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

The 2016 international patellofemoral pain (PFP) consensus statement 1 suggested exercise therapy targeting the hip and knee, combined interventions and prefab-ricated foot orthoses can be used to improve pain and function in people with PFP. These recommendations are based on strong foundations including synthesis of multiple high-quality systematic reviews combined with voting from the International Patellofemoral Research Network group.


Should we consider changing traditional physiotherapy treatment of patellofemoral pain based on recent insights from the literature?
Christian J Barton, 1,2 Kay M Crossley, 1,2 Erin M Macri 3,4 The 2016 international patellofemoral pain (PFP) consensus statement 1 suggested exercise therapy targeting the hip and knee, combined interventions and prefabricated foot orthoses can be used to improve pain and function in people with PFP.These recommendations are based on strong foundations including synthesis of multiple high-quality systematic reviews combined with voting from the International Patellofemoral Research Network group.

But, iS thiS currEnt focuS on traditional phySiothErapy optimal?
A recent prognostic paper indicated that nearly 50% of people with PFP are likely to benefit from traditional physiotherapy in the longer term. 2 However, 57% report unfavourable outcomes 5-8 years after being enrolled in a traditional physiotherapy clinical trial, indicating a need for alternative approaches in these individuals. 2mportantly, patient outcomes may be improved by providing interventions tailored to their needs.Efforts are under way to optimise subgrouping of patients in order to target traditional physiotherapy interventions.The purpose of this Editorial is a 'call to action' for researchers and clinicians (see box 1) to also consider exploring, incorporating and tailoring non-traditional physiotherapy interventions to optimise patient outcomes.Based on recent insights contained within two systematic reviews and one randomised clinical trial published in the British Journal of Sports Medicine, this may include weight management, addressing psychological factors and improving the provision of patient education.

Weight management
Hart et al's 3 systematic review highlighted greater body mass index (BMI) in adults with PFP compared with asymptomatic people.There is certainly more research needed to elucidate the nature of the association of BMI with pain in PFP, and to determine whether weight loss reduces pain, or to what extent it alters potential mechanisms for pain such as patellofemoral joint loads.Regardless, as physiotherapists, we should be offering weight management education as part of our treatment.This could enable secondary prevention of BMI-related issues such as knee osteoarthritis, cardiovascular disease, diabetes and other physical and psychological impairments. 4

Limited
evidence synthesised in Maclachlan et al's 5 systematic review highlights a number of psychological features which may be elevated in people with PFP, including anxiety, depression, catastrophising and fear of movement. 5Importantly, these psychological features may influence the development of widespread pain, healthcare usage and adherence to traditional physiotherapy treatments such as exercise therapy. 5Therefore, research and clinical practice is encouraged to consider psychological characteristics during assessment, along with the potential value of interventions to address them.We support the recommendations to use the short form Orebro Musculoskeletal Pain Questionnaire suggested by Maclachlan et al 5 as a starting point for physiotherapists to implement early in consultation to identify those who may require more detailed assessment and management of psychological factors.

load management education
Despite a paucity of supporting evidence, international experts propose patient education as a vital component in the treatment of PFP. 6 Esculier et al 7 recently reported large reductions in running-related pain (2.5-2.9/10)following patient education focused on load management.There were limited additional improvements when this education was combined with 8 weeks of exercise therapy targeting the hip and knee musculature, or running retraining primarily focused on increasing cadence.These findings highlight that a critical treatment component in runners with PFP may be load management education and something not to be missed by physiotherapists.
Moving forward, education of other factors beyond load management may benefit people with PFP.Based on previous suggestions by international experts 6 and recent insights from the published literature, other education targets could of patients report unfavourable longterm outcomes.Thus, traditional physiotherapy may not be enough.Our 'call to action' is to provide traditional physiotherapy treatment tailored to patient needs, and consider non-traditional physiotherapy interventions.Limited evidence from recently published literature provides insights that these considerations could include weight management and addressing psychological features where indicated, along with optimising and placing a greater emphasis on patient education.
Further associated multimedia resources to optimise learning opportunities from this editorial and 'call to action' for researchers and clinicians can be found here (https:// ipfrn.org/ virtual-edition-2018/). contributors CJB conceived the idea and drafted the original manuscript.EMM and KMC contributed to the manuscript.All authors approved the final manuscript.
funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Collins NJ, Matthews MLG, et al.The psychological features of patellofemoral pain: a systematic review.Br J Sports Med 2017;51:732-42.6 Barton CJ, Lack S, Hemmings S, et al.The 'best practice guide to conservative management of patellofemoral pain': incorporating level 1 evidence with expert clinical reasoning.Br J Sports Med 2015;49:923-34.7 Esculier JF, Bouyer LJ, Dubois B, et al.Is combining gait retraining or an exercise programme with education better than education alone in treating runners with patellofemoral pain?A randomised clinical trial.Br J Sports Med 2018;52.8 Barton CJ, Rathleff MS. 'Managing my patellofemoral pain': the creation of an education leaflet for patients.BMJ Open Sport Exerc Med 2016;2:e000086.copyright.on May 6, 2022 at Erasmus MC Medical Library.Protected by http://bjsm.bmj.com/Br J Sports Med: first published as 10.1136/bjsports-2017-098695 on 1 June 2018.Downloaded from