Four Outcome Measures for Patellofemoral Joint Problems

Patient-Reported Outcome Measures for Adults and Adolescents With Patellofemoral Pain: A Systematic Review of Construct Validity, Reliability, Responsiveness, and Interpretability Using the COSMIN Methodology

OBJECTIVE: We aimed to appraise the construct validity, reliability, responsiveness, and interpretability of patient-reported outcome measures (PROMs) used to assess function and pain in adults and adolescents with patellofemoral pain (PFP). DESIGN: Systematic review of measurement properties LITERATURE SEARCH: We searched the PubMed, CINAHL, Scopus, SPORTDiscus, and Cochrane Library databases from inception to January 6, 2022. STUDY SELECTION CRITERIA: We included studies that assessed the measurement properties of English-language PROMs for PFP and their cultural adaptations and translations. DATA SYNTHESIS: Using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology, we determined overall ratings and quality of evidence for construct validity, internal consistency, reliability, measurement error, and responsiveness. We extracted data related to interpretability for clinical use. RESULTS: After screening 7066 titles, 61 studies for 33 PROMs were included. Only 2 PROMs had evidence of "sufficient" or "indeterminate" quality for all measurement properties. The Knee injury and Osteoarthritis Outcome Score patellofemoral subscale (KOOS-PF) had "low" to "high" quality evidence for a rating of "sufficient" for 4 measurement properties. The Lower Extremity Functional Scale (LEFS) had very low-quality evidence for a "sufficient" rating for 4 measurement properties. The KOOS-PF and LEFS were rated "indeterminate" for structural validity and internal consistency. The KOOS-PF had the best interpretability with reported minimal important change and 0% ceiling and floor effects. No studies examined cross-cultural validity. CONCLUSION: The KOOS-PF and LEFS had the strongest measurement properties among PROMs used for PFP. More research is needed, particularly regarding structural validity and interpretability of PROMs. J Orthop Sports Phys Ther 2023;53(8):1-20. Epub: 20 June 2023. doi:10.2519/jospt.2023.11730.

Additional effects of core stability exercises on pain and function of patients with patellofemoral pain: A randomized controlled trial

Background/purpose:

Recently, there is more emphasis on the role of core muscles in pathogenesis and rehabilitation of patellofemoral pain (PFP). We aimed to investigate whether increased core muscle strength and endurance improve clinical outcomes.

Methods:

In a randomized controlled trial, 60 patients (M/F: 25/35, age = 32.28 (5.9) years) with PFP were randomly allocated into two groups of routine exercise (control) and combined core plus routine exercise (intervention). Home exercise was scheduled at least 5 times/week for 12 weeks. We assessed the outcomes of pain (Visual analogue scale) and function (Anterior knee pain score) before and immediately after interventions.

Results:

Significant improvements were reported in both groups (P < 0.001). There were significant between-group differences in both outcomes in favor of the intervention (Pain: 12.4, CI 95%: 7.1–17.8, P < 0.001; Function: 6.4, CI 95%: 2.2–10.5, P = 0.003).

Conclusion:

Outcome improvements were significantly greater in intervention group. Inclusion of core stability exercises may lead to additional benefits.

Patellofemoral Pain

Patellofemoral pain (PFP) is a common musculoskeletal-related condition that is characterized by insidious onset of poorly defined pain, localized to the anterior retropatellar and/or peripatellar region of the knee. The onset of symptoms can be slow or acutely develop with a worsening of pain accompanying lower-limb loading activities (eg, squatting, prolonged sitting, ascending/descending stairs, jumping, or running). Symptoms can restrict participation in physical activity, sports, and work, as well as recur and persist for years. This clinical practice guideline will allow physical therapists and other rehabilitation specialists to stay up to date with evolving PFP knowledge and practices, and help them to make evidence-based treatment decisions. J Orthop Sports Phys Ther. 2019;49(9):CPG1-CPG95. doi:10.2519/jospt.2019.0302.

Clinical Outcomes After the Nonoperative Management of Lateral Patellar Dislocations: A Systematic Review

Background:

The first-line treatment for patellar dislocations is often nonoperative and consists of physical therapy and immobilization techniques, with various adjuncts employed. However, the outcomes of nonoperative therapy are poorly described, and there is a lack of quality evidence to define the optimal intervention.

Purpose:

To perform a comprehensive review of the literature and assess the quality of studies presenting patient outcomes from nonoperative interventions for patellar dislocations.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

The MEDLINE, AMED, Embase, CINAHL, Cochrane Library, PEDro, and SPORTDiscus electronic databases were searched through July 2017 by 3 independent reviewers. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Study quality was assessed using the CONSORT (Consolidated Standards for Reporting Trials) criteria for randomized controlled trials and the Newcastle-Ottawa Scale for cohort studies and case series.

Results:

A total of 25 studies met our inclusion criteria, including 12 randomized controlled trials, 7 cohort studies, and 6 case series, consisting of 1066 patients. Studies were grouped according to 4 broad categories of nonoperative interventions based on immobilization, weightbearing status, quadriceps exercise type, and alternative therapies. The most commonly used outcome measure was the Kujala score, and the pooled redislocation rate was 31%.

Conclusion:

This systematic review found that patient-reported outcomes consistently improved after all methods of treatment but did not return to normal. Redislocation rates were high and close to the redislocation rates reported in natural history studies. There is a lack of quality evidence to advocate the use of any particular nonoperative technique for the treatment of patellar dislocations.

The patellofemoral pain and osteoarthritis subscale of the KOOS (KOOS-PF): development and validation using the COSMIN checklist

Background

Patellofemoral pain and osteoarthritis are prevalent and associated with substantial pain and functional impairments. Patient-reported outcome measures (PROMs) are recommended for research and clinical use, but no PROMs are specific for patellofemoral osteoarthritis, and existing PROMs for patellofemoral pain have methodological limitations. This study aimed to develop a new subscale of the Knee injury and Osteoarthritis Outcome Score for patellofemoral pain and osteoarthritis (KOOS-PF), and evaluate its measurement properties.

Methods

Items were generated using input from 50 patients with patellofemoral pain and/or osteoarthritis and 14 health and medical clinicians. Item reduction was performed using data from patellofemoral cohorts (n=138). We used the COnsesus-based Standards for the selection of health Measurements INstruments guidelines to evaluate reliability, validity, responsiveness and interpretability of the final version of KOOS-PF and other KOOS subscales.

Results

From an initial 80 generated items, the final subscale included 11 items. KOOS-PF items loaded predominantly on one factor, pain during activities that load the patellofemoral joint. KOOS-PF had good internal consistency (Cronbach’s α 0.86) and adequate test–retest reliability (intraclass correlation coefficient 0.86). Hypothesis testing supported convergent, divergent and known-groups validity. Responsiveness was confirmed, with KOOS-PF demonstrating a moderate correlation with Global Rating of Change scores (r 0.52) and large effect size (Cohen’s d 0.89). Minimal detectable change was 2.3 (groups) and 16 (individuals), while minimal important change was 16.4. There were no floor or ceiling effects.

Conclusions

The 11-item KOOS-PF, developed in consultation with patients and clinicians, demonstrated adequate measurement properties, and is recommended for clinical and research use in patients with patellofemoral pain and osteoarthritis.

Effects of physical therapist-guided quadriceps-strengthening exercises for the treatment of patellofemoral pain syndrome: a systematic review

STUDY DESIGN

Systematic literature review.

OBJECTIVE

To summarize the evidence for physical therapist-guided quadriceps-strengthening exercises as a treatment for patellofemoral pain syndrome.

BACKGROUND

Although quadriceps strengthening is often included in the plan of care for patellofemoral pain syndrome, a systematic review published in 2003 found only limited evidence that exercise was more effective than no exercise for this common condition.

METHODS

The PubMed, Embase/MEDLINE, and Cochrane Central Register of Controlled Trials databases, from inception to January 9, 2014, were searched for randomized controlled trials comparing the use of quadriceps-strengthening exercises to interventions consisting of advice/information or a placebo. Outcomes of interest were pain measures and function, as measured with self-report questionnaires. The methodological quality of the randomized controlled trials was assessed with the Physiotherapy Evidence Database scale. Results were summarized using a best-evidence synthesis and graphically illustrated using forest plots without meta-analysis.

RESULTS

Seven studies were included in the literature review. These studies reported strong evidence that isolated quadriceps strengthening is more effective in reducing pain and improving function than advice and information alone. In addition, compared to advice and information or placebo, there was strong evidence that quadriceps-strengthening exercises combined with other interventions may be more effective in reducing pain immediately postintervention and after 12 months, but not in improving function.

CONCLUSION

The literature provides strong evidence for the use of quadriceps-strengthening exercises, with or without other interventions, for the treatment of patellofemoral pain syndrome.

A feasibility study for a pragmatic randomised controlled trial comparing cast immobilisation versus no immobilisation for patients following first-time patellar dislocation

BACKGROUND

The purpose of this feasibility study was to begin to determine the efficacy of cylinder cast immobilisation compared to no form of immobilisation for patients following first-time patellar dislocation (FTPD).

MATERIALS AND METHODS

Participants were patients who attended a National Health Service Accident and Emergency department following a FTPD. Patients were randomised to receive immobilisation for four weeks in a cylinder cast followed by rehabilitation, versus no immobilisation and early rehabilitation. All patients were followed-up over a three month period, assessed using the Visual analogue scale for pain, Short Form-36, the Lysholm knee score and the Modified Functional Index.

RESULTS

Forty-one patients were approached to participate. Eight satisfied the pre-defined eligibility criteria and were randomised between the two groups. Whilst the results indicated a trend for superior short-term functional outcomes for those patients not immobilised compared to those immobilised following a FTPD, the small sample and baseline imbalances between the groups may have had a substantial influence on the results.

CONCLUSION

This feasibility study has indicated that the outcome measurements adopted were appropriate to answer this research question, but the assessment of return to normal activity, recurrent instability and dislocation and cost-effectiveness over a longer follow-up period is recommended. Similarly, defining a more pragmatic eligibility criteria and recruiting from multiple centres would be recommended for the definitive trial requiring a sample of 348 patients to demonstrate a statistical significant treatment effect.

Kinesiophobia and symptomatology in chronic fatigue syndrome: a psychometric study of two questionnaires

OBJECTIVES

The aims of the study were to examine the reliability of the Dutch and French versions of the Tampa scale kinesiophobia (TSK) version chronic fatigue syndrome (CFS), and to examine the reliability and validity of the Dutch and French versions of the CFS symptom list.

DESIGN

Repeated-measures design.

METHODS

Native Dutch speakers (N=100) and native French (N=48) speakers fulfilling the diagnostic criteria for CFS were asked to list the five most important symptoms and to complete the TSK-CFS, the CFS symptom list, and the Short Form 36 Health Status Survey or SF-36. A modified version of the TSK-CFS and the CFS symptom list was filled in within 24 hours of the first assessment.

RESULTS

The French and Dutch version of the TSK-CFS and CFS symptom lists displayed good reliability (ICC>or=.83). The CFS symptom list was internally consistent (Cronbach's alpha>or=.93) and concurrently valid with the SF-36. For the native Dutch and French speakers, respectively, 82 and 78% of the self-reported symptoms matched the content of CFS symptom list.

CONCLUSIONS

The results are in support of the psychometric properties of the French and Dutch versions of both the TSK-CFS and the CFS symptom list for assessing kinesiophobia and symptom severity, respectively.

Disability in patients with chronic patellofemoral pain syndrome: a randomised controlled trial of VMO selective training versus general quadriceps strengthening

This study was a prospective single blind randomised controlled trial to compare the effects of rehabilitation with emphasis on retraining the vastus medialis (VMO) component of the quadriceps femoris muscle and rehabilitation with emphasis on general strengthening of the quadriceps femoris muscles on pain, function and Quality of Life in patients with patellofemoral pain syndrome (PFPS). Patients with PFPS (n=69) were recruited from a hospital orthopaedic clinic and randomised into three groups: (1) physiotherapy with emphasis on selectively retraining the VMO (Selective); (2) physiotherapy with emphasis on general strengthening of the quadriceps femoris muscles (General); and (3) a no-treatment control group (Control). The three groups were then compared before and after an eight-week rehabilitation period. The Selective and General groups demonstrated statistically significant and 'moderate' to 'large' effect size reductions in pain when compared to the Control group. Both the Selective and General groups displayed statistically significant and 'moderate' and 'large' effect size improvements in subjective function and Quality of Life compared to the Control group. Knee flexion excursion during the stance phase of gait, demonstrated that there were no statistical significant differences and only 'trivial' to 'small' effect size differences between the Selective or General groups and the Control group. A large number of PFPS patients can experience significant improvements in pain, function and Quality of Life, at least in the short term, with quadriceps femoris rehabilitation, with or without emphasis on selective activation of the VMO component. Both approaches would seem acceptable for rehabilitating patients with PFPS. It may be appropriate to undertake exercises involving selective activation of the vastus medialis early in the rehabilitation process, however, clinicians should not overly focus on selective activation before progressing rehabilitation, especially in more chronic cases with significant participation restrictions.

Diagnostic value of five clinical tests in patellofemoral pain syndrome

The current study is aimed at examining the validity of five clinical patellofemoral tests used in the diagnosis of patellofemoral pain syndrome (PFPS). Forty-five knee patients were divided into either the PFPS or the non-PFPS group, based on the fulfilment of the diagnostic criteria for PFPS. An investigator, blinded to the group assignment, performed the vastus medialis coordination test, patellar apprehension test, Waldron's test, Clarke's test, and the eccentric step test. The positive likelihood ratio was 2.26 for both the vastus medialis coordination test and the patellar apprehension test. For the eccentric step test, the positive likelihood ratio was 2.34. A positive outcome on either the vastus medialis coordination test, the patellar apprehension test, or the eccentric step test increases the probability of PFPS to a small, but sometimes important, degree. For the remaining tests, the positive likelihood ratios were below the threshold value of 2, indicating that given a positive test result, the probability that the patient has PFPS is altered to a small, and rarely important degree. The negative likelihood ratios for all tests exceeded the threshold value of 0.5, suggestive of clinically irrelevant information. These data question the validity of clinical tests for the diagnosis of PFPS.

Cold legs: a potential indicator of negative outcome in the rehabilitation of patients with patellofemoral pain syndrome

PURPOSE

The purpose of this paper is to explore the link between a poor outcome in response to an exercise based approach to physiotherapy, in patients with patellofemoral dysfunction and a self-report of legs feeling cold even in warm surroundings.

SCOPE

The study was carried out in the physiotherapy outpatients department of Burnley General Hospital, Lancashire, UK with 87 consecutively referred patients with a diagnosis of patellofemoral pain syndrome being assessed for suitability for entry into the study. Of these 77 entered the study with 14 (18%), of these responding 'Yes' to the question 'Do your legs feel cold even in warm surroundings?' All patients were assessed using four outcome measures prior to the commencement of a standardised rehabilitation programme consisting of lower limb biarticular muscle stretching, vastus medialis training and patella taping or biofeedback. The patients were reassessed using the same outcome measures 3 months after completing their course of treatment.

CONCLUSIONS

Patients who responded 'Yes' to the question 'Do your legs feel cold even in warm surroundings?' reported higher pain levels and tolerated less physical activity than non-cold sufferers at initial assessment, these differences were statistically significant. The cold sufferers showed less improvement on all of the outcome measures although the differences between the two groups only reached statistical significance for one of the outcome measures. The implications of this in relation to clinical practice are discussed.