Guidance for the conservative management of
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Guidance for the conservative management of patellofemoral pain: Combining international expert opinion with level 1 evidence Christian Barton,* Simon Lack, Steph Hemmings , Saad Tufail , Dylan Morrissey. BACKGROUND

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Christian completesportscare au completesportscare au

Guidance for the conservative management of patellofemoral pain: Combining international expert opinion with level 1 evidence

Christian Barton,* Simon Lack, StephHemmings, SaadTufail, Dylan Morrissey

  • BACKGROUND

  • A vast array of conservative interventions options for patellofemoral pain (PFP) exist. This mixed methods study combines findings from high quality systematic reviews with international expert opinion, providing clinicians with a comprehensive guide to treating PFP, and a summary of priorities for future research.

  • METHODS

  • A review and summary of findings from high quality systematic reviews (previous 5 years)

  • Qualitative research to explore international experts’ perceptions of evidence for, and clinical reasoning when applying, non-pharmacological conservative interventions for PFP

  • 17 International experts; 5 years clinical experience, and published and active researchers on the topic of PFP

  • RESULTS AND DISCUSSION

  • Multimodal interventions and overarching principles

  • Multimodal interventions possess the strongest and most consistent evidence [1]

  • The same multimodal program for all PFP patients is inefficient – each program should be tailored - “The multimodal approach can sometimes be quite inefficient in that some parts of the package aren’t really going to help the patient.”

  • Immediate pain relief to gain patient trust and focus on active and not passive interventions is important - “The most important aspect, probably reducing their pain, that’s obviously what they’ve come for.”

  • ACTIVE INTERVENTIONS

  • Exercise prescription principles

  • Exercise prescription is clearly effective. However, it is unclear whether open or closed kinetic chain exercise is more effective, or how important supervision is to ensuring successful outcomes [1]

  • Closed rather than open kinetic chain exercises are preferred in order to replicate function - “I always do closed kinetic chain, and mainly because I think it’s specificity of training.”

  • Exercise should be supervised where possible to ensure correct techniques. However, high levels of supervision may not always be practical - “We need to supervise it to some degree, because we need to make sure that they’re doing it correct. And then I think you need to make sure that they can do it on (their) own.”

  • The number of exercises should be limited (e.g. 3-4) to ensure compliance, and completed frequently - “The simpler you make it, the better it is, the more likelihood you have of someone being compliant.”

  • Exercise specifics

  • Quadriceps strengthening dominates current evidence base.

  • Specific VMO electromyography (EMG) biofeedback may not

  • improve rehabilitation outcomes [1]

  • Biofeedback may still be useful in some patients, but time and practical

  • restraints of using EMG biofeedback in a clinical setting must be considered –

  • “Biofeedback-wise, I actually don’t use it in a clinic because I think it takes too long.”

  • There is currently a paucity of level 1 evidence to support gluteal strengthening in PFP

  • Exercise to reverse proximal movement and strength deficits is important –

  • “Iookat doing strengthening exercises at the hip in order to try and facilitate hip and pelvic control.”

  • Consider incorporation of core stability or trunk strengthening exercises - “Trunk

  • strengthening, I think it’s important for postural control and dynamic control of movement.”

  • Distal strengthening may in some instances be equally or more effective

  • compared to foot orthoses- “strengthening the feet as opposed to orthotics.”

  • Lower limb stretching currently lacks level 1 evidence, but has

  • been included in multimodal programs

  • Consideration to stretching is recommended, particularly the hamstrings and

  • calf

  • Gait and movement pattern retraining

  • There is currently a paucity of evidence to support gait and movement pattern retraining

  • Use mirrors and video to facilitate reversal of poor hip and knee mechanics - “Video feedback is going to give you an ability for the patient to understand better what they’re doing wrong.”

  • Movement pattern retraining should be considered for a range of activities including walking, running, stair negotiation and sit to stand – “rather than focusing on exercises, focusing on the actual movement pattern and teaching them how to move properly.”

  • PASSIVE INTERVENTIONS

  • Patellar taping and bracing

  • Medially directed patellar taping and bracing provides immediate pain reduction [2]

  • Taping is very good at providing immediate pain reduction - “In terms of pain,

  • I think taping is often very effective.”

  • Braces only considered where taping is inappropriate - “Bracing, I would only use

  • for someone who couldn’t tape because their skin wouldn’t allow it.”

  • Conclusions drawn from high quality systematic reviews regarding

  • the value of taping beyond the immediate term are inconsistent. [2-4]

  • Views on the value of taping in the longer term are inconsistent

  • Foot orthoses

  • Foot orthoses have a small therapeutic effect in short term (6 weeks), however, not in the longer term (12-52 weeks), and may not provide additional benefit to exercise or multimodal physiotherapy [1, 3, 5, 6]

  • Efficacy may be improved by targeting individuals based on measurement of

  • pronation or foot mobility, or using a treatment direction test - “People that are

  • more mobile are more pronated in the foot, probably more likely to respond to a foot orthoses.”

  • Massage, mobilisation and other adjuncts

  • Massage and PFJ mobilisation often form part of multimodal programs evaluated but possess no isolated evidence. Limited evidence indicates acupuncture may be beneficial, but ultrasound is not [1]

  • Care should be taken not to mobilise a hypermobile PFJ – “If it’s (the joint)

  • hypermobile, the last thing you want to do is start mobilising the joint even more.”

  • There is a lack of consensus on the value of acupuncture and massage

  • The use of ultrasound is not recommended - “that’s bad medicine.”

  • GAPS IN THE EVDIENCE AND FUTURE RESEARCH DIRECTIONS

  • Empirical research is needed to compare the effectiveness of open and closed kinetic chain exercise, and establish the value of core and distal strengthening

  • An up to date systematic review to evaluate the effectiveness of gluteal strengthening is needed

  • Identification of risk factors and the source of pain is needed to optimise treatment and prevention programs

  • Identification of screening tools able to identify chronic cases and those likely to develop osteoarthritis, and improved management strategies for these individuals is needed

  • Improved knowledge and ability to tailor interventions will optimise care

  • Evaluation of the effectiveness of long term interventions (> 6 weeks) is needed

  • Understand more about the impact of psychosocial factors and how to identify them

  • Evaluation of the effectiveness of gait and movement pattern retraining is needed

  • Understand how the foot, footwear and foot orthoses relate to pathology

  • CONCLUSION

  • A tailored multimodal intervention program is the key to effective PFP management

  • Active components should include quadriceps and gluteal exercise, with consideration to distal strengthening and movement pattern/gait retraining

  • Stretching should also be considered based on individual assessment

  • Patellar taping should be applied to facilitate pain reduction in the early stages of rehab

  • Foot orthoses, massage, PFJ mobilisation and acupuncture may be considered as possible adjuncts in the management of PFP.

  • ACKNOWLEGEMENTS

  • Thank you to the insightful and invaluable thoughts and ideas of the international experts who gave up there valuable time to be interviewed.

  • REFERENCES

  • 1. Collins et al. Sports Med. 2012;42(1):31-49

  • 2. Warden et al. Aritis Rheum. 2008;59(1):73-83

  • 3. Swart et al. Br J Sports Med. 2012;46(8):570-7

  • 4. Callaghan and Selfe. Cochrane Database Syst Rev. 2012;4:CD006717

  • 5. Barton et al. Sports Med. 2010;40(5):377-95

  • 6. Hossain et al. Cochrane Database Syst Rev. 2011;1:CD008402

[email protected] www.completesportscare.com.au

[email protected] www.completesportscare.com.au


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