'Managing My Patellofemoral Pain': the creation of an education leaflet for patients

Physical therapists' prognosis of outcomes after a hip or quadriceps exercise intervention in patients with patellofemoral pain: A secondary analysis of a randomized trial

OBJECTIVE: Can physical therapists who are treating patients with Patellofemoral Pain (PFP) predict the outcome of a 12-week exercise intervention based on initial assessment, and what are the physical therapists' reasons for prediction? DESIGN: Secondary analysis of a randomized trial. METHODS: After the initial assessment, physical therapists were asked to predict the prognosis of 200 patients with PFP who were allocated to 12 weeks of quadriceps exercises (QE) or hip exercises (HE) on a 1-10 Likert scale, and to describe their reasoning for the prediction score. Outcome measures were changes from baseline to week 12 and 26 on the Anterior Knee Pain Scale (AKPS; range 0-100) and a transition questionnaire (TransQ). Linear mixed-effects models were used to assess the prediction. Secondly, we used a qualitative approach to summarize the physical therapists' reasoning (written notes) when predicting the outcome. RESULTS: There was no association between physical therapists' prognosis and changes in AKPS for QE or HE at week 12 and 26 (Slopes: -0.14 to -0.51 with wide 95% confidence intervals [CI]). There was no association between physical therapists' assessment of prognosis using TransQ for QE or HE at week 12 and 26 (OR: 0.99 to 1.17 with wide 95% CIs). physical therapists. CONCLUSION: Physical therapists' prognosis based on initial assessment was not associated with outcomes after weeks 12 of either quadriceps or hip exercise-therapy among patients with PFP. Physical therapists' prognoses were not useful as a source of information and to identify PFP patients with poor or good projected outcomes.

Exploring User Visions for Modeling mHealth Apps Toward Supporting Patient-Parent-Clinician Collaboration and Shared Decision-making When Treating Adolescent Knee Pain in General Practice: Workshop Study

BACKGROUND

Long-standing knee pain is one of the most common reasons for adolescents (aged 10-19 years) to consult general practice. Generally, 1 in 2 adolescents will continue to experience pain after 2 years, but exercises and self-management education can improve the prognosis. However, adherence to exercises and self-management education interventions remains poor. Mobile health (mHealth) apps have the potential for supporting adolescents' self-management, enhancing treatment adherence, and fostering patient-centered approaches. However, it remains unclear how mHealth apps should be designed to act as tools for supporting individual and collaborative management of adolescents' knee pain in a general practice setting.

OBJECTIVE

The aim of the study was to extract design principles for designing mHealth core features, which were both sufficiently robust to support adolescents' everyday management of their knee pain and sufficiently flexible to act as enablers for enhancing patient-parent collaboration and shared decision-making.

METHODS

Overall, 3 future workshops were conducted with young adults with chronic knee pain since adolescence, parents, and general practitioners (GPs). Each workshop followed similar procedures, using case vignettes and design cards to stimulate discussions, shared construction of knowledge and elicit visions for mHealth designs. Young adults and parents were recruited via social media posts targeting individuals in Northern Jutland. GPs were recruited via email and cold calling. Data were transcribed and analyzed thematically using NVivo (QSR International) coding software. Extracted themes were synthesized in a matrix to map tensions in the collaborative space and inform a conceptual model for designing mHealth core-features to support individual and collaborative management of knee pain.

RESULTS

Overall, 38% (9/24) young adults with chronic knee pain since adolescence, 25% (6/24) parents, and 38% (9/24) GPs participated in the workshops. Data analysis revealed how adolescents, parents, and clinicians took on different roles within the collaborative space, with different tasks, challenges, and information needs. In total, 5 themes were identified: adolescents as explorers of pain and social rules; parents as supporters, advocates and enforcers of boundaries; and GPs as guides, gatekeepers, and navigators or systemic constraints described participants' roles; collaborative barriers and tensions referred to the contextual elements; and visions for an mHealth app identified beneficial core features. The synthesis informed a conceptual model, outlining 3 principles for consolidating mHealth core features as enablers for supporting role negotiation, limiting collaborative tensions, and facilitating shared decision-making.

CONCLUSIONS

An mHealth app for treating adolescents with knee pain should be designed to accommodate multiple users, enable them to shift between individual management decision-making, take charge, and engage in role negotiation to inform shared decision-making. We identified 3 silver-bullet principles for consolidating mHealth core features as enablers for negotiation by supporting patient-GP collaboration, supporting transitions, and cultivating the parent-GP alliance.

The quality of YouTube videos related to patellofemoral pain syndrome is insufficient

BACKGROUND

Videos uploaded to YouTube do not go through a review process. The educational aspect of these videos may be insufficient for patellofemoral pain syndrome (PFP).

OBJECTIVE

To examine the reliability and educational quality of PFP videos on YouTube.

METHODS

A standard search was performed in the YouTube database using the following terms: patellofemoral pain syndrome/anterior knee pain syndrome/anterior knee pain/patellofemoral pain. For each search term, the top 50 videos based on "relevance" assignment of YouTube's algorithm were included in the examination. The remaining 96 videos after exclusion were included in the study. The educational quality and reliability of videos was analyzed using DISCERN, JAMA (The criteria of Journal of the American Medical Association), GQS (Global Quality Score) and PFPSS (Patellofemoral Pain Specific Score).

RESULTS

According to PFPSS, 81.2% of the videos were evaluated as low and very low quality. According to the DISCERN classification, 74.9% of the videos were evaluated as poor and very poor. According to GQS, 59.4% of the videos had scores of 2 or less, which were considered poor quality. According to JAMA, 41.7% of the videos scored 2 and below.

CONCLUSIONS

The information content of YouTube videos is inadequate. Video design should be created to be understandable by patients and to attract their attention while making these videos.

Exploring the barriers and facilitators for supporting adolescents with knee pains adherence to mobile health apps: A think-aloud study

Background

Mobile health (mHealth) applications have the potential to support adolescents' self-management of knee pain. However, ensuring adherence remains a barrier when designing mHealth concepts for adolescents.

Objective

This study aimed to explore barriers and facilitators for adhering to mHealth interventions to inform design principles.

Methods

Think-aloud tests were conducted with 12 adolescents (aged 12.5 years median) with knee pain, using a low-fidelity prototype. The prototype was informed by the authors previous work, rapid prototyping sessions with seven health professionals, and synthesis via the Behavioral Intervention Technology Model. The think-aloud tests were video recorded and analyzed thematically to identify design principles.

Results

The analysis based on user testing with adolescents with knee pain identified three themes: "user experience and feedback," "contextual challenges," and "new features" and nine subthemes. Adolescents were able to use mHealth behavioral features such as self-tracking, goal setting, education, and data visualization to capture and reflect on their knee pain developments, which facilitated use. However, adolescents struggle with timing interventions, breaking down management behaviors, and biases towards interventions were identified as internal threats to adherence. Competing activities, parental meddling, and privacy concerns were external adherence barriers. Twelve design principles were identified for integrating these insights into mHealth designs.

Conclusion

Participants' motivations for adherence were influenced by internal and external factors. While adolescents were able to use mHealth behavioral features to capture and reflect on knee pain developments, understanding how to accommodate adolescents' cognitive abilities, competing activities, and need for independence is quintessential to enhance adherence in everyday contexts.

Confidence and Knowledge of Athletic Trainers in Managing Patellofemoral Pain

CONTEXT

Patellofemoral pain (PFP) is prevalent and challenging to manage. Most patients with PFP are unsatisfied with their knee function at 6 months after treatment and report ongoing pain up to 16 years after diagnosis. The confidence and knowledge of athletic trainers (ATs) in providing evidence-based care to people with PFP is unknown.

OBJECTIVE

To investigate the confidence and knowledge of ATs in the diagnosis, risk factors, prognosis, and treatment with current evidence for PFP.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PATIENT OR OTHER PARTICIPANTS

A random sample of 3000 ATs were invited to participate; 261 completed the survey (10% participation rate, 88% completion rate).

MAIN OUTCOME MEASURES(S)

We surveyed AT demographics, confidence in PFP management, and knowledge related to diagnosis, risk factors, prognosis, and treatment. The confidence and knowledge of ATs in managing PFP was assessed. Their beliefs about evidence were compared with the available evidence (ie, consensus statements, position statements, systematic reviews).

RESULTS

Of the ATs surveyed, 91% were confident that their management of PFP aligned with the current evidence, but only 59% were confident in identifying risk factors for PFP development. In addition, 91% to 92% of ATs agreed that quadriceps and hip muscle weakness were risk factors for PFP, which aligns with the current evidence for the former but not the latter. Moreover, 93% to 97% of ATs' responses related to therapeutic exercise aligned with current evidence. However, 35% to 48% supported the use of passive treatments, such as electrophysical agents and ultrasound, which did not align with the current evidence.

CONCLUSIONS

Most ATs were aware of supporting evidence for therapeutic exercise in PFP management and were confident providing it, creating a strong foundation for evidence-based care. However, varying levels of awareness of the evidence related to risk factors and passive treatments for PFP highlight the need for professional development initiatives to better align ATs' knowledge with the current evidence.

Do exercises for patellofemoral pain reflect common injury mechanisms? A systematic review

OBJECTIVES

Current best evidence has reported that therapeutic exercise programs that are designed to treat patellofemoral pain (PFP) should include both hip and knee specific exercises. The purpose of this review was to (1) examine the quality/comprehensiveness of exercise reporting in this field; (2) quantify the extent to which individual exercises comprised task-specific elements (single limb stance; eccentric control of the hip; rotational z-axis control) most likely to address key pathomechanics associated with PFP.

DESIGN

Systematic review: a systematic survey of RCTs.

METHODS

PubMed, CINAHL, Medline, Physiotherapy Evidence Database (PEDro) and SPORT Discus databases were searched for randomized controlled trials that addressed PFP utilizing a proximal control hip focused rehabilitation paradigm. The therapeutic exercise programs were evaluated, and each individual exercise was extracted for analysis. Quality assessments included the PEDro Scale and the Consensus on Exercise Reporting Template (CERT) was utilized to score the reporting of the interventions.

RESULTS

19 studies were included in the final analysis. 178 total exercises were extracted from the proximal hip and knee rehabilitation programs. The exercises were analyzed for the inclusion of elements that align with reported underlying biomechanical mechanisms.

CONCLUSIONS

The vast majority of the exercises were sagittal plane, concentric, non-weight bearing exercises, whereas multiplanar exercises, single limb weightbearing, and exercises where loading was directed around the longitudinal z-axis, were considerably under-represented. Current exercises for PFP utilize simplistic frameworks that lack progression into more task specific exercise, and are not reflective of the complex injury etiology.

Novel Stepped Care Approach to Provide Education and Exercise Therapy for Patellofemoral Pain: Feasibility Study

Background

Patellofemoral pain (PFP) impairs joint- and health-related quality of life and may be associated with knee osteoarthritis. We developed a novel, 2-phase, stepped-care approach for PFP, combining (1) self-directed web-based education and exercise therapy with (2) physiotherapist-supported education and exercise therapy. Physiotherapy sessions can be provided using 2 different modalities: face-to-face and telerehabilitation.

Objective

This study aims to (1) determine the feasibility of our stepped-care approach, (2) explore patient-reported outcomes following self-directed web-based education and exercise therapy in people with PFP (phase 1), and (3) estimate the differences in treatment effects between face-to-face and telerehabilitation to support further education and exercise therapy (phase 2) in those who had not completely recovered following self-directed care.

Methods

Phase 1 involved 6 weeks of self-directed web-based education and exercise therapy. Phase 2 involved random allocation to a further 12 weeks of physiotherapist-led (up to 8 sessions) education and exercise therapy delivered face-to-face or via telerehabilitation to participants who did not rate themselves as completely recovered following phase 1. Feasibility indicators of process, adherence, and participant retention were collected as primary outcomes alongside patient-reported outcomes on Global Rating of Change and knee pain, disability, knee-related quality of life, pain catastrophism, kinesiophobia, and knee self-efficacy. All participants were assessed at baseline, 6 weeks, and 18 weeks.

Results

A total of 71 participants were screened to identify 35 participants with PFP to enter the study. Overall, 100% (35/35) and 88% (31/35) of the participants were followed up with at 6 and 18 weeks, respectively. In phase 1 of the study, participants accessed the My Knee Cap website for an average of 6 (7.5) days and performed the exercises for an average of 2.5 (3.6) times per week. A total of 20% (7/35) of the participants reported that they had completely recovered at 6 weeks. Furthermore, 93% (26/28) of the participants who were followed up and had not completely recovered at 6 weeks agreed to be enrolled in phase 2. No statistically significant differences were found between the face-to-face and telerehabilitation groups for any outcome. The novel stepped-care approach was associated with marked improvement or complete recovery in 40% (14/35) of the participants following phase 1 and 71% (25/35) of the participants following phase 2.

Conclusions

Self-directed web-based education and exercise therapy for people with PFP is feasible, as noted by the high rate of participant retention and home exercise adherence achieved in this study. Furthermore, 20% (7/35) of people reported complete recovery at 6 weeks. Both face-to-face and telerehabilitation physiotherapy should be considered for those continuing to seek care, as there is no difference in outcomes between these delivery modes. Determining the efficacy of the stepped-care model may help guide more efficient health care for PFP.

Patients' perceptions of recovery following a 6-week exercise intervention for the treatment of patellofemoral pain: A mixed methods study

Background

Patellofemoral pain (PFP) is a common and complex condition. The diagnosis and causal mechanisms are not well understood and therefore the long-term prognosis tends to be poor. Exercise is currently the only evidence-based treatment strategy suggested to improve pain and function in the long term. However, no qualitative studies have been conducted to establish patients’ perceptions of recovery in the long term following an exercise intervention.

Objectives

To measure self-reported recovery on a 7-point Likert scale in 31 participants with PFP 6 months after a 6-week physiotherapy intervention. To explore the subjective accounts of patients who received a physiotherapy intervention for PFP, regarding their expectations and perceptions of recovery.

Method

Semi-structured exit interviews were conducted electronically 6 months after intervention to ascertain the patients’ perspectives on whether expectations of treatment were met, and factors that influenced their recovery experience.

Results

Quantitative analysis of self-reported recovery on a 7-point Likert scale showed that 48.4% of participants felt that they were ‘recovered’. Qualitative analysis showed three main categories: expectations of treatment, perceptions of recovery and changes in functional abilities.

Conclusion

Clinicians should address patients’ expectations of treatment and include the patients in decision-making regarding their treatment. Long-term follow-up is essential to ensure that treatment effects have been maintained, and this should include information about patients’ self-reported recovery.

Clinical implications

This study suggests that patients’ expectations of treatment and perceptions of recovery from PFP may influence prognosis. Clinicians need to collaborate with patients and involve them in decision-making to achieve their goals. An individualised treatment approach is essential to adequately address patients’ experiences, priorities and beliefs.

A proximal progressive resistance training program targeting strength and power is feasible in people with patellofemoral pain

OBJECTIVES

To evaluate the feasibility of a 12-week progressive resistance training program for people with patellofemoral pain (PFP) targeting proximal muscle strength and power; and resulting clinical and muscle capacity outcomes.

DESIGN

Feasibility study.

SETTING

Clinical environment.

PARTICIPANTS

Mixed-sex sample of people with PFP.

MAIN OUTCOME MEASURES

Feasibility outcomes included eligibility, recruitment rate, intervention adherence, and drop-outs. Secondary outcomes included perceived recovery, physical function (AKPS and KOOS-PF), worst pain (VAS-cm), kinesiophobia (Tampa), physical activity (IPAQ), and hip strength (isometric and 10 repetition maximum) and power.

RESULTS

Eleven people, from 36 who responded to advertisements, commenced the program. One participant withdrew. Ten participants who completed the program reported improvement (3 completely recovered; 6 marked; and 1 moderate). Higher AKPS (effect size [ES] = 1.81), improved KOOS-PF (ES = 1.37), and reduced pain (ES = 3.36) occurred alongside increased hip abduction and extension dynamic strength (ES = 2.22 and 1.92, respectively) and power (ES = 0.78 and 0.77, respectively). Isometric strength improved for hip abduction (ES = 0.99), but not hip extension.

CONCLUSION

A 12-week progressive resistance training program targeting proximal muscle strength and power is feasible and associated with moderate-large improvements in pain, function, and hip muscle capacity in people with PFP. Further research evaluating the efficacy of progressive resistance training is warranted.

How to manage patellofemoral pain - Understanding the multifactorial nature and treatment options

Patellofemoral pain (PFP) is one of the most prevalent conditions within sports medicine, orthopaedic and general practice settings. Long-term treatment outcomes are poor, with estimates that more than 50% of people with the condition will report symptoms beyond 5 years following diagnosis. Additionally, emerging evidence indicates that PFP may be on a continuum with patellofemoral osteoarthritis. Consensus of world leading clinicians and academics highlights the potential benefit of delivering tailored interventions, specific to an individual's needs, to improve patient outcome. This clinical masterclass aims to develop the reader's understanding of PFP aetiology, inform clinical assessment and increase knowledge regarding individually tailored treatment approaches. It offers practical application guidance, and additional resources, that can positively impact clinical practice.

Patellofemoral pain in athletes: clinical perspectives

Patellofemoral pain (PFP) is a very common problem in athletes who participate in jumping, cutting and pivoting sports. Several risk factors may play a part in the pathogenesis of PFP. Overuse, trauma and intrinsic risk factors are particularly important among athletes. Physical examination has a key role in PFP diagnosis. Furthermore, common risk factors should be investigated, such as hip muscle dysfunction, poor core muscle endurance, muscular tightness, excessive foot pronation and patellar malalignment. Imaging is seldom needed in special cases. Many possible interventions are recommended for PFP management. Due to the multifactorial nature of PFP, the clinical approach should be individualized, and the contribution of different factors should be considered and managed accordingly. In most cases, activity modification and rehabilitation should be tried before any surgical interventions.

THE EFFECTS OF A MULTIMODAL REHABILITATION PROGRAM ON PAIN, KINESIOPHOBIA AND FUNCTION IN A RUNNER WITH PATELLOFEMORAL PAIN

BACKGROUND AND PURPOSE

Multimodal interventions possess the strongest evidence in the long-term management of patellofemoral pain, but despite receiving evidence-based treatments that are initially effective many patients report recurrent or persistent symptoms for years after the initial diagnosis. Untreated psychological factors could be a possible explanation for persistent symptoms and poor treatment outcome. The purpose of this case report was to describe and evaluate the effects of a multimodal rehabilitation program that included pain education, a graded program of lower limb strengthening, and running retraining on pain, kinesiophobia, and function in a runner with patellofemoral pain.

CASE DESCRIPTION

The subject was a 37-year-old female runner reporting a 12-month history of anterior knee pain with previous failed physiotherapeutic treatment. She discontinued running when symptoms gradually worsened, approximately six months after initial onset. She was advised to avoid painful activities. Clinical examination revealed pain during the performance of a weight-bearing functional task, fear of movement, and functional limitations. Treatment focused on pain education, self-management strategies, and progressive loading of the involved tissues through a graduated program of exercises and running retraining.

OUTCOMES

Clinically meaningful improvements were seen in pain, kinesiophobia, and function following a 21-week multimodal rehabilitation program.

DISCUSSION

This case report illustrates several important aspects of clinical reasoning contributing to successful outcomes for a runner with patellofemoral pain. The multimodal rehabilitation program utilized was based upon the neurophysiology of pain (pain education) rather than the tissue pathology model. The findings from this case report may be used to benefit clinicians with similar subject presentations and drive future research into the use of these interventions based upon neurophysiology models of pain in the treatment of patellofemoral pain.

LEVEL OF EVIDENCE

Level 4.

Is combining gait retraining or an exercise programme with education better than education alone in treating runners with patellofemoral pain?A randomised clinical trial

Design

Single-blind randomised clinical trial.

Objective

To compare the effects of three 8-week rehabilitation programmes on symptoms and functional limitations of runners with patellofemoral pain (PFP).

Methods

Sixty-nine runners with PFP were randomly assigned to one of three intervention groups: (1) education on symptoms management and training modifications (education); (2) exercise programme in addition to education (exercises); (3) gait retraining in addition to education (gait retraining). Symptoms and functional limitations were assessed at baseline (T0), and after 4, 8 and 20 weeks (T4, T8 and T20) using the Knee Outcome Survey of the Activities of Daily Living Scale (KOS-ADLS) and visual analogue scales (VASs) for usual pain, worst pain and pain during running. Lower limb kinematics and kinetics during running, and isometric strength were also evaluated at T0 and T8. The effects of rehabilitation programmes were assessed using two-way analysis of variance.

Results

No significant group × time interactions (p<0.447) were found for KOS-ADLS and VASs. All three groups showed similar improvements at T4, T8 and T20 compared with T0 (p<0.05). Only the exercises group increased knee extension strength following rehabilitation (group × time: p<0.001) and only the gait retraining group (group × time: p<0.001) increased step rate (+7.0%) and decreased average vertical loading rate (−25.4%).

Conclusion

Even though gait retraining and exercises improved their targeted mechanisms, their addition to education did not provide additional benefits on symptoms and functional limitations. Appropriate education on symptoms and management of training loads should be included as a primary component of treatment in runners with PFP.

Trial registration number

ClinicalTrials.gov (NCT02352909).