Patellofemoral pain: Treatment KAY M CROSSLEY CHRISTIAN J BARTON

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1 Patellofemoral pain: Treatment KAY M CROSSLEY CHRISTIAN J BARTON

2 Important PFP resources Br J Sports Medicine 2016: 6;50:

3 Evidence: Systematic review: Methods 13 (5 moderate; 1 high quality) exercise therapy, 5 (3 moderate; 1 high quality) foot orthoses, 4 (2 moderate; 1 high quality) patellar taping &bracing, 2 (1 moderate quality) combined interventions, 7 (2 moderate quality) related to other adjunctive Consensus Attendees at ipfp RR (clinicians/ researcher)

4 Exercise Therapy

5 Exercise-therapy

6 Recommendations Exercise therapy reduces pain and symptoms, in the shortterm Exercise therapy reduces pain and symptoms, and improves function in the medium- and long-term Crossley et al, PFP consensus BJSM: 50: 2016

7 Exercise Therapy What about hip strengthening??

8 Hip and knee targeted

9 Hip targeted

10 Recommendations Hip targeted exercises, combined with knee targeted, are superior to knee focussed exercises alone to reduce pain in the short- and medium/long-term Hip targeted exercises, combined with knee targeted, are superior to knee focussed exercises alone to improve function in the short- and medium/long-term Crossley et al, unpublished data PFP consensus BJSM 2016

11 What do we need to consider? Exercise therapy

12 Mechanism of action Types of exercise Adherence Exercise therapy

13 Exercise works for those who did it! 100% 75% 50% 25% 21% 29% 36% 55% 0% 0-1/week 1-2/week 2-3/week 3/week Rathleff et al. 2015, BJSM

14 Patellar tape / bracing

15 Patellar taping

16 Recommendations Uncertain: regarding taping effects Crossley et al, PFP consensus BJSM:

17 What do we need to consider? Patellar taping

18 Adjunctive to treatment? Mechanism of action? Types of taping? Optimal use? Patellar taping

19 Foot orthoses

20 Foot orthoses

21 Recommendations Foot orthoses (pre-fabricated, heat moulded to comfort) are an effective short-term intervention for patellofemoral pain

22 What do we need to consider? Foot Orthoses

23 Mechanism of action Types of orthoses Optimal use Foot Orthoses

24 Combined interventions Education Manual PFJ and soft tissue mobilisation Patellar taping Combined interventions?

25 Combined interventions

26 Recommendations Combined interventions (exercise + taping/mobilistaion/foot orthoses/education) are an effective short-term to medium term intervention for reduction of pain Emerging evidence (one RCT) indicates that combined interventions (exercise + education) is an effective short-term to long term intervention for reduction of pain in adolescents Crossley et al, PFP consensus BJSM :

27 Rathleff et al BJSM 2015

28 Methods Physiotherapy treatment Neuromuscular retraining (foot knee and hip) Strength training A home exercise program was prescribed daily Education Patellar taping Manual PFJ and soft tissue mobilisation

29 Methods Control Pain management Load management Physical activity Knee alignment Pacing Other info Physiotherapy led education (online resource) One session with adolescent and parents (30mins)

30 Results 121 participants with PFP Baseline assessment Blinded assessor physiotherapy N= 62 control N=59 Randomisation concealed allocation N=48 N=51 2 years Final assessment Blinded assessor

31 Multimodal physiotherapy: efficacy Recovered adolescents (%) Physiotherapy Education * * * 0 3 months 6 months 1 year 2 years OR [95% CI] 1.88 [ ] 1.43 [ ] 1.73 [ ] 2.52 [ ] Rathleff MS et al, 2015, Brit J Sports Med, 49(6):406-12

32 What about PFJ OA? Biomechanical link between PFJ pain and PFJ OA? Patellar malalignment Quadriceps dysfunction Hip dysfunction Movement dysfunction robertsontrainingsystems.com

33

34 Methods Physiotherapy treatment Manual PFJ and soft tissue mobilisation Patellar taping Functional retraining (VMO and hip) Strength training (quads and hip) Education A home exercise program was prescribed 4 times per week

35 Methods Control Healthy eating Physical activity Dealing with pain Medicines Complementary therapies Emotions Physiotherapy led education

36 Results 92 participants with PFJ OA Baseline assessment Blinded assessor physiotherapy N= 44 control N=48 Randomisation concealed allocation N=39 N=42 3 months Final assessment Blinded assessor

37 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Global rating of change RR 4.31 (1.79 to 10.36) NNT 3 (2 to 105) physiotherapy control physiotherapy control 12 weeks 9 months much improved improved same worse much worse

38 Combined interventions Combinations of exercise-therapy, with taping, mobilisation and education appears to be beneficial for adolescents with PFP (up to 2 years) and older people with PFJ OA (in the shortterm)

39 What do we need to consider? Interventions

40 Further considerations Despite efficacious treatments, lack of recovery and persistent pain is problematic for 40-50% of adults and adolescents adherence to interventions (new technologies / patient education) individualisation of treatments to patient presentations (studies into responders) longer treatments (top up / check up) additional treatments (eg movement retraining may be required) Weight management vital consideration to pain processing and psychosocial factors are vital

41 Others / Ajunctives

42 6 Recommendations 1. Exercise-therapy is recommended to reduce pain in the short, medium and long term, and improve function in the medium and long term. 2. Combining hip and knee exercises is recommended to reduce pain and improve function in the short, medium and long term, and this combination should be used in preference to knee exercises alone. 3. Combined interventions are recommended to reduce pain in adults with patellofemoral pain in the short and medium term. 4. Foot orthoses are recommended to reduce pain in the short term. 5. Patellofemoral, knee and lumbar mobilisations are not recommended. 6. Electrophysical agents are not recommended

43

44 Mixed Methods Design Quantitative Summarise the findings from high quality reviews Qualitative Semi-structured interviews with 17 international experts Explore clinical reasoning for the treatment of PFP Italics indicates no evidence expert opinion only

45

46

47 @DrChrisBarton

48 Dr Michael Rathleff Dr Christian Barton

49

50

51 PFP across the lifespan: treatments asymptomatic PFP PFJ OA continuum of PFJ disease adolescents young adults older adults PFP is important to identify and manage early on using conservative interventions with known efficacy may optimise prognosis, especially with respect to PFJ OA

52 PFP across the lifespan: treatments PFP across the lifespan: contributors asymptomatic PFP PFJ OA continuum of PFJ disease adolescents young adults older adults PFP is multifactorial & heterogeneous need to consider each potential contributor in each individual patient

53 PFP across the lifespan: treatments PFP across the lifespan: interventions asymptomatic PFP PFJ OA continuum of PFJ disease adolescents young adults older adults Good evidence for physiotherapy interventions no recipe approach! select interventions based on contributors involve the patient in clinical decision making

54 Follow us on 5 th International Patellofemoral Pain Research Retreat Gold Coast, July 2017 Clinical Symposium Brisbane, 22 July 2017

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