Ep 62: Patellofemoral pain CPG: what are the best treatments? with Dr Christian Barton (Part 2 of 2)

[Music] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Clara Don, the editor-in-chief of the Journal of Orthopedic and Sports Physical Therapy. It's great to have you listening today. Welcome to this second part of our two-part episode with Dr. Christian Barton, covering the JOSPT Clinical Practice Guideline on Patelophamoral Pain. If you missed the first episode, I highly recommend you stop, go back, and check it out. For those who just need a quick refresher before we get into treatments, the main four categories of patients who present with Patelophamoral Pain can typically be subgrouped into over-user overload, muscle performance deficits, muscle coordination and movement pattern deficits, as well as mobility impairments. Now, Dr. Barton was also kind enough to walk us through an additional two categories that in his experience are worth looking at during your evaluation to make sure you're addressing each and every potential contributing factor to your patient's rehabilitation and those two are psychological factors as well as lifestyle factors. Once again, welcome to the second part of our episode on Patelophamoral Pain with Dr. Christian Barton. Without further ado, let's get to the treatment recommendations. So we talked about those four categories, though, and the way that they go into treatment. So let's go actually dive into the treatment portion of the CPG. And I want to hear what are the like, what are the recommended, what is research backing up for effective treatment interventions for this? So you sort of mentioned applying these things to life in general, and I think if we take a step back in muscular skeletal pain, if you look at clinical practice guidelines more broadly, they'll typically recommend education, exercise, weight management for people who need it. That's kind of the key thing of Musco's total pain in general. Now, what's really interesting about Patelophamoral Pain is we have zero evidence to support efficacy and effectiveness of education. Zero. So there is no trial that would compare education intervention to wait and see or usual care. That research, it doesn't exist. I don't think that means we can't provide education right? I think that's what's a really important point about this conversation. And we certainly in the clinical practice guideline, education is one of the first recommendations that we kind of make and we'll come back to what that should involve in a second. If we go to exercise therapy, then we have really strong evidence of exercise therapy is a beneficial treatment. And it's beneficial compared to usual care. It's beneficial in combination with other adjunctive therapies compared to placebo treatment. So there's a nice RCT by one of my mentors, Kaye Crosley, way back in 2002, which provided exercise therapy, manual therapy taping and compared it to a sham treatment of detuned ultrasound, a whole range of different things that made the person think they're getting physio. And we see that it comes out as being beneficial. So exercise therapy is an essential part. Now, the question then asks is what type of exercise? Because exercise therapy, we can think about aerobic exercise, we can think about resistance training, we can think about functional exercise, arguably gate retraining could be considered an exercise therapy. We'll come back to that. All we can really conclude from the literature is that exercise therapy targeting the hip and knee is beneficial. And it's beneficial for pain, it's beneficial for disability, beneficial for function. The reason we can't say that strength training or muscle power training is beneficial or what type is that the exercise programs in literature are so poorly described in general that we actually can't replicate what was done until we published a paper on that a few years ago. Typically, the programs as well, and this is good and bad, the programs are typically short duration. So they're typically go from four to max 12 weeks, but most of them are sort of four to eight or ten weeks programs. And if we think about resistance training of trying to address the strength impairments and muscle power impairments that we might see, in someone who's got pain, where it might take you three or four weeks to build their confidence to engage in exercise, we're never going to hit the loading that would improve muscle size, muscle bulk, muscle power. So I don't think we really know the potential value of longer term resistance training that might address strength and muscle power. Nonetheless, lower level resistance training, which typically what seems to happen in these studies seems to be beneficial. I think the other important consideration from the evidence that we can take around exercises, we have many patients come to us in an irritable setting, so they've got a really stirred up knee. And what we can see from the literature is that if we have a hip targeted exercise program, it's frequently to bear outcomes in the knee target exercise program in the short term. So in that first month, that makes logical sense because if you start doing a knee target exercise, if you're not sure where to start and you've got that irritated knee patient front of you, it's probably we've starting at the hip, but in the longer term, certainly combining those two things together is important. What we couldn't put into the guidelines is anything to do with more distal exercise therapy. So car free training, so thinking about gastroxolias, footnacle strength for muscle power, because the evidence isn't there, hasn't been tested. So it's not to say that it's not beneficial. Certainly in my own clinical setting, I find it very variable, especially for more high level athletes. So thinking about doing rehab of saleas with seed car phrases, doing heal raises, all those types of things become quite important and loading them up and working on power. But the evidence at the moment we couldn't make recommendations specifically for that. Patelotapings, an interesting and controversial area amongst clinicians. If we look at the research and the data, and if we want to apply a Patelotapie, it could certainly help in the short term, but the important caveat with that is that it only helps in the short term. Longer term probably doesn't make any difference. So C1, T, EMG, etc. And it probably needs to take some tailoring of that taping for it to be effective. So when we look at short term pain reduction, if we tailor it to the person, we seem to be able to have a better outcome in terms of faster and better recovery in a short term. Now by tailoring what we're talking about in the studies, they consider tilt glide and rotation of the tower. I'm not going to sit here and tell you that we can assess that reliably either because we can't. So what you typically do is just play around with using your tape to try and augment some more glide, less glide, more rotation, less rotation, find the taping technique that is most beneficial for that person's pain. So have an assessment where you test their squat and then retest it. And if you find a technique that's helpful, then that's what we run with and you go with that. And that seems to help in that first month or so in terms of hastening the recovery. It's not the big fish. The big fish is the exercise. Braces are interesting. When we look at evidence for it, there's no evidence to suggest that a knee brace is going to help with pain and function in the short or longer term. So they're not recommended in the guideline. I will say carry it to the listeners though. I have many patients come to me and they swear the braces help them a lot and they feel that they give them a lot of support. So I don't tell people to stop wearing braces. That's important because if we use a brace and it helps someone to engage in exercise and to load their knee more, that's going to help them to get stronger. It's going to help them to recover. And hopefully in time, they won't need that brace. So that's really important. Occasionally, I might use a brace in someone who is finding taping really helpful. I'll typically go taping because I find it more beneficial and they can find a brace that kind of replicates what they're trying to do with taping. But by and large, I would not recommend too many people get a brace from the outset because typically we've got other things to focus on. The other thing that braces can be really helpful for. And this is probably more so in your post-traumatic knee injury population who might subsequently have a telephone or pain. Is it often helps with knee joint confidence? So it might not change their pain, but it makes them more confident to load their knee and to exercise. And that's certainly something that comes out in literature as well. So when we're making recommendations in the guideline, we're making them based on the potential for that treatment to have an effect on pain and function. But of course, there's so many other things to consider and confidence being one of them. And sometimes a brace can help with that as well. And then if we move to another potential, I guess, a junkative treatment for exercise that might help someone engage more in exercise, foot orthosis is also an interesting topic. Now, there isn't any trials that compare a pre-fabricated. So one that you might take off the shelf, which you can customize by the way. So you can do adding posts and various things to that. And comparing that to what's commonly considered customized or molded orthosis. So there's no research comparing those two things, moving to telephone or pain population. The really strong randomized controlled trials coming out of University of Queensland group of Bill Vincenzyno and Natalie Collins and more recently Mark Matthews use a pre-capfabricated version, which is customized to optimize comfort. Now, when we look at the research that they've produced from that, it has a really beneficial effect in the short term compared to a sham intervention. The number needed to treat is between two and four. So what that means is you could prescribe somewhere between two and four orthotics and you would have one additional person have a really positive effect from that intervention. And in Australia, I'm not sure what they might cost in other parts of the world, but in Australia, this device to buy wholesale will cost $40 and you might sell it for $80. So it's not an expensive intervention. So in my clinical setting, I typically start with exercise and then we might consider using an orthotic. Now, there is some research looking at how to identify those who might benefit from an orthotic. There's some studies that would indicate that someone with more foot mobility is more likely to benefit from that foot orthotic. In Mark Matthews study, which I just mentioned before, they actually tested this really well and it wasn't a predictor of someone doing an orthotic. My own PhD in a number of years ago working in a biomechanics lab, we looked at complicated 3D motion analysis. We also So I did clinical measures of foot mobility and foot posture. We didn't find much at all that would indicate that an orthotic is likely to benefit someone more if they've got a more mobile foot. The thing that we found to predict it and I'd encourage you using your clinic and we sort of talk about this briefly in the guideline is if you have a immediate reduction in pain during a squatting task, when activity is painful, then at 12 weeks, the more likely to have a had a bad for beneficial effect of that orthotic device. So keeping it really simple, that is probably the way to go. So that's orthotic. So there are the things that we have some evidence to really support. And then the final one is, "Gate retraining", which is an emerging area that most people probably say have become familiar with. So you might have a runner who's got the telephone or pain, we might try and change the way they run. And the common interventions that people consider are changing strike pattern. So from a rear foot strike to a non-refoot strike or a four foot strike and increasing step rate and cadence, there's some small randomized controlled trial evidence that indicates that changing from a rear foot strike to a non-refoot strike might be beneficial as someone in the short term in terms of reducing pain, the telephone or pain. But the caveat to that is, it also is likely to increase ankle pain. So even in the study that's been done, there was a report that around one quarter of the participants had some media ankle pain as a result of that intervention. And that makes sense, we can't magically make loads disappear. So if you're going to use gate retraining for your population, you need to be really careful. You don't just shift load somewhere else and cause a new injury. The other interventions from gate retraining perspective things like step rate as I mentioned, which there's some case series that indicates adding that to an education program. It probably doesn't make much difference. There's also things like changing hip-hop action and curing people to open their knees, which has been researched and getting case series which might be worth considering. But nowhere in a mys control trials to test this out properly. And then there's a whole lot of different expert opinion. So we've done some qualitative work in this space, which indicates maybe you can consider proximal mechanical changes, which might shift some load away from the knee as well. We could probably talk going into the clinical reason around that for a long time. It's probably a whole other episode to chat about. So it won't dive too deep. But I think if you do use gate retraining, use it really cautiously and make sure that you're not going to cause a new injury. It's probably a really important thing to consider. It has to be accompanied by some strength or like you can't just like change it without changing something else. - Right. So that's our more active interventions that kind of cover it in the guideline. And then we have some passive therapies, which despite probably their wide use, some people might pick up our guideline and say, "Oh, I don't agree with this guideline. I'm just gonna put it down because there's a lot of things in here that I'm being told not to do." So if we talk through that a little bit, I think it's quite valuable to do. So the first thing to discuss is dry knee-dwelling and acupuncture. When we look at the research, we don't have the evidence to support that adding dry knee-dwelling to an exercise program is beneficial. So it's not dissimilar to what we see with BMG by feedback. So that doesn't mean that your own clinical experience doesn't indicate that you do dry knee-dwelling on someone and they don't have improvements in their pain and tell you, "Thanks for doing that. I feel great after that." But the point is that it's only transient and it doesn't seem to make any difference to quality exercise program in longer term. So our recommendation in the guideline was not to use that. Now if you do use it as an adjunct, that might be beneficial, but you certainly shouldn't be using it in isolation. And one of the key things about it is if you're spending 25 minutes of the 30-minute session doing dry knee-dwelling or acupuncture, and then you're spending five minutes lip service to some education and exercise, you're probably not doing your patient justice. They're probably not gonna do the exercise program well and they're probably not gonna be able to change their lifestyle, et cetera, and things that might help. So that's that point. And it probably carries for all of these things. Now manual therapy is commonly used in combined or multimodal intervention studies in physical therapy practice. But when we actually tease it out and we say does adding manual therapy, whether that be the knee, the lumbar spine, whole range of areas, adding that to exercise therapy programs, does that help? The answer to that question is no, it doesn't seem to help. It doesn't seem to make any difference to pain and disability outcomes. Again, that doesn't mean it might not help that individual person in front of you in that immediate term. But over a number of weeks, it's not likely to add a lot of value to your treatment and to your rehabilitation for that person. So I think it's important that we, but necessarily throw the baby out with a bath or a soda spaken, there might be some circumstances and settings where it is helpful to get someone on board to help them to engage with exercise, et cetera. But you need to be really clear and honest with your patient that this is not the long-term solution. So again, don't spend 25 minutes on manual therapy and five minutes on the important stuff. So I think that's really important. And then we have other things like electro-physical agent or biophysical agent. So I think we term them in the clinical practice guidelines. So these are things like ultrasound, interferential, even things like heat and cold. And it's the same story. These things really don't add any value to exercise. So they're not a recommended treatment from the guideline. I said we'd circle back to patient education. I think what's really important about patient education, although it doesn't have evidence of effectiveness or efficacy, a really interesting review by a post-doc who works with us at the TROBE Denilo D'Aloe Vera Silver, we actually compared patient education to exercise therapy because as many studies that do that, this is actually published in GERSPT. The pain and function outcomes, or subjective function outcomes, are very similar between those two interventions. So it doesn't seem like education is inferior to exercise therapy. The caveat to that is the education interventions are probably not what we consider optimal patient education interventions in the trials. And the exercise therapy interventions are also not what we consider as optimal exercise therapy interventions in the trials. So I guess to make the point that if we know that exercise therapy is more beneficial to use your care or wait and see, an education is not inferior to that, then we can pretty confidently speculate that providing some patient education is going to be beneficial to that person. So then the question is, what should we provide? From the research studies that have been done, which shows some reason, where that comes, it's things like load management. It's things like educating someone about how to actively manage their condition and self-management condition, not do too much to assume those types of things, giving them education and reassurance about the condition, about what might be causing it, those types of things. What hasn't been tested all that well in the literature is education around addressing fear of pain, fear of damage, education, and lifestyle support for address, weight management, and those types of things. So although we don't have evidence for those things, we do have evidence in other musculoskeletal conditions and conditions like persistent knee pain and knee osteoporitis in older populations. So we can't make recommendations in our guideline based on the telepharmal pain population, but I think we can maybe extend beyond the guideline that was published and say these are probably important things that we also need to consider and address in our clinical setting. So address the fear of pain, address the fear of damage, address someone's diet and sleep in those types of things or bringing other professionals who can help with that. These are all gonna be potentially important things for this population. - Not doing passive modalities, that seems to be a across the board recommendation, not super helpful there. But then for things like it seems like, and correct me if I'm wrong, it's the CPG saying that things like taping, foot orthoreses, gateway training, dry knee deling, manual therapy, it's all like, there's more, there's better research for the foot orthoreses taping and gateway training, but it depends on how your patient presents. If your patient's hypomobile, then they have a hypomobile patella, then doing some manual therapy on their patella, potentially could help them, but most other people maybe it wouldn't, especially if they don't present with a hypomobile patella. If their gate isn't affected, then maybe that's not the treatment for them. If their foot mechanics aren't at play, you really have to examine your patient, find out what's actually contributing to that pain and then treat that. So there's definitely not a one size fits all. And even if you're in one category of, even I know you, I know you want the six categories, but if we just focus on the four that are in the CPG, even if they're just in one of those categories, you still can't even say if they're in this category, then you can only do this because only educating about overuse and overload, we know doesn't actually work either. So there has to be a combination and you have to use your clinical judgment to be a little determined that. Absolutely right. And I think the short message is that life is a bulk of every person who's on a bell curve, you take all those factors, everyone's on a different place on that bell curve and we combine them together, every single person is unique. And so you've got to treat that unique person in front of you. And if we circle back to the when to use adjuncts and how to use them, what often happens is people make a hypothesis about what's driving their condition, they apply these adjuncts and then they send people on their way and hope for the best, whereas perhaps the best approach is still to do your same assessments to develop your hypothesis about what might be contributing. When you apply an adjunct like taping or Lycanophotic or even a manual therapy, retest a functional activity or a functional task or often the exercise program you're trying to provide to them and if the exercise that you're providing to them becomes easier as a result of those interventions, then they're a very sensible intervention for that person. If it doesn't become easier, or their pain or symptoms doesn't change in that immediate term, then move on. Your hypothesis was wrong. You got the hypothesis wrong and that's okay. That's how we learn. So just move on. - I love that. It's a humble approach and it's important. But overall, you still have to do exercise therapy. That's the most important. And that's the biggest takeaway. In some way or another, you've got to get them to do as an exercise therapy because that will help them. - Yeah, correct. - And you need to talk to them about all their other factors because humans are humans. - Christian, thank you so much for taking the time today. I really appreciate it. Those beautifully laid out. I think it's really gonna help clinicians. Again, this very common thing. that people will walk into the clinic with. I think it just makes it a little bit more simple. So thanks for very effectively summarizing the CPG. - My pleasure, thanks for having me. - So one last time we want to thank Dr. Christian Barton for coming on the show, sharing his time, his experience and his knowledge with all of us in all of you. And as always, we want to thank you for listening to JOSPT Insights. - Thanks for listening to this episode of JOSPT Insights. For more discussion of the issues in Musculoskeletal rehabilitation that are relevant to your practice, subscribe to JOSPT Insights. On Apple podcasts, Spotify, Tune in, Stitcher, Google, or your favourite podcast app. If you like JOSPT Insights, help others find us. Tell your friends and colleagues and raid and review us. To keep up to date with all the latest JOSPT content, be sure to follow us on Twitter, we're @JOSPT and Facebook, we're JOSPT official. Talk with you next time.