Prevalence of Patellofemoral Pain (PFP)

Transcription

1 10/11/2017 Evaluation of a Sequential Cognitive and Physical Treatment Approach for Patients with Patellofemoral Pain: A Randomized Controlled Trial Mitchell Selhorst, Todd Degenhart, Michael Jackowski, William Rice, Shaun Coffman Nationwide Children s Hospital Sports and Orthopedic Physical Therapy Prevalence of Patellofemoral Pain (PFP) PFP is easy! 1

2 Then why do we fail? 80% of individuals completing rehab still report pain Up to 91% of patients report persistent or recurring pain that lasts for years. What is PFP? The underlying cause of PFP remains unknown Multi-factorial clinical diagnosis Can arise from any innervated patellofemoral joint structure, or combination of structures One-size-fits-all approach unlikely Previous Classification Systems 2

3 10/11/2017 Recent Classification Systems Selfe et al 2016 Patients With PFP Strong Weak and Tighter Weak and Pronated Foot 91% of patients fell into multiple subgroups Only addresses physical impairments Psychosocial Impact Injury Pain 3

4 Stress Happiness Anxiety Sleep Injury Fear CNS Processing Home Life Depression Experience = Pain Our PFP Algorithm A Sequential Checklist Psychosocial factors Flexibility Lower extremity mechanics High level strengthening Return to sport Study Objective The purpose of this study is to assess the efficacy of the PFP algorithm to treat individuals with PFP. Function Pain Patients perceived improvement 4

5 Methods Single-blinded randomized controlled trial Nationwide Children s Hospital PT clinics Interventions Both groups attended PT 2 x/week for 4-6 weeks Session lasted minutes Interventions were individualized to the patient and based on therapists discretion Comparator Group Impairment-based approach addressing the lower quarter Exercise, manual therapy, taping, orthoses, modalities, and patient education Specific attention paid to hip and quadriceps strength, flexibility, and lower extremity mechanics 5

6 PFP Algorithm PFP Psychosocial Factors Flexibility Functional Malalignment High Level Strengthening Goal-Based Treatments FABQ-PA Appropriate Fear-Avoidance Beliefs? Yes No FEAR-AVOIDANCE SUBGROUP Sufficient Primary Muscle Flexibility Quadriceps, Soleus, Gastrocnemius, WB DF Yes Sufficient Secondary Muscle Flexibility Hamstring, Hip flexors, IT band, and Adductors Yes Functional Alignment Testing Passed Single Leg Squat Test Passed on Lateral Step Down Test Yes > 1 primary muscles tight No FLEXIBILITY SUBGROUP FUNCTIONAL MALALIGNMENT SUBGROUP Functional Strength Testing Scored >90%* all tests Single Leg Hop Test Triple Hop Test Cross-over Hop Test Timed step down Testing Yes No FUNCTIONAL STRENGTHENING SUBGROUP Passed 6

7 Fear-Avoidance Group Testing Fear Avoidance Belief Questionnaire: Physical Activity subscale Scores >15/24 associated with increased FAB Fear-Avoidance Group Pain Science Education Biopsychosocial Approach to treatment Graded Exposure Activity Pacing Goal Setting Problem Solving Cognitive Restructuring Attention Diversion Maintenance Strategies Flexibility Subgroup Testing (Primary) Prone Quadriceps Flexibility <130 deg positive Prone Gastroc Flexibility <12 deg positive Prone Soleus Flexibility <20 deg positive WB DF ROM <48 deg positive 7

8 10/11/2017 Flexibility Subgroup Functional Malalignment Subgroup Testing Lateral Step Down >1 positive Single Leg Squat >1 positive Malalignment Subgroup 8

9 10/11/2017 Functional Strengthening Testing Single Leg Hop for Distance Triple Hop for Distance Cross-over Hop for distance Timed Step Down Test Limb Symmetry Index Involved limb/uninvolved limb= LSI % LSI of >90% passes Functional Strengthening Subgroup Outcomes Baseline, 3 weeks, 6 weeks and 6 months Primary Outcome Anterior Knee Pain Scale Secondary Outcomes Numeric Pain Rating Scale Global Rating of Change 9

10 Sample Size A priori calculations determined a sample size of 50 necessary (25 in each group) Alpha= 0.05 Beta= 0.20 MCIDof Anterior Knee Pain Scale=10 Standard deviation=12.4 Data Analysis We used an intent-to-treat design Multiple-imputation model used for missing data Repeated-Measures Analysis of Covariance Covariates= Duration of Symptoms Fear-Avoidance Beliefs Questionnaire 10

11 Baseline Characteristics All Patients PFP Algorithm Comparator Characteristics (n=55) (n=28) (n=27) Age (years) 14.3 ± ± ±1.7 Sex (% female) BMI (kg/m 2 ) 23.8 ± ± ±6.2 Duration of symptoms (weeks) 16 (6; 38) 16 (6; 49) 12 (6; 30) Bilateral knee pain, (% yes) Sport Participant, (% yes) FABQ-PA 12.8 ± ± ± 3.4 Anterior Knee Pain Scale (AKPS) 73.7 ± ± ± 9.5 Pain (NPRS) 6.0 ± ± ± Function Anterior Knee Pain Scale PFP algorithm Compartor Adjusted Difference P value (95% CI) (0.8, 7.9) Baseline 3 week 6 week 6 month Numeric Pain Rating Scale Pain Adjusted Difference P value (95% CI) (1.3, 0.0) PFP algorithm Comparator 0 Baseline 3 week 6 week 6 month 11

12 Global Rating of Change Perceived Improvement PFP algorithm Comparator Adjusted Difference P value (95% CI) (-0.2, 1.2) 0 Baseline 3 week 6 week 6 month Assessing the PFP Algorithm 100 AKPS at 6 months 95 Only 1/3 rd of patients successfully passed Successfully Passed Did not Pass 9/28 19/28 Discussion The PFP algorithm resulted in quicker and greater improvements in function and pain. Successfully completing all aspects of the PFP algorithm may improve long-term function. 12

13 PFP Algorithm Strengths Patients cannot be classified into multiple subgroups System addresses important psychosocial factors A third of patients had elevated fearavoidance beliefs Adaptability regarding clinicians strengths and evolving evidence PFP Algorithm Weaknesses Cutoffs for treatment have not been validated and optimal thresholds are unknown. Mechanism is not understood Sequential approach Addressed psychosocial factors Required test-retest of important impairments Study Limitations Clinicians could not be blinded Fear-avoidance beliefs never reassessed -Unclear if interventions were successful Sample only included adolescent patients -Unknown if similar results seen in adults 13

14 Conclusion A sequential cognitive and physical treatment approach resulted in superior outcomes when compared to a traditional impairment-based approach Future Research Validating impairment thresholds for each treatment subgroup References 1. StathopuluE, BaildamE. Anterior knee pain: a long-term follow-up. Rheumatology (Oxford) 2003;42(2): RathleffMS, RathleffCR, OlesenJL, et al. Is Knee Pain During Adolescence a Self-limiting Condition? Prognosis of Patellofemoral Pain and Other Types of Knee Pain. Am J Sports Med 2016;44(5): Davis IS, Powers CM. Patellofemoral pain syndrome: proximal, distal, and local factors, an international retreat, April 30-May 2, 2009, Fells Point, Baltimore, MD. J Orthop Sports Phys Ther 2010;40(3):A RathleffMS. Patellofemoral pain during adolescence: much more prevalent than appreciated. Br J Sports Med 2016;50(14): RathleffMS, RoosEM, OlesenJL, et al. Exercise during school hours when added to patient education improves outcome for 2 years in adolescent patellofemoral pain: a cluster randomisedtrial. Br J Sports Med 2015;49(6): MolgaardC, RathleffMS, SimonsenO. Patellofemoral Pain Syndrome and Its Association with Hip, Ankle, and Foot Function in 16-to 18-Year-Old High School Students A Single-blind Case-control Study. J Am Podiat Med Assn 2011;101(3): Myer GD, Ford KR, Di Stasi SL, et al. High knee abduction moments are common risk factors for patellofemoral pain (PFP) and anterior cruciate ligament (ACL) injury in girls: Is PFP itself a predictor for subsequent ACL injury? Br J Sports Med 2015;49(2): Maclachlan LR, Collins NJ, Matthews ML, et al. The psychological features of patellofemoral pain: a systematic review. Br J Sports Med WitvrouwE, Callaghan MJ, Stefanik JJ, et al. Patellofemoral pain: consensus statement from the 3rd International Patellofemoral Pain Research Retreat held in Vancouver, September Br J Sports Med 2014;48(6): Powers CM, BolglaLA, Callaghan MJ, et al. Patellofemoral pain: proximal, distal, and local factors, 2nd International Research Retreat. J Orthop Sports Phys Ther 2012;42(6):A1-54. References 11. PivaSR, Fitzgerald GK, Wisniewski S, et al. Predictors of pain and function outcome after rehabilitation in patients with patellofemoral pain syndrome. J Rehabil Med 2009;41(8): Fulkerson JP. Diagnosis and treatment of patients with patellofemoral pain. Am J Sports Med 2002;30(3): LankhorstNE, Bierma-ZeinstraSM, van MiddelkoopM. Factors associated with patellofemoral pain syndrome: a systematic review. Br J Sports Med 2013;47(4): Doucette SA, Goble EM. The effect of exercise on patellar tracking in lateral patellar compression syndrome. Am J Sports Med 1992;20(4): SalsichGB, PermanWH. Patellofemoral joint contact area is influenced by tibiofemoral rotation alignment in individuals who have patellofemoral pain. J Orthop Sports Phys Ther 2007;37(9): Wilk KE, Davies GJ, MangineRE, et al. Patellofemoral disorders: a classification system and clinical guidelines for nonoperative rehabilitation. J Orthop Sports Phys Ther 1998;28(5): WitvrouwE, Werner S, MikkelsenC, et al. Clinical classification of patellofemoral pain syndrome: guidelines for non-operative treatment. Knee Surg Sports TraumatolArthrosc 2005;13(2): SelfeJ, Janssen J, Callaghan M, et al. Are there three main subgroups within the patellofemoral pain population? A detailed characterisationstudy of 127 patients to help develop targeted intervention (TIPPs). Br J Sports Med 2016;50(14): KeaysSL, Mason M, NewcombePA. Individualized physiotherapy in the treatment of patellofemoral pain. Physiother Res Int 2015;20(1): Selhorst M, Rice W, Degenhart T, et al. Evaluation of a treatment algorithm for patients with patellofemoral pain syndrome: a pilot study. Int J Sports Phys Ther 2015;10(2):

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