Are we paying ‘Lip Service’ to Health Communication?
This is a no-paywall blogpost with some (I think) valuable information. If you find this post of value, please consider ‘Buying Me A Coffee’ to say thanks and help me continue to be motivated to share everything I’ve learned in the clinic with the world for free.
Hot off the presses is another article on Patellofemoral Pain (PFP) with some big names in PFP attached to it (Winters, Holden et al. 2021):
Winters, M., Holden, S., Lura, C. B., Welton, N. J., Caldwell, D. M., Vicenzino, B. T., … & Rathleff, M. S. (2021). Comparative effectiveness of treatments for patellofemoral pain: a living systematic review with network meta-analysis. British journal of sports medicine, 55(7), 369–377.Freely available at: https://bjsm.bmj.com/content/55/7/369.abstract
With it comes a tidy little infographic:
I have so much love for the researchers involved in these big reviews, I am a family man, a clinician and a guy who generally hates paperwork/admin/bureaucracies so I respect the time, effort and heartbreaks that my Academic cousins have to endure.
As a Clinician working with active patients who often present with PFP this is a nice update for me to browse and add to my bank of PFP research in order to guide my management of patients with PFP.
However, for me Clinically, I really value the role that Education plays and included in ‘Education’ is ‘Activity and Load Modification’, so as I discuss ‘Education’ below please include Activity and Load Modification in that.
Although it does depend on the patient, I have a pretty standardised Education component which I feel is very significant in management of patients with PFP, which is specific in the types of activities it addresses, which is based on Lenhart, Thelen et al. ( 2014) (available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3925193/) and Sanchis-Alfonso, McConnell et al. (2016) (available at https://jisakos.bmj.com/content/1/3/161?hootPostID=ee9dd25eb738d59c63711190e0c255ae)
In particular it involves educating the patient on making changes to activities (external loads) based on this table which is adapted from Hart et al (2022).
I pair it with my objective assessment which is linked to the above PF joint loads. I test patients functionally with walking, running, squatting, jumping and step-up/down. I don’t ‘poke the bear’, if the patient is sore with running I’m not going to make them do plyometrics.
I also do a poor-mans isometric knee extension test with a hand held dynamometer (in the absence of a $$$ isokinetic dynamometer) at 90, 60 and 20 degs of knee flexion to test the PF joints tolerance to producing force (note I didn’t say “strength”). Specifically I want to know the patients pain-free isometric force production and compare it with the other side. I use this difference (as a %) to help guide activity and load advice.
Again, every patient is different, some are runners, many are doing those gym classes that are meant to be ‘resistance training’ but are just an unprescribed overdose of jumping, squatting, step activities with a more cardiovascular focus.
For years I had been looking into correcting valgus and “knee postures” as well as chasing “weak quads” which in hindsight was just Patellofemoral joint inhibition of quads (or… “Kneecap Ouchy Ouchy leading to Quads Weaky Weaky”). Over the years I was pushing a boulder up the hill as I was not appropriately educating the patient about activities and PF joint loads and planning out their training fortnights with them and giving them plans for dialling up and dialling back depending on their feelings. Also…. using the Traffic Light system (thanks again to Tom Goom https://twitter.com/tomgoom for this pic)
I have found that getting my education/activity modification advice right is enough, in itself, to settle down cranky Patellofemoral Joints, and for the short-to-medium term conditions the quads strength returns as it is less inhibited. If you have kept the patient active they have had less loss of quads strength. Obviously the longer it goes on and the more the patient has dialled things back we’d then need to chase down the quads strength.
So, I was a little confused and had my bias (formed from my clinical experience, briefly summarised above) challenged when the Winters et al (2021) Systematic Review and Meta-Analysis came out and Education by itself wasn’t very effective.
However then digging into to the cited articles that were referenced for ‘Education’ (Collins, Crossley et al. 2008, van Linschoten, van Middelkoop et al. 2009, Rathleff, Roos et al. 2015) only the Rathleff 2015 study described the “Education” and none of it had anything to do with Patellofemoral Loads but was more focused on the valgus knee-postures with activities, so presumably patients can continue doing everything with less valgus?
In other words, ‘internal loads’ (postures, weaknesses, flexibility, joint tracking) are the focus and ‘external loads’ (activities, load) are lost in the noise. This is mirrored by other big contributors to PFP education in the past 10 years such as Davis and Powers (2010) and Barton, Lack et al. (2015), their “Best Practice Guide” mentions ‘education’ many times and expresses how important it is and again… I can’t find what it entails, other than “limit doing things that hurt”, there’s no examples of specific activities that are better or worse than others.
There’s always plenty of focus on exercise therapies, orthoses, taping and manual therapy, but “education” always seems to be lacking…. What exactly was discussed with patients?… Did it involve also ‘activity and load modification’?… If it was ‘standardised’ why not describe it succinctly? Indeed is it possible at all to standardise “education” in these studies as every patient is different and it becomes 50/50 an art and a science to apply it?
I find this has also happened with Lateral Elbow Tendinopathy (Tennis Elbow) research. Lots of examining treatments, taping etc, but no “stop repetitive gripping in a palm down position (pronation)” as it would again be different from patient to patient depending on how they stirred up their elbow isin the first place.
I’d love to see more of a focus on the education/advice and activity modification in these big reviews, particularly with PFP and Tennis Elbow. These two conditions combined contribute to so much disability and healthcare burden. It doesn’t have to spell out a ‘recipe’ for clinicians to use to education patients (or a handout.. as has been done in the past), just some more discussion on this topic, with reference to specific activities that are common in active people, so it can further guide the less experienced Clinicians who are still coming out of university expecting that some off-the-shelf orthotics, taping, addressing valgus and doing glutes/quads strength is going to fix all of their PFP patients.
Of course, if I missed some big review (particularly on PFP) which has covered “education” succinctly, please let me know and I’ll trash this blogpost and run over to that research and dive into it.
Again, much love to all the Academics/Researchers out there.
Select here to read how I manage patients with PFP.
References
Barton, C. J., et al. (2015). “The ‘Best Practice Guide to Conservative Management of Patellofemoral Pain’: incorporating level 1 evidence with expert clinical reasoning.” British journal of sports medicine 49(14): 923–934.
Collins, N., et al. (2008). “Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial.” Bmj 337.
Davis, I. S. and C. Powers (2010). “Patellofemoral pain syndrome: proximal, distal, and local factors — international research retreat, April 30–may 2, 2009, Baltimore, Maryland.” journal of orthopaedic & sports physical therapy 40(3): A1-A48.
Hart, H. F., Patterson, B. E., Crossley, K. M., Culvenor, A. G., Khan, M. C., King, M. G., & Sritharan, P. (2022). May the force be with you: understanding how patellofemoral joint reaction force compares across different activities and physical interventions — a systematic review and meta-analysis. British journal of sports medicine.
Lenhart, R. L., et al. (2014). “Increasing running step rate reduces patellofemoral joint forces.” Medicine and science in sports and exercise 46(3): 557.
Rathleff, M. S., et al. (2015). “Exercise during school hours when added to patient education improves outcome for 2 years in adolescent patellofemoral pain: a cluster randomised trial.” British journal of sports medicine 49(6): 406–412.
Sanchis-Alfonso, V., et al. (2016). “Diagnosis and treatment of anterior knee pain.” Journal of ISAKOS: Joint Disorders & Orthopaedic Sports Medicine 1(3): 161–173.
van Linschoten, R., et al. (2009). “Supervised exercise therapy versus usual care for patellofemoral pain syndrome: an open label randomised controlled trial.” Bmj 339.
Winters, M., et al. (2021). “Comparative effectiveness of treatments for patellofemoral pain: a living systematic review with network meta-analysis.” British journal of sports medicine 55(7): 369–377.
Did you enjoy this blog or learn something new that will help you with your clinical practise?
Are you a patient and has this helped you with your condition?
‘Buy Me A Coffee’ to say thanks and help me continue to be motivated to share everything I’ve learned in the clinic with the world for free.
https://www.buymeacoffee.com/nickilicphysio
