A few weeks ago our trainee elves considered whether exercise therapy was an effective intervention for patients with patellofemoral pain (PFP). This raised many questions about how best to manage this condition, which has a wide variety of risk factors and can affect individuals for many years.
We found this mixed methods study, which combined findings from high-quality systematic reviews with clinical reasoning from international clinical experts to produce a best practice guide for clinicians managing PFP.
Here’s what they did
To update a previous review published by one of the authors (Barton 2008), they searched MEDLINE, EMBASE, CINAHL and Current Contents for systematic reviews published after May 2007.
No exclusion was made for language. To be included, studies must focus on PFP and evaluate non-pharmacological interventions. The authors applied the same scale used in the earlier review to assess quality of included studies.
Then semi-structured interviews were carried out with participants (n=17) identified as experts in the field to explore their perception of current evidence and its applicability. Requirements for inclusion were: at least 5 years clinical experience with PFP, be actively involved in PFP research, and contributing to specialist international meetings.
Here’s what they found
In high quality systematic reviews (level 1 evidence) mulitimodal interventions resulted in the strongest and most consistent evidence . Physiotherapy consisting of quadriceps and gluteal strengthening, PFJ mobilisation and taping has a moderate to large therapeutic effect in shorter term (6-12 weeks) and a smaller effect in the longer term (1 year).
Framework analysis of the semi-structured interviews identified four key over-arching principals:
- PFP is a multi factorial condition requiring an individually tailored mulitmodal approach
- Immediate pain relief should be a priority to gain patient trust
- Patient empowerment by emphasising active over passive interventions is important
- Good patient education and activity modification is essential
Considering both the published level 1 evidence and expert opinion:
- Exercise provides large and clinically meaningful reductions in pain compared to control or placebo. Experts suggest preference should be given to closed chain, functional exercise with supervision particularly in early stages to ensure correct technique and optimal movement patterns.
- Electromyography (EMG) Biofeedback may not improve rehabilitation outcomes and experts identified feasibility and practical restraints for its use in clinical settings.
- Both medially directed patellar taping and bracing provide immediate pain reduction which is strongly desirable in the initial stages. Benefits in the longer term are inconsistent.
- Prefabricated foot orthoses do not improve outcome at 12 or 52 weeks compared to placebo, expert clinical reasoning suggests efficacy may be improved by targeting specific individuals.
- There is limited evidence that Acupuncture may be effective and expert opinion regarding its value was conflicting.
The authors concluded
A tailored multimodal intervention programme, complemented with patient education and activity modification is the key to effective PFP management.
The Musculoskeletal Elf’s view
This is a very useful review combining both expert opinion and clinical evidence to facilitate the application of research into practice. This has helped answer some of the questions about the best management approach for patellofemoral pain.
What do you think?
Do you use a multimodal approach for this condition?
Do the findings of this research resonate with your experience of this condition?
Barton J.C., Simon Lack, S., Hemmings, S., Tufai S. & Morrissey D. 2015, The ‘Best Practice Guide to Conservative Management of Patellofemoral Pain’: incorporating level 1 evidence with expert clinical reasoning, British Journal of Sports Medicine, [Abstract]
Barton C.J., Webster K.E. & Menz H.B. 2008, Evaluation of the scope and quality of systematic reviews on nonpharmacological conservative treatment for patellofemoral pain syndrome. Journal of Orthopaedic Sports Physical Therapy. 2008 Sep;38 (9):529-41