Danilo de Oliveira Silva

How to manage patellofemoral pain – Understanding the multifactorial nature and treatment options

Patellofemoral pain (PFP) is one of the most prevalent conditions within sports medicine, orthopaedic and general practice settings. Long-term treatment outcomes are poor, with estimates that more than 50% of people with the condition will report symptoms beyond 5 years following diagnosis. Additionally, emerging evidence indicates that PFP may be on a continuum with patellofemoral osteoarthritis. Consensus of world leading clinicians and academics highlights the potential benefit of delivering tailored interventions, specific to an individuals needs, to improve patient outcome. This clinical masterclass aims to develop the readers understanding of PFP aetiology, inform clinical assessment and increase knowledge regarding individually tailored treatment approaches. It offers practical application guidance, and additional resources, that can positively impact clinical practice.

Delayed onset of electromyographic activity of the vastus medialis relative to the vastus lateralis may be related to physical activity levels in females with patellofemoral pain

The aims of this study were to examine group differences in muscle activation onset of the vastus medialis (VM) in relation to the vastus lateralis (VL) and pain level during stair ascent in females with patellofemoral pain (PFP) who maintain high and moderate levels of physical activity; to determine the association between physical activity level and muscle activation onset. Forty-three females with PFP and thirty-eight pain-free females were recruited and divided into four groups based on their level of physical activity: females with PFP (n=26) and pain-free females (n=26) who practiced a moderate level of physical activity and females with PFP (n=17) and pain-free females (n=12) who practiced an intense amount of physical activity. Participants were asked to ascend a seven-step staircase and the VM and VL activation onset was determined. Females with PFP who practiced high level of physical activity demonstrated delayed onset of VM (4.06ms) compared to healthy females (-14.4ms). Conversely, females with PFP who practiced moderate level of physical activity did not present VM delay (-2.48ms) in comparison to healthy females (-9.89ms). Furthermore, physical activity significantly correlated to the muscle activation onset difference (p=0.005; R=0.60). These findings may explain why controversial results regarding VM and VL muscle activation onset have been found.

Different pain responses to distinct levels of physical activity in women with patellofemoral pain

Highlights • Intense physical activity can lead to higher levels of PFP.• Asymptomatic women were not influenced by the PFJ loading protocol.• The PFJ loading protocol has the capability to equalize pain in women with PFP.

Reliability of electromyography parameters during stair deambulation in patellofemoral pain syndrome

A reprodutibilidade e essencial para todos os aspectos da medida, uma vez que mostra a qualidade da informacao e permite conclusoes racionais no que diz respeito aos dados. Alem disso, os resultados sao controversos sobre parâmetros eletromiograficos avaliados durante a subida e descida de escada em individuos com sindrome da dor femoropatelar (SDFP). Portanto pretende-se determinar a reprodutibilidade de parâmetros eletromiograficos nos dominios do tempo e da frequencia em ambos os gestos em mulheres com SDFP. Foram selecionadas 31 mulheres com SDFP. Os dados dos musculos vasto lateral e vasto medial foram coletados durante a subida e a descida de escada. Os parâmetros selecionados foram: o onset automatico, frequencia mediana, bandas de baixa, media e alta frequencia. Determinou-se a reprodutibilidade atraves do coeficiente de correlacao intraclasse e do erro padrao da medida. As variaveis no dominio da frequencia apresentaram boa reprodutibilidade, com a subida apresentando os melhores indices, e o onset mostrou-se inconsistente. Os resultados sugerem que a subida de escada e mais confiavel do que a descida da escada para avaliar individuos com SDPF na maioria dos casos.La reproducibilidad es esencial para todos los aspectos de la medida, ya que muestra la calidad de la informacion y permite conclusiones racionales con respecto a los datos. Ademas, los resultados son controvertidos en parametros electromiograficos evaluados durante el ascenso y descenso escaleras en las personas con sindrome de dolor patelofemoral (SDPF). Por eso tenemos la intencion de determinar la reproducibilidad de los parametros electromiograficos en el tiempo y la frecuencia en ambos gestos en mujeres con SDPF. 31 mujeres com SDPF fueron seleccionadas. Se recogieron datos del vasto lateral y medial durante ascenso y descenso de escaleras. Los parametros seleccionados fueron: inicio automatico, frecuencia mediana, bandas de baja, media y alta frecuencia. La reproducibilidad se determino mediante el coeficiente de correlacion intraclase y el error estandar de medicion. Las variables en el dominio de la frecuencia mostraron buena reproducibilidad, el ascenso presento los mejores indices, y el inicio demostro ser inconsistente. Estos resultados sugieren que el ascenso de la escalera es mas confiable que el descenso para evaluar individuos con SDPF en la mayoria de los casos.

Association between increase in vertical ground reaction force loading rate and pain level in women with patellofemoral pain after a patellofemoral joint loading protocol

BACKGROUND The etiology of patellofemoral pain (PFP) is thought to be the result of increased patellofemoral joint (PFJ) load and aberrant lower extremity mechanics, including altered vertical ground reaction forces (VGRF). However, few studies have investigated the association between an increase in pain and VGRF loading rates in the context of PFP. Thus, this study aimed to investigate the immediate effects of PFJ loading on pain and VGRF loading rate, and to see if there is a link between modification of both pain and VGRF loading rate during stair negotiation. METHODS Thirty-four women with PFP underwent VGRF analysis during stair negotiation under two conditions: with (condition 2) and without (condition 1) being previously submitted to a PFJ loading protocol in order to or not to exacerbate their knee pain, respectively. RESULTS The VGRF loading rates were significantly higher in condition 2 (Mean ± standard deviation (SD)=4.0±0.6N/s) compared to condition 1 (Mean±SD=3.6±0.5N/s) during stair ascent and during stair descent (Mean±SD: condition 1=6.3±1.1N/s; condition 2=7.0±1.4N/s). In addition, VGRF loading rates were higher during stair descent compared to stair ascent in both conditions. There were significant correlations between the increase in pain and VGRF loading rate during both tasks. CONCLUSION There seemed to be an important relation between the increase in pain and VGRF loading rates in women with PFP. Based on these findings, interventions aimed at reducing VGRF loading rates are important in the context of PFP.

Which is the best predictor of excessive hip internal rotation in women with patellofemoral pain: Rearfoot eversion or hip muscle strength? Exploring subgroups

BACKGROUND Patellofemoral pain (PFP) has been linked to increased patellofemoral joint stress as a result of excessive hip internal rotation. Lower hip strength and/or excessive rearfoot eversion have been used to explain such altered movement pattern; however, it is unknown which one is the best predictor of excessive hip internal rotation. RESEARCH QUESTION To investigate if peak rearfoot eversion and/or peak concentric hip abductor strength can predict peak hip internal rotation during stair ascent in women with PFP. METHODS This cross-sectional study included thirty-seven women with PFP which underwent three-dimensional kinematic analysis during stair ascent and hip abductor strength analysis in an isokinetic dynamometer. A forced entry linear regression model analysis was carried out to determine which independent variables present the best capability to predict the hip internal rotation. RESULTS Peak concentric hip abductor strength significantly predicted peak hip internal rotation during stair ascent (R2 = 0.27, p = 0.001). Peak rearfoot eversion did not predict peak hip internal rotation during stair ascent (R2 < 0.01, p = 0.62). A Post-hoc analysis was conducted to explore if a subgroup with excessive rearfoot eversion would predict hip internal rotation. Based on a previous reported cut-off point, 48.6% of the participants were classified as excessive rearfoot eversion. For the subgroup with excessive rearfoot eversion, peak concentric hip abductor strength and peak rearfoot eversion significantly predicted peak hip internal rotation during stair ascent (R2 = 0.26, p = 0.02; R2 = 0.42, p = 0.003, respectively). For non-excessive rearfoot eversion subgroup, peak concentric hip abductor strength significantly predicted peak hip internal rotation during stair ascent (R2 = 0.53; p < 0.001); and peak rearfoot eversion did not (R2 = 0.01; p = 0.65). SIGNIFICANCE Findings indicate that hip muscle strength seems to be related with hip internal rotation in all women with PFP. Rearfoot eversion seems to be related with hip internal rotation only in a subgroup with excessive rearfoot eversion.

What interventions can improve quality of life or psychosocial factors of individuals with knee osteoarthritis? A systematic review with meta-analysis of primary outcomes from randomised controlled trials

Objective To systematically review evidence of primary outcomes from randomised controlled trials (RCTs) examining the effect of treatment strategies on quality of life (QoL) or psychosocial factors in individuals with knee osteoarthritis (OA). Design Systematic review with meta-analysis. Data sources Medline, Embase, SPORTDiscus, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Web of Science were searched from inception to November 2017. Eligibility criteria for selecting studies We included RCTs investigating the effect of conservative interventions on QoL or psychosocial factors in individuals with knee OA. Only RCTs considering these outcomes as primary were included. Results Pooled data supported the use of exercise therapy compared with controls for improving health-related and knee-related QoL. There was limited evidence that a combined treatment of yoga, transcutaneous electrical stimulation and ultrasound may be effective in improving QoL. Limited evidence supported the use of cognitive behavioural therapies (with or without being combined with exercise therapy) for improving psychosocial factors such as self-efficacy, depression and psychological distress. Summary/Conclusion Exercise therapy (with or without being combined with other interventions) seems to be effective in improving health-related and knee-related QoL or psychosocial factors of individuals with knee OA. In addition, evidence supports the use of cognitive behavioural therapies (with or without exercise therapy) for improving psychosocial factors such as self-efficacy, depression and psychological distress in individuals with knee OA. PROSPERO registration number CRD42016047602.

Comparison of the level of patellofemoral pain, physical activity, and quality of life between female and male adolescents

DOI: 10.15448/1980-6108.2017.1.25250 Aims: To compare the level of pain, physical activity, and quality of life of female and male adolescents with patellofemoral pain. Methods: A total of 46 female adolescents and 46 male adolescents aged 12 to 18 years were recruited from public and private schools in the town of Presidente Prudente, Sao Paulo, Brazil. To be included in the study, adolescents needed to report knee pain of insidious onset, exacerbated in some activities, and lasting for at least 6 weeks. In addition, adolescents should report worse pain over the previous week of at least 30 mm on the Visual Analog Scale and could not show signs, symptoms or any occurrence of any other knee dysfunction. The participants were requested to mark their self-reported knee pain in the last month on a Visual Analog Scale. The level of physical activity was evaluated by the Baecke Questionnaire of Habitual Physical Activity and the quality of life subscale of the Knee Outcome in Osteoarthritis Survey questionnaire was used to investigate the participants’ quality of life. The independent t-test was used to find differences between the groups regarding the level of physical activity, quality of life, and knee pain. Results: According to the Visual Analog Scale, male adolescents presented a level of knee pain of 5.1±1.4 in the previous month and female adolescents, of 4.4±1.6 (p = 0.029). The physical activity score was 8.8±1.3 for male adolescents and 7.5±1.6 for female ones (p<0.001). The quality of life subscale scores were 77.9±19.0 for adolescent girls and 70.8±13.5 for male adolescents (p=0.042). Conclusions: Among adolescents with patellofemoral pain, males had a higher level of knee pain, higher level of physical activity, and lower quality of life compared to female adolescents.

A low proportion of systematic reviews in physical therapy are registered: a survey of 150 published systematic reviews

BACKGROUND Systematic reviews provide the best evidence about the effectiveness of healthcare interventions. Although systematic reviews are conducted with explicit and transparent methods, discrepancies might occur between the protocol and the publication. OBJECTIVES To estimate the proportion of systematic reviews of physical therapy interventions that are registered, the methodological quality of (un)registered systematic reviews and the prevalence of outcome reporting bias in registered systematic reviews. METHODS A random sample of 150 systematic reviews published in 2015 indexed on the PEDro database. We included systematic reviews written in English, Italian, Portuguese and Spanish. A checklist for assessing the methodological quality of systematic reviews tool was used. Relative risk was calculated to explore the association between meta-analysis results and the changes in the outcomes. RESULTS Twenty-nine (19%) systematic reviews were registered. Funding and publication in a journal with an impact factor higher than 5.0 were associated with registration. Registered systematic reviews demonstrated significantly higher methodological quality (median=8) than unregistered systematic reviews (median=5). Nine (31%) registered systematic reviews demonstrated discrepancies between protocol and publication with no evidence that such discrepancies were applied to favor the statistical significance of the intervention (RR=1.16; 95% CI: 0.63-2.12). CONCLUSION A low proportion of systematic reviews in the physical therapy field are registered. The registered systematic reviews showed high methodological quality without evidence of outcome reporting bias. Further strategies should be implemented to encourage registration.

Patellofemoral pain and sports practice: reduced symptoms and higher quality of life in adolescent athletes as compared to non-athletes

Patellofemoral pain (PFP) is common in athletes and physically active individuals and it is one of the most frequent knee disorders among adolescents. However, the impact of the severity of PFP symptoms on quality of life (QOL) has been barely investigated. Thus, we aimed to compare the level of PFP and the self-reported QOL between adolescent athletes and non-athletes, and to explore the relationship between the severity of PFP symptoms and QOL. Fifty-six adolescents with PFP (22 athletes and 34 non-athletes) were asked to fulfill the Anterior Knee Pain Scale (AKPS) and the QOL dimension of the Knee Outcome in Osteoarthritis Survey (KOOS). Between groups comparisons indicated that adolescent non-athletes presented higher severity of PFP symptoms and lower QOF as compared with adolescent athletes. Significant correlations between the severity of PFP and QOL were found for both groups, regardless of the athletic status.