Smith, Benjamin E.
(2019)
A loaded self-managed exercise programme for patellofemoral pain: a mixed methods feasibility study.
PhD thesis, University of Nottingham.
Abstract
Patellofemoral pain (PFP) is a common musculoskeletal disorder, with one in five young adults suffering at any one time. The main symptoms include pain behind or around the patella (kneecap) during activities that load the joint, such as climbing stairs and exercise.
Despite the implementation of evidence based physiotherapy, long-term outcomes are poor; 91% of patients still report pain and dysfunction four years post-diagnosis and treatment.
It is not known whether patient outcomes are better with physiotherapy prescribed exercises designed around contemporary pain models (where exercises are designed to load and temporarily aggravate patients’ symptoms) and self-management strategies, compared with usual physiotherapy. In relation to terminology, in the context of this thesis, the intervention has been referred to as a loaded self-managed exercise programme. This thesis presents a programme of work with the primary aim to establish the feasibility and acceptability of conducting a definitive randomised controlled trial (RCT) on the new intervention. Secondary aims build towards this, with refinement and development of the intervention, comprising: two systematic reviews; a cross-sectional online questionnaire survey; a qualitative interview study; and a feasibility RCT, with a further embedded qualitative study.
The first systematic review aimed to identify the incidence and prevalence data for this condition, which should inform clinical decision-making and the allocation of healthcare and research funding. The review demonstrated high incidence and prevalence levels for PFP, across adolescent, adult, military and athletic populations.
The second systematic review aimed to establish the effectiveness of loaded painful exercises for musculoskeletal (MSK) pain in general and identify the important components of such an exercise programme. The review concluded that pain during exercise need not be a barrier to successful outcomes and was able to offer some preliminary guidance in relation to the contextual factors of pain and exercise prescription.
A cross-sectional online questionnaire survey was designed to understand the current management strategies undertaken by UK physiotherapists. The survey concluded there was no standardised management approach for PFP in the UK, and there was large variability in response to pain with exercise and physical activity.
Semi-structured qualitative interviews were completed to gain a detailed account of the experience of people living with PFP. A convenience sample of ten participants were recruited. The five major themes that emerged from the data were: (1) impact on self; (2) uncertainty, confusion and sense-making; (3) exercise and activity beliefs; (4) behavioural coping strategies and (5) expectations of the future. The study suggested that current best-evidence treatments alone may not be adequate to address the fears and beliefs identified.
The findings of this work were used to refine the proposed loaded self-managed exercise programme and inform the design of a feasibility RCT.
Following this, a feasibility RCT was conducted to establish the feasibility and acceptability of conducting a definitive RCT which will evaluate the clinical and cost-effectiveness of the new intervention. Sixty patients with PFP were randomised to receive either a loaded self-managed exercise programme (intervention) (n=30) or usual physiotherapy (control) (n=30). Baseline assessment included demographic data, average pain within the last week, fear-avoidance behaviours, catastrophising, self-efficacy, sport and leisure activity participation, and general quality of life (Euro-QOL); follow-up was at three and six months and included the global rating of change scale. Feasibility indicators of process, resources, and management were collected. Participants in both groups showed improvements from baseline. The results of the study confirmed that it was feasible and acceptable to deliver a loaded self-managed exercise programme to adults with PFP in an NHS physiotherapy setting. However, there remained uncertainty on some feasibility aspects of study design, with between-group differences in loss to follow-up and poor exercise diary completion.
To explore the possible implementation barriers and facilitators embedded semi-structured qualitative interviews were completed. The intervention was acceptable to patients and physiotherapists; contrary to popular concerns relating to painful exercises, all participants in the intervention group reported positive engagement. Implementation, delivery and evaluation of the intervention in clinical settings may be challenging, but feasible with the appropriate training for physiotherapists.
The principal conclusions from this programme of work were that there is some preliminary evidence that interventions designed to load and temporarily aggravate patients’ symptoms, combined with pain education and self-management strategies, may be beneficial to people with PFP. Additionally, that it is feasible and acceptable to deliver a loaded self-managed exercise programme to adults with PFP. However, there remained uncertainty on some feasibility aspects of the trial design.
This research is the first RCT incorporating pain science in treatment strategies for people with PFP in the UK and is, therefore, an important and novel development of the evidence-base.
This PhD has thus offered new insights and expanded the evidence-base into the understanding and management of PFP, and more broadly the public health priorities of all MSK pain and physical activity.
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