Patellofemoral pain: challenging current practice – a case report

Patellofemoral pain (PFP) is a common problem in young people, with 1 in 6 suffering at any one time. It is unclear which management approach is the optimal method for treating PFP in the long term, with traditional physiotherapy examination focusing on assessing for specific structural dysfunction. A rationale for a different assessment and treatment approach, one that moves the focus away from a biomedical/tissue pathology model towards one directed at the neurophysiology of pain, has been suggested. The patient was a 21 year old male with a 6 year history of PFP with previous failed physiotherapeutic treatment. He reported previous multiple healthcare practitioners' advice to avoid activities that were painful as reasons for being unable to participate in sporting activities. No specific structural testing was performed, such as specific muscle strength, length, foot position, patella movement and position, or movement patterns. Descriptions of tissue based pathology models of pain, e.g. patella mal-tracking, were actively discouraged and challenged. The patient was taught to perform one uncomfortable/painful exercise as part of his rehabilitation programme twice a day. The patient achieved 80% improvement in his symptoms over 7 appointments and a return to physical activity following a 5 month rehabilitation programme purposively designed to elicit pain by means of gradually exercising and loading the tissues. This case report highlights the need for further research into exercise protocols for patients suffering with PFP based upon neurophysiology models of pain

Regaining Confidence after Stroke (RCAS): a feasibility randomised controlled trial (RCT)

Background: The Regaining Confidence after Stroke Course (RCAS) was designed to facilitate adjustment for people with stroke discharged from rehabilitation. The aim of the trial was to evaluate the feasibility of conducting a randomised trial to compare a RCAS course with usual care. The rates feasibility of screening and recruitment, rates of consent and retention, acceptability of outcome measures and the acceptability and fidelity of the intervention, were evaluated. Methods: Participants with stroke were recruited from hospital databases and community services and randomly assigned to the Regaining Confidence after Stroke (RCAS) course or usual care. The course comprised 11 weekly 2 hour sessions with 6-8 participants, delivered by two rehabilitation assistants. Carers were invited to attend three of the sessions. Sessions were video recorded. A six item checklist was developed from the manual content. Each item was rated as met, partially met, or not met. Fidelity was assumed if >75% of the criteria were met. Outcomes were assessed 3 and 6 months after randomisation. Semi-structured interviews, were conducted using open ended questions to assess the acceptability of the intervention. Results: Of 47 participants (mean age 66.9 years [SD 14.9]; 26 men) 22 were randomly allocated to the intervention and 25 to usual care. Participants attended a mean of 8.2 out of 11 sessions [SD 2.6]. Fidelity outcomes suggested that the content corresponded to the manual but further training of the therapist was needed. Interview findings indicated the intervention was acceptable and considered beneficial. At three months, 35 (78%) participants returned questionnaires and 30 (67%) at 6 months, but only 38(42 %) were fully completed. Conclusion: The results support the feasibility of conducting a randomised trial to evaluate the effectiveness of a RCAS course compared to usual care

Should exercises be painful in the management of chronic musculoskeletal pain?: a systematic review and meta-analysis

Background: Chronic musculoskeletal disorders are a prevalent and costly global health issue. A new form of exercise therapy focused on loading and resistance programmes that temporarily aggravates a patient’s pain has been proposed. The object of this review was to compare the effect of exercises where pain is allowed/encouraged, compared with non-painful exercises on pain, function or disability in patients with chronic musculoskeletal pain within randomised controlled trials. Methods: Two authors independently selected studies and appraised risk of bias. Methodological quality was evaluated using the Cochrane risk of bias tool and the GRADE system was used to evaluate the quality of evidence. Results: The literature search identified 9,081 potentially eligible studies. Nine papers (from seven trials) with 385 participants met the inclusion criteria. There was short term significant difference in pain, with moderate quality evidence for a small effect size of -0.27 (-0.54 to -0.05) in favour of painful exercises. For pain at medium and long term; and function and disability at short, medium and long term there was no significant difference. Conclusion: Protocols using painful exercises offer a small, but significant benefit over pain-free exercises at short term, with moderate quality of the evidence. At medium and long term there is no clear superiority of one treatment over another. Pain during therapeutic exercise for chronic musculoskeletal pain need not be a barrier to successful outcomes. Further research is warranted to fully evaluate the effectiveness of loading and resistance programmes into pain for chronic musculoskeletal disorders. PROSPERO Registration: CRD4201603888

The experience of living with patellofemoral pain: loss, confusion and fear-avoidance: a UK qualitative study

Objectives: To investigate the experience of living with patellofemoral pain. Design: Qualitative study design using semi-structured interviews, and analysed thematically using the guidelines set out by Braun and Clarke. Setting: A National Health Service (NHS) physiotherapy clinic within a large UK teaching hospital. Participants: A convenience sample of ten participants, aged between 18 and 40, with a diagnosis of patellofemoral pain and on a physiotherapy waiting list, prior to starting physiotherapy. Results: Participants offered rich and detailed accounts of the impact and lived experience of patellofemoral pain, including: loss of physical and functional ability; loss of self - identity; pain related confusion and difficulty making sense of their pain ; pain related fear, including fear -avoidance and ‘damage’ beliefs; inappropriate coping strategies and fear of the future. 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. Conclusions: These findings offer an insight into the lived experience of individuals with patellofemoral pain. Previous literature ha s focused on pain and biomechanics, rather than the individual experience, attached meanings and any wider context within a sociocultural perspective. Our findings suggest future research is warranted into biopsychosocial targeted interventions aimed at the beliefs and pain related fear for people with patellofemoral pain. The current consensus that best - evidence treatments consisting of hip and knee strengthening may not be adequate to address the fears and beliefs identified in the current study. Further qualitative research may be warranted on the impact and interpretation of medical terminology commonly used with this patient group, for example, ‘weakness’ and ‘patellar mal-tracking’ and its impact and interpretation by patients

Developing and internally validating a prognostic model (P Risk) to improve the prediction of psychosis in a primary care population using electronic health records:the MAPPED study

BACKGROUND: An accurate risk prediction algorithm could improve psychosis outcomes by reducing duration of untreated psychosis. OBJECTIVE: To develop and validate a risk prediction model for psychosis, for use by family doctors, using linked electronic health records. METHODS: A prospective prediction study. Records from family practices were used between 1/1/2010 to 31/12/2017 of 300,000 patients who had consulted their family doctor for any nonpsychotic mental health problem. Records were selected from Clinical Practice Research Datalink Gold, a routine database of UK family doctor records linked to Hospital Episode Statistics, a routine database of UK secondary care records. Each patient had 5-8 years of follow up data. Study predictors were consultations, diagnoses and/or prescribed medications, during the study period or historically, for 13 nonpsychotic mental health problems and behaviours, age, gender, number of mental health consultations, social deprivation, geographical location, and ethnicity. The outcome was time to an ICD10 psychosis diagnosis. FINDINGS: 830 diagnoses of psychosis were made. Patients were from 216 family practices; mean age was 45.3 years and 43.5 % were male. Median follow-up was 6.5 years (IQR 5.6, 7.8). Overall 8-year psychosis incidence was 45.8 (95 % CI 42.8, 49.0)/100,000 person years at risk. A risk prediction model including age, sex, ethnicity, social deprivation, consultations for suicidal behaviour, depression/anxiety, substance abuse, history of consultations for suicidal behaviour, smoking history and prescribed medications for depression/anxiety/PTSD/OCD and total number of consultations had good discrimination (Harrell's C = 0.774). Identifying patients aged 17-100 years with predicted risk exceeding 1.0 % over 6 years had sensitivity of 71 % and specificity of 84 %

Rehabilitation potential in older people living with frailty: a systematic mapping review

BackgroundFollowing periods of acute ill-health and injury, older people are frequently assessed and provided with rehabilitation services. Healthcare practitioners are required to make nuanced decisions about which patients are likely to benefit from and respond to rehabilitation. The clinical currency in which these decisions are transacted is through the term “rehabilitation potential”. The aim of this study was to explore information about rehabilitation potential in older people to inform the development of an evidence-based assessment tool.MethodsA systematic mapping review was completed to describe the extent of research and the concepts underpinning rehabilitation potential. We searched Medline, CINHAL, EMBASE, AMED, PsycINFO, PEDro, Cochrane Library, Web of Science, ProQuest, Trip and EThOS from inception to December 2020. We included studies which focused on rehabilitation potential and/or assessing for rehabilitation interventions for older people with comorbidities in the hospital and community setting. Reviewer pairs independently screened articles and extracted data against the inclusion criteria. A descriptive narrative approach to analysis was taken.Results13,484 papers were identified and 49 included in the review. Rehabilitation potential was found to encompass two different but interrelated concepts of prognostication and outcome measurement. 1. Rehabilitation potential for prognostication involved the prediction of what could be achieved in programmes of rehabilitation. 2. Rehabilitation potential as an outcome measure retrospectively considered what had been achieved as a result of rehabilitation interventions. Assessments of rehabilitation potential included key domains which were largely assessed by members of the multi-disciplinary team at single time points. Limited evidence was identified which specifically considered rehabilitation potential amongst older people living with frailty.ConclusionsCurrent approaches to rehabilitation potential provide a snapshot of an individual’s abilities and conditions which fail to capture the dynamic nature and fluctuations associated with frailty and rehabilitation. New approaches to measures and abilities over time are required which allow for the prognostication of outcomes and potential benefits of rehabilitation interventions for older people living with frailty