Should we consider changing traditional physiotherapy treatment of patellofemoral pain based on recent insights from the literature?

In 2016, the international Patellofemoral Research Network (iPFRN) provided a consensus statement on physical interventions for patellofemoral pain (PFP). This statement recommended exercise-therapy targeting the hip and knee, combined interventions and prefabricated foot orthoses that can be used to improve pain and function in people with PFP.

In a recent BJSM Editorial, we proposed that physiotherapy outcomes may be improved by rethinking what good physiotherapy treatment might involve for PFP.

Read the paper

Christian J Barton, Kay M Crossley, Erin M Macri

We have provided a range of multimedia resources and a ‘call to action’ on this page to help the clinician learn more about the recent research in this space. We hope you enjoy!

As clinicians, I think it is fair to say that we have come to think of patellofemoral pain (PFP) as a condition that is generally self-limiting, and responds well to traditional physiotherapy (PT). In the case of PFP, this would be a primarily exercise-based approach, one in which we work hard to address biomechanical impairments that may have led the pain in the first place.

Our international Patellofemoral Research Network published a consensus statement in 2016 summarizing the best evidence for physical interventions for PFP. They consist of 6 key recommendations related to traditional PT:

Unfortunately, while there is certainly value in individualizing an active rehab program to the person presenting to us, it is becoming clear that traditional PT may not work for everyone. In fact, it may not work for a whole lot of people.  With close to 60% of participants in a clinical trial reporting a lack of success 5 to 8 years after treatment – in other words, still in pain 8 years later – the writing is on the wall that we need to start rethinking PFP.

 

Dr. Harvi Hart recently published a systematic review investigating associations between body mass index (BMI) and PFP, including PF osteoarthritis. She followed up her review with a clinically relevant blog article outlining her key findings and offering some suggestions on how clinicians can actively engage patients in setting and achieving realistic weight management goals. This is possibly one of the more challenging aspects of being a clinician: talking about weight can be a sensitive issue (I’ve had patients fire their Doctors for being told they should lose weight!). As PTs, it is important we take the time to build the trust and rapport necessary to have some difficult conversations with our patients about their health.

As a society, we know that excess body weight is not good for our health. It increases the risk of an array of physical and mental health conditions such as hypertension, type II diabetes, coronary heart disease, stroke, osteoarthritis, depression, and anxiety. But what does obesity mean for your knees?

Read the rest of Dr Harvi Hart and Prof Kay Crossley’s blog here

The biopsychosocial model is certainly not new to clinicians. However, we are only just beginning to understand how this trifecta interacts when it comes to PFP. And according to Liam Machlachlan and Dr. Bill Vicenzino, the role of psychological factors in particular may be more important than we previously thought. In this recent podcast, I caught up with Liam and Bill to ask them to review the clinically relevant findings of their recent systematic review looking at psychological factors in PFP.

Why have we included patient education here as something ‘beyond’ traditional PT? Doesn’t everyone educate patients as a core part of treatment?

Sure. Everyone educates their patients. But are we focusing on the right aspects of their condition and their treatment? Are we using the right language, sending the right messages? Are we enabling buy-in or scaring them away? I am sure we have all at some point made a crucial mistake in educating a patient without ever even knowing it. Afterall, after that mistake the patient never came back. Like the women who came to me after firing her Doctor. How many times have I been fired?

In fact, very little research has been undertaken to look at how to educate patients with PFP. Until now. Here, I met up with Dr. Michael Rathleff to ask about some innovative work he and his team in Denmark are doing to improve how we approach patient education.

Subsequent to the interview, I asked Michael Rathleff and a PhD student of his, Simon Kristoffer Johansen, to walk me through Michael’s educational slides and go over tips on how best to use the slides in a clinic setting. That blog, including downloadable education slides, can be found here. In addition, Michael collaborated recently with Janus Laust Thomsen and Christian Barton to write a short editorial about education in PFP here. Finally, Christian and Michael developed this evidence-based, patient-centred education leaflet with input from patients, clinicians and researchers:

Education of course is not limited to adolescents. Here is another example of some fantastic work being done by Dr. Jean Francois Esculier from Canada. His passion is to help runners with PFP get back to running, and staying there. In this video, JF talks about some of the key features of how best to educate runners on load management during recovery from PFP.

CALL TO ACTION

Patellofemoral pain researchers

  • Explore the potential benefits of weight management to improve symptoms, function, quality of life and general health of people with patellofemoral pain (PFP)
  • Evaluate the influence of psychological factors on patient presentation including symptoms, function and quality of life
  • Evaluate the potential benefits of interventions targeting psychological factors in people with PFP
  • Develop high quality education resources for patients including an online multimedia platform

Considerations for clinicians treating patients with patellofemoral pain

  • Consider the potential influence of a patient’s weight on rehabilitation outcomes and other general health
  • Discuss the potential influence of PFP on weight and refer for assistance in managing where appropriate
  • Consider early implementation of questionnaires such as the short form Orebro Musculoskeletal Pain Questionnaire to identify those who may require more detailed assessment and management of psychological factors
  • Consider the potential importance of, and place a greater emphasis on patient education, particularly related to load management