 
19.0 Setting 
19.1 This study will recruit potential subjects from two cohorts of DPT 
students. The students are currently attending the SAHP at LSUHS 
in Shreveport, LA. Recruitment will take place via the procedures 
outlined in section 9.2. Procedures for research will be performed in 
the SAHP at LSUHS. Anthropometric data will be collected in the 
rehabilitation faculty clinic. The motion analysis lab, room 2-217, 
will be used for the sEMG data collection, FSDT, and education of 
the HEP. There is no composition or involvement of any community 
advisory board. The research will not be conducted outside of the 
organization or its affiliates.  

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20.0 Resources Available 
20.1 The two student investigators (CH and MS) are DPT students in the 
SAHP at LSUHS. They will be educated on the procedures of the 
FSDT, described in Park et al18, sEMG electrode placement21, and 
data collection and interpretation19,22 by the primary investigator 
(DF), who is a board-certified orthopedic physical therapist with 10 
years of experience and the co-investigator (EM), who is a board-
certified orthopedic physical therapist with 5 years of experience. 
The primary (DF) and co-investigator (EM) will assist the student 
investigators as needed throughout the study, including assisting 
with data collection and analysis. 
20.2 The total number of first and second year DPT students enrolled in 
the SAHP at LSUHS is 67. Given the required N=35, there are 
enough potential participants to successfully complete this 
investigation. The student investigators (CH and MS) are enrolled in 
an independent study for the Fall 2022 semester to receive IRB 
approval. In the spring of 2023, the data collection portion of the 
study will begin and be concluded by May 2023. The investigators 
will be enrolled in Research IV during this semester to allow time to 
begin working on the poster presentation. Drs. Flowers and 
McCallister will each provide 5% FTE for their involvement in the 
study. During the summer semester of 2023, the student investigators 
will begin analyzing the data and disseminating. All data analysis 
will be concluded by August 2023. The motion analysis lab, room 2-
217 in SAHP at LSUHS has a treatment mat, sEMG materials and 
technology, in addition a large open space used for motion analysis. 
The Rehabilitation Faculty Clinic is located on the ground floor of 
the SAHP at LSUHS and is where the anthropometric data will be 
collected. Our study has less than minimal risk. The PI will complete 
the DOA, including the assigning of roles and responsibilities, and 
educate each investigator at the time of signing. 
21.0 Prior Approvals 
21.1 Dr. Edward Mahoney will need to provide approval for the study to 
commence since he serves as Chair of the Physical Therapy 
Department. 
22.0 Recruitment Methods 
22.1 One investigator (CH) will inform one DPT cohort in room 1-117 
inside the SAHP at LSUHS via word of mouth. During this time, the 
investigators will obtain informed consent. If the required number of 
participants is not met (N = 35), the other investigator (MS) will 
recruit students from the other DPT cohort via word-of- mouth about 
the investigation and obtain informed consent until the required 
number of participants are enrolled. 

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22.2 The subjects will be either 1st or 2nd year DPT students in the SAHP 
at LSUHS. 
22.3 Potential subjects will first be identified from one DPT by entering 
room 1-117 of the SAHP at LSUHS. If not enough participants are 
enrolled, the remainder will be recruited via word of mouth from the 
other DPT cohort.  
22.4 N/A 
22.5 N/A 
23.0 Local Number of Subjects 
23.1 At least 35 participants will be recruited locally.  
23.2 We hope to enroll 35 participants. 
24.0 Provisions to Protect the Privacy Interests of Subjects 
24.1 Individuals participating in the study will be given an identification 
number to protect personal identity. Participants will only be 
expected to interact and provide personal information to the 
investigators on the study. 
24.2 There will only be the investigators in the room during data 
collection, and any questions will be asked individually with the 
investigators. If another participant is to be in the room learning the 
HEP, the view will be obstructed with a divider to ensure 
confidentiality. Any written data will refer to the participants with 
numbers, not actual names. No previous medical history will be 
entered into the data collection. 
24.3 Any information about the subjects will be verbally reported to 
investigators. 
25.0 Compensation for Research-Related Injury 
25.1 It does not involve greater than minimal risk. 
25.2 N/A 
26.0 Economic Burden to Subjects 
26.1 There will be no economic burden to the participants. Any required 
materials will be provided. The only thing the participants will be 
responsible for is transportation to the facility where study is 
conducted. 
27.0 Consent Process 
27.1 The consent process will take place in the SAHP at LSUHS in rooms 
1-117 and 3-314. There is no waiting period between informing the 
prospective subject and obtaining the consent. Continued verbal 
consent will be given during the FSDT/sEMG process both before 

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Institutional Review Board 
 
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and after HEP. We will be using “SOP: Informed Consent Process 
for Research (HRP-090).” 
Non-English Speaking Subjects 
N/A 
Waiver or Alteration of Consent Process (consent will not be 
obtained, required information will not be disclosed, or the 
research involves deception) 
N/A 
Subjects who are not yet adults (infants, children, teenagers) 
N/A 
Cognitively Impaired Adults 
N/A 
Adults Unable to Consent 
N/A 
Adults Unable to Consent 
N/A 
28.0 Process to Document Consent in Writing 
28.1 We will be using “SOP: Written Documentation of Consent (HRP-
091).” 
28.2 Our research does not involve more than minimal risk.  
28.3 See attached completed informed consent form submitted with this 
protocol.  
29.0 Drugs or Devices 
 
N/A, no device 
 
 
 

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References:  
 
1.  
Nascimento LR, Teixeira-Salmela LF, Souza RB, Resende RA. Hip and knee 
strengthening is more effective than knee strengthening alone for reducing pain 
and improving activity in individuals with patellofemoral pain: A systematic 
review with meta-analysis. J Orthop Sports Phys Ther. 2018;48(1):19-31. 
doi:10.2519/jospt.2018.7365 
2.  
Mascal CL, Landel R, Powers C. Management of Patellofemoral Pain Function : 2 
Case Reports. J Orthop Sport Phys Ther. 2003;33(11):647-660. 
3.  
Rabelo ND dos A, Lucareli PRG. Do hip muscle weakness and dynamic knee 
valgus matter for the clinical evaluation and decision-making process in patients 
with patellofemoral pain? Brazilian J Phys Ther. 2018;22(2):105-109. 
doi:10.1016/j.bjpt.2017.10.002 
4.  
Collins NJ, Barton CJ, Van Middelkoop M, et al. 2018 Consensus statement on 
exercise therapy and physical interventions (orthoses, taping and manual therapy) 
to treat patellofemoral pain: Recommendations from the 5th International 
Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017. Br J Sports 
Med. 2018;52(18):1170-1178. doi:10.1136/bjsports-2018-099397 
5.  
Bolgla LA, Boling MC, Mace KL, DiStefano MJ, Fithian DC, Powers CM. 
National athletic trainers’ association position statement: Management of 
individuals with patellofemoral pain. J Athl Train. 2018;53(9):820-836. 
doi:10.4085/1062-6050-231-15 
6.  
Stearns-Reider KM, Powers CM. Rate of Torque Development and Feedforward 
Control of the Hip and Knee Extensors: Gender Differences. J Mot Behav. 
2018;50(3):321-329. doi:10.1080/00222895.2017.1363692 
7.  
Flowers DW, Brewer W, Ellison J, Mitchell K, Frilot C. Transversus abdominis 
activation does not alter gait impairments in patients with and without knee 
osteoarthritis. Clin Biomech. 2021;82(May 2020):105270. 
doi:10.1016/j.clinbiomech.2020.105270 
8.  
Fisher BE, Southam AC, Kuo Y-L, Powers CM. Evidence of altered corticomotor 
excitability following targeted activation of gluteus maximus training in healthy 
individuals. Neuroreport. 2016;27(6). 
9.  
Chan MK, Chow KW, Lai AY, Mak NK, Sze JC, Tsang SM. The effects of 
therapeutic hip exercise with abdominal core activation on recruitment of the hip 
muscles. BMC Musculoskelet Disord. 2017;18(1):1-11. doi:10.1186/s12891-017-
1674-2 
10.  
Cannon J, Weithman BA, Powers CM. Activation training facilitates gluteus 
maximus recruitment during weight-bearing strengthening exercises. J 
Electromyogr Kinesiol. 2022;63(August 2021):102643. 
doi:10.1016/j.jelekin.2022.102643 
11.  
Flowers DW, Brewer W, Mitchell K, Ellison J, Frilot C. The Effect of Core 
Stabilization Training on Improving Gait and Self-Perceived Function in Patients 
with Knee Osteoarthritis: A Single-Arm Clinical Trial. Pathophysiology. 
2022;29(3):495-506. doi:10.3390/pathophysiology29030040 
12.  
McCallister E, Flowers D. Can the Forward-Step-Down Test Be Used Reliably in 
the Clinical Setting to Assess Movement Changes Resulting from Maximal 

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Exertion? A Pilot Study. Internet J Allied Heal Sci Pract. 2020;18(4). 
doi:10.46743/1540-580x/2020.1931 
13.  
Shih Y, Fisher BE, Smith JA, Powers CM. Corticomotor Excitability of Gluteus 
Maximus Is Associated. J Mot Behav. 2021;53(1). 
14.  
McGovern RP, Martin RL, Christoforetti JJ, Kivlan BR. Evidence-Based 
Procedures for Performing the Single Leg Squat and Step-Down Tests in 
Evaluation of Non-Arthritic Hip Pain: a Literature Review. Int J Sports Phys Ther. 
2018;13(3):526-536. doi:10.26603/ijspt20180526 
15.  
Earl-Boehm JE, Bolgla LA, Emory C, Hamstra-Wright KL, Tarima S, Ferber R. 
Treatment success of hip and core or knee strengthening for patellofemoral pain: 
Development of clinical prediction rules. J Athl Train. 2018;53(6):545-552. 
doi:10.4085/1062-6050-510-16 
16.  
Powers CM. The influence of abnormal hip mechanics on knee injury: A 
biomechanical perspective. J Orthop Sports Phys Ther. 2010;40(2):42-51. 
doi:10.2519/jospt.2010.3337 
17.  
Loudon JK, Wiesner D, Goist-Foley HL, Asjes C, Loudon KL. Intrarater reliability 
of functional performance tests for subjects with patellofemoral pain syndrome. J 
Athl Train. 2002;37(3):256-261. 
18.  
Park KM, Cynn HS, Choung SD. Musculoskeletal predictors of movement quality 
for the forward step-down test in asymptomatic women. J Orthop Sports Phys 
Ther. 2013;43(7):504-510. doi:10.2519/jospt.2013.4073 
19.  
Selkowitz DM, Beneck GJ, Powers CM. Comparison of electromyographic 
activity of the superior and inferior portions of the gluteus maximus muscle during 
common therapeutic exercises. J Orthop Sports Phys Ther. 2016;46(9):794-799. 
doi:10.2519/jospt.2016.6493 
20.  
Selkowitz DM, Beneck GJ, Powers CM. Which exercises target the gluteal 
muscles while minimizing activation of the tensor fascia lata? Electromyographic 
assessment using fine-wire electrodes. J Orthop Sports Phys Ther. 2013;43(2):54-
64. doi:10.2519/jospt.2013.4116 
21.  
Konrad P. The ABC of EMG: A Practical Introduction to Kinesiological 
Electromyography. Noraxon U.S.A.; 2006. 
22.  
Harput G, Ulusoy B, Akmese R, Ergun N. Comparison of muscle activation levels 
and knee valgus between individuals with medial patellofemoral ligament 
reconstruction and healthy individuals during fatiguing step down task. Clin 
Biomech. 2020;78(May):105067. doi:10.1016/j.clinbiomech.2020.105067