Activity modification and load management for adolescents with patellofemoral pain?

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About

This masterclass focuses on the treatment of adolescents with patellofemoral pain (PFP). We will discuss the typical profile of adolescents with PFP, the definition of the diagnosis, and the population in which this condition occurs most frequently. The masterclass will then provide evidence-based information regarding prognosis (which can be shared with patients) before addressing the practical management of adolescents with PFP. Emphasis will be placed on how to use activity modification and load management, as well as on supporting the self-management of symptoms by adolescents.

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Introduction and goals

Hi, my name is Michael Skovdal Rathleff, I am a full-time professor at the University of Aalborg, where I split my time between the Center for General Medicine and the Department of Health Sciences and Technology. One of the things that has interested me the most in the last few years, about 10-15 years, is patellofemoral pain in adolescents.

Today, we are going to focus directly on patellofemoral pain in adolescents, which seems very interesting to me and I think that we can really change things if we do the right thing. So we're going to start by asking ourselves: who are these patients with patellofemoral pain? I am going to provide classic examples in order to set the scene and talk a bit about the diagnosis. Next, we'll look at the prognosis of patellofemoral pain in adolescents, because we also know that these are the most common questions we get asked by teens and their parents. And we will end up with the practical management of adolescent patellofemoral pain, where I will try to deepen current knowledge, by focusing on recent studies that we have done, and by trying to answer the question of why is exercise therapy not enough to help adolescents with patellofemoral pain?

Clinical case

One of the typical patients I might have seen, when I was a bit more into clinical practice, could have been Amanda, a 15-year-old runner. She has been running for 3 years, she runs about 30 km per week, sometimes a little more, sometimes a little less. At this stage, the most important thing is to be consistent in training. Then in December 2019, she started experiencing progressive pain in her right knee. As a runner or a physically active person, you are not worried about these small pains because they are part of the game. And for her, it's the same thing. They always disappear. It's still a small problem, but I can always keep on running. But after 6 weeks of pain, it got a bit worse and then she started to feel pain in her left knee and lower back. And then it got so bad that she had to stop running because of her knee pain. That's when she consulted us.

So what are its expectations and what are its challenges? That's what we need to consider every time we see a patient. For Amanda, she wanted to be told that there was room for improvement and that she could run again. She also wanted to understand her pain and wanted validation of what she was feeling, a diffuse pain that moved into her knee, and she wanted to be assured that it was possible. She was wondering when she could go back to running at full speed and run again with her friends. We asked her if she had any concerns or challenges and she opened up about her concerns about missing training because of the upcoming championships because she was worried about not being able to participate, a goal she had set for the season. It was also one of the first times she had experienced pain so severe that she had to stop running, which made her very anxious. She wondered if it was the end of her sports career, in part because a friend had to stop running after being diagnosed with patellar chondromalacia and was advised to stop running to avoid a knee replacement. Amanda wondered if she was facing the same fate. She also had crepitus in her knee and was worried that it was due to a cartilage problem that would prevent her from running. These thoughts made her feel anxious, but she was also nervous about asking about it.

An enigma

We diagnosed Amanda with patellofemoral pain, a condition similar to non-specific low back pain but located in the knee. It is a pain around the patella that occurs when using the knee or during physical activities such as going up or down stairs, or running, where there is a diffuse pain in the front of the knee in the absence of any specific intra-articular pathology. When you've ruled out all other tissue-specific conditions and all that's left is diffuse anterior knee pain, we call it patellofemoral pain. An article in the British Journal of Sports Medicine by Kay Crossley and colleagues, available in open access, may provide more in-depth information on this specific diagnosis.

Remember that this is not patellar chondromalacia, which is completely different. The case of Amanda, a young girl with patellofemoral pain, is an example of a clinical diagnosis where no type of imaging is required.

Previously, patellofemoral pain was thought to be simply due to biomechanical abnormalities, as illustrated on the left, where it was believed that over-pronation caused an internal rotation of the tibia, causing forced valgus in the knee or hip, with a drop in the pelvis and adduction of the hip, leading to knee joint dysfunction. This explanation is now considered obsolete.

Today, patellofemoral pain is instead considered to be a non-specific pain similar to non-specific low back pain. Increasingly, it is thought to affect the whole person, our well-being and social interactions, and our nervous system as a whole, with growing evidence that pain occurs locally in the knee and also higher up.

This indicates that it is a non-specific pain complaint and we need to be very effective in treating it. I hope that this conference will give you some pointers on possible actions.

Prevalence/Incidence

Patellofemoral pain is common, with studies showing that about 6 to 7 percent of teens in a public school experience this pain, or about one in fourteen teens.

Military recruits and runners are particularly likely to develop patellofemoral pain, often associated with increased physical activity. However, there is no very pronounced risk factor for why people develop this pain, and recent systematic studies could provide more accurate information.

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Teens often wonder when they will be able to return to sports and when the pain will go away. We have been following a group of adolescents for 10 years and the results suggest that pain can have a significant impact in the short and long term.

So when they ask you, “When can I go back to sport?” I think it's about accompanying the message with a lot of attention, because there's a lot of evidence to suggest that the long-term prognosis is poor. I usually say that, of course, there is a risk that you will have pain, but the more you take ownership of your condition the more time and energy you invest in getting better, the more likely you are to be pain-free.

So I am trying to turn the situation around and say that if they follow some of the advice we give them and the principles of education, they are much more likely to be pain-free. Because, if you see that 50% of you will have pain in 5 years, that's not a very positive message. It is therefore necessary to reverse the situation, to try to encourage them and to create a feeling of: “you can do it” to promote self-management among this population.

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What care?

And when we talk about management, what do we do? We know that the highest level of evidence is from Cochrane. And if one looks at the Cochrane Review, the latest study on the treatment of patellofemoral pain, it is said that the review found weak data that suggests that exercise therapy may have clinically important effects in reducing pain and improving function.

We can exercise in a variety of ways. And when we look at the evidence, we did as well, people interpret exercise therapy in different ways. Some use hip exercises, some use knee exercises, some use a combination, and still others use distal exercises. We tried to answer the question of what is the most effective specific exercise. But the evidence is not entirely clear. They actually suggest that no matter what type of exercise you do, you get these low to moderate benefits.

The latest review, also published in open access in the British Journal of Sports Medicine by Rudi Hansen, compared knee exercises and hip exercises and showed that they had exactly the same effects, no difference between the two interventions. So exercises may be a good thing, but my interpretation is that it's only part of what we need to do to help adults and teens with patellofemoral pain.

The exercise yes but not only!

Then, if we look at consensus reports that tell us what to do to help these patients with patellofemoral pain, the focus is on what treatment we should prescribe. It is mainly a question of knowing what exercises we should prescribe. I think we missed an important point if we only focus on the effects of exercising hip abduction or external rotation, because I think the key to managing such a condition, which is very likely a long-term condition, is to ask ourselves: how can we help the patient manage their symptoms? They will only be staying with us for a very short time, but on a day-to-day basis, they are the ones who need skills to manage their illness.

When they have a surge in pain, when should they decide whether to stay home on the couch today, or should I go out and do some physical activity with my friends? And that's part of what we're going to talk about today. How can we build skills so that they can manage this long-term modality themselves?

Therapeutic education

The reason why I say that physical exercise may be one element, but certainly not the only one, is based on this article by JF with editorial support, that we did, where I think the interesting part is that JF did a randomized controlled trial (RCT) based on good load management, and the modification of activities against the same thing, but added exercise therapy or modification of the walk, show no difference between these 3 groups.

This means that if you add therapeutic exercise in addition to what we would call activity modification or patient education, there is no greater effect. And I think that underscores the premise that you can do a lot with simple things, that is, with education.

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In this part, they were adults, but it's the same for teenagers, they were taught what they can do to manage their pain. And when we talk about developing skills to manage their illness, one of the key things that I teach my students when we talk about patient education, to stimulate or develop self-management skills, it's important that it's not this old school, old school, patronymic approach, where we think we know everything and that we just need to give information to the patient. Because just because we give them knowledge or information does not necessarily lead to change or to the acquisition of self-management skills.

So when we talk about patient education, it's something different, just providing information and advice. We need to teach them practical skills so they can manage their illness. It's not just about giving them advice on what to do. I will come back to some more practical examples later.

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And the reason why I think, coming back to Amanda, take some time to think, maybe press pause. Do you think that exercise therapy, specific exercises, will answer his concerns, his fears. She was worried: “Is this going to be the end of my running career? Do I have poor quality cartilage like my friend?” And when we read the Cochrane report that advised us to use exercise therapy, do you really think that exercise therapy alone will solve all of their problems and concerns? No The management of these pathologies is not limited to exercises.

I think, and this is my bias, that the physio 2.0 is thinking about where we should be in 5 or 10 years to be good in the health care system, I think we need to understand a lot more about what we can do besides prescribing exercises. And I think patellofemoral pain, with its large-scale consequences for the individual, is this area where we really need to think carefully about what we need to do in addition to focusing on the exercises, which is actually the main thing.

Indeed, when we conduct clinical practice surveys today, many of these patients are simply cared for with a large number of different exercises. And this area of self-management, education, which can be called in different ways, is really, really neglected. And I'm going to end by showing why it's dangerous, why it's dangerous to just focus on exercises, because I know that people focus on exercises because they think that people with patellofemoral pain often have low hip and knee strength. We need to improve their strength for them to improve. But it's based on a rationale that by improving strength, we're also improving symptoms. Is it really that easy? No, and I'll get back to that in a few minutes.

Load vs capacity

One of the things we need to teach them is this idea of load versus capacity, because sometimes the way I do it, I've printed these slides and I have a few brochures for patients, which you can also print and use in your clinical consultation in English, where I'm trying to show you this idea of training load versus ability to manage the load. So when you overdo it, compared to your ability to cope with the load, it can lead to symptoms. Next, we need to find out if it's more of an imbalance between the training load and your ability to handle that load.

Then I try to use it as a bridge to tell them that the burdens of life and their ability to manage those burdens are critical because there are a lot of different things that can influence their pain and symptoms, both in terms of initial development and on daily symptoms and pain. I often use the example of sleep. I ask them if they ever wondered how they felt after a night of very, very poor sleep. Many respond that the next day they have more worries about their pain. It can also be used as a bridge for days when they are feeling sadder or more anxious than usual. Often the symptoms may be a bit more severe on these days.

It's about finding a balance between the load and our ability to manage it.

In the studies we have done on the management of patellofemoral pain in adolescents, one of the key points today is to think about how we deliver education and how we develop self-management skills. Sometimes I use the analogy of learning a new language: you can't teach someone a new language all at once. It takes several sessions over a longer period of time to acquire the necessary skills.

We need to offer them challenges and use them to develop skills over time. That's what we built our interventions on, to teach them the right things at the right time, and to use each symptom flare-up as a way to learn.

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3 blocks of 4 weeks

In the study that we published in the American Journal of Sports Medicine in 2019, we developed this intervention based on both theory and engagement with adolescents and focused it on these 3 blocks, as we call them, 3 blocks or 4 weeks each. Then in the first block, the first 4 weeks, we asked them to get away from their usual sport and don't forget that these are adolescents who have had chronic symptoms for 18 months. So it has been there for a long time. In fact, we took them out of the sport for 4 weeks so that their symptoms would ease but to make sure they didn't lose muscle strength while staying physically active, they did two-limb bustier bridges and a few static postures just to do something for the lower extremities. We then targeted the education of this 1st phase so that they really understand why we are doing this and what will happen during these 12 weeks of intervention. So the aim was both to explain why they have patellofemoral pain, by talking about the burden and the management of the burden, what are the risk factors, at least what we think is the risk and the justification for this treatment.

Then after 4 weeks, we started to initiate the activity scale, which I will present in a few minutes, and some simple hip and knee exercises that they can do themselves. We talked about how they can be their best coach when it comes to adjusting their level of training, but also the amount of exercises they do at home, hip and knee exercises. We told them how to monitor and how to make progress by pushing, pushing, pushing, but don't push too fast, because in some of the other studies we've done, we can find that when we give people advice by saying, “You need to reduce the amount of running or physical activity and then get back to it slowly,” it's a common practice in clinical practice, they don't know how to do it. It's a big, big challenge when it's not very specific. As part of this intervention, we made sure to give concrete advice, so that they know when to continue and when to stop. That's where we used the activity scale. Then the last 4 weeks, block number 3, is the return to sport after reaching the 6th stage on the activity scale. Then the gradual return to sport where they added 15 to 30 minutes per week depending on the evolution of their symptoms.

So that's the general extent of what we've done. In fact, we published a clinical manual or a clinician's guide, as well as a guide for the patient, on how to implement these things. This brochure, which we call “anterior knee pain”, was developed based on empowering, explaining and making understood by these people and their parents. It is therefore a question of getting them to appropriate the tools necessary for their self-management. The aim was therefore to increase their confidence and their ability to take care of their patellofemoral pain themselves.

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A very, very simple leaflet whose most important components, I think, are the following: the activity scale and the pain monitoring scale. This old scale, based by Karin Silbernagel and myself, where we made it even simpler, in which we used the notions of “go” and “no go”. So, if they performed the activities between 0 and 2 on the NRS scale, that's good, they can make progress. But if the activities keep them between 3 and up to 10, then you have to stay here or go down a notch. And the idea was to make sure that they didn't get pushed to the extreme too quickly, because if you look at the small diagram at the bottom, that's what we can see in a lot of our previous studies, that these teens, as soon as they get a little improvement in pain, they go back to their usual level or the level before they had pain, and then they have a flare-up of symptoms again. So we wanted them to have a more gradual pace to get back into the sport, making sure they keep moving forward, but not too fast.

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Then there were simple exercises that they received instructions for, specific exercises for the 3 different blocks. I don't think the exercises are that important.

You can choose the exercises that you think are important. I think the most important thing about exercises is not that they improve strength, but when we prescribe the exercises to the teenager, we use them to encourage them. We use them to say, “Wow, you are very, very strong I can see that your muscles are working very, very well.” Because a lot of these teens don't have a lot of faith. They lack faith or trust in their knees. We've also seen this in several studies. So we should use the exercise not to improve strength, but actually to improve their confidence in their knees.

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And if you look at the right-hand side, it's about the activity scale. It therefore relies on Kolb's learning circle. It's a way to build skills. So the idea was to start at stage number 1, walking and biking. Then they will try to do this activity. And when they have been able to do this activity in the OK zone, the green zone, they can then move on to step number 2 on the activity ladder. This could therefore mean that for some adolescents, they have started the 3rd stage. That's where they started. For others, it was a matter of starting with the first step. Then, depending on how they responded to the symptoms when they did, they stayed there or moved on. And if they had a symptom or a flare-up, they were able to take a step back and were encouraged to use that way of thinking. Always moving forward, but not too fast. So it's about making sure you have a scale, but you also have something to assess it on to make sure they know when it's too much. When can we make progress safely. So that's what we did.

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Did it work? We included 151 adolescents who had pain for almost 18 months, 6 and a half months on a large scale. Quite intense pain, significant reduction in the quality of life, they were very hampered in their sports practice. We used the overall assessment of change as the main result. So if teens said, “I've improved or improved a lot,” then that's a success. But if they said, “No, I'm only improving slightly or that hasn't changed.” It is not a success. What we could see here, the most important point in the study, because we're following them up for 12 months, is that 85% of them improved or improved a lot from where they started. One in four people have taken painkillers. Only 7% used painkillers for 3 consecutive months, and 95% of them would recommend the same treatment to a friend with knee pain, and 75% of them returned to sport after 3 months. So I think the important part here from a methodological perspective is that this is a cohort study. So this is a single group of 151 adolescents who are all exposed to the same strategic treatment that I have just presented to you.

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And to put things into context, you can ask yourself whether that's a good thing or a bad thing.

85%? But when we compare them to other studies that we've done, because we've done 3 clinical trials, on adolescents with patellofemoral pain, and then we have this one, which is the most recent one, which is load management and a focus on self-management, after 3 months, after 3 months, 85% of teens experienced improvement, whether it's very improved or improved. If we compare these results to the 2 previous trials that we conducted, mainly focused on exercises, supervised exercises, 3 times a week for 12 weeks. So a lot of sessions but it's in line with a lot of other studies that have been done in this field. Only 1 out of 3 is actually better or much better after 3 months. The two previous trials we did involve a lot more sessions with a physical therapist. But this new procedure, which requires 3 to 4 visits to a physical therapist, who has focused on something completely different, improves the short-term results after 3 months, but also the long-term results after 1 year. So it's quite interesting, I think, because it requires fewer sessions, but seems to improve the results more.

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What in this exercise improves strength? Indeed, this test showed that they all became stronger. This essay that I have just outlined to you includes adolescents between 10 and 14 years old. They all became significantly stronger than their peers without knee pain. But we didn't see an association between improvements in their strength and improvements in pain or function. This is what we also showed in another study of adults with patellofemoral pain that improved strength did not affect improvements in symptoms. What I think these days, more and more, exercise has a non-specific effect. I think the exercise is really, really good at challenging the lack of confidence, where some of them also feel like, “Oh, my knees are fragile.” But if you use the exercise, if you encourage them, if you say, “Wow, you have strong knees.” So I think that exercise can be used for something completely different, that improves confidence in their knees, by targeting some of their functional beliefs that they have about their pain. And maybe that's also why they're increasing their physical activity levels, why they're getting better all the time. It's not because we're improving strength. Today, we have at least 2 or 3 studies in the field of patellofemoral pain. We just published one 1 week ago in the British Journal of Sports Medicine World that really highlights that improvements in strength are not important for improving pain. So it is very interesting and it is something we must take into account that the exercises have many non-specific effects.

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In summary

The take-home messages from these 30 minutes about how we can help teens with patellofemoral pain. I think the key is to move away from just focusing on exercise and to think about exercises for a purpose other than what we are doing today, and to add load management and modification of activities that are delivered through patient education. And when we talk about patient education, it's not just about giving them advice or a brochure. It's about developing their skills. And when you work with these teens, they come back to you on the 2nd visit and they say, “Oh, I've had a big increase in my pain.” In that case, you should just say, “Great,” let's try to dissect and figure out why you had this increase.” Because when they get a raise and they come back to you, it's a great time to learn, or teach them what they could have done to avoid the incident the next time. So it's a great opportunity to learn, both for you and for them. And the bottom line is that based on all the studies that we've done in this area and in clinical practice, I think that successfully managing adolescent patellofemoral pain is actually quite complex. And you need much more than simple exercises if you want to get good results. Thank you so much! If you have questions about the course material. I tried to download some of the flyers we used. It is in English, but feel free to translate it into any other language you think is appropriate. Thank you so much for listening to me.