Supervised Exercise Therapy May Be Helpful for Patellofemoral Pain Syndrome

Author: Laurie Barclay, MD

http://cme.medscape.com/viewarticle/711501?src=cmemp&uac=45143PK

October 29, 2009 — Supervised exercise therapy may be helpful in treatment of patellofemoral pain syndrome in general practice, according to the results of an open-label, randomized controlled trial reported in the October 21 issue of the BMJ.
"There is no agreement concerning the aetiology of patellofemoral pain syndrome or the most appropriate treatment," write R. van Linschoten, from Erasmus University Medical Centre in Rotterdam, the Netherlands, and colleagues. "There is, however, general consensus that the preferred treatment approach is non-surgical. Rest during periods of pain and refraining from pain-provoking activities are advised; this 'wait and see' approach is advocated in the Dutch national GP [general practice] guidelines and is considered usual care."
The goal of this study was to compare the efficacy of supervised exercise therapy vs usual care for 131 patients with patellofemoral pain syndrome, in recovery, pain, and function. Patients who had a new episode of patellofemoral pain syndrome were recruited by their general practitioner (GP) or sports physician and randomly selected to the intervention group (n = 65) or to usual care (n = 66).
In the intervention group, patients took part in a standardized exercise program for 6 weeks. This was tailored to individual performance and supervised by a physical therapist. In addition, patients were instructed to practice the tailored exercises at home for 3 months. Usual care consisted of a "wait and see" approach, with rest during periods of pain and avoiding activities that caused pain. Patients in both groups received written information about patellofemoral pain syndrome and general instructions regarding home exercises.
The main endpoints of the study at 3-month and 12-month follow-up were self-reported recovery on the 7-point Likert scale, pain at rest and during activity on a 0- to 10-point numeric rating scale, and function measured with a 0- to 100-point Kujala patellofemoral score.
Outcomes at 3 months were better in the intervention group vs the control group in pain at rest (adjusted difference, −1.07; 95% confidence interval [CI], −1.92 to −0.22; effect size, 0.47), pain during activity (adjusted difference, −1.00; 95% CI, −1.91 to −0.08; effect size 0.45), and function (adjusted difference, 4.92; 95% CI, 0.14 - 9.72; effect size, 0.34).
Outcomes at 12 months continued to be better in the intervention group vs the control group in pain at rest (adjusted difference, −1.29; 95% CI, −2.16 to −0.42; effect size, 0.56) and pain during activity (adjusted difference, −1.19; 95% CI, −2.22 to −0.16; effect size 0.54) but not function (adjusted difference, 4.52; 95% CI, −0.73 to 9.76).
Recovery was reported by more patients in the exercise group vs the control group (41.9% vs 35.0% at 3 months and 62.1% vs 50.8% at 12 months), but these differences were not statistically significant. Although patients recruited by sports physicians (n = 30) did not benefit from the intervention, those recruited by GPs (n = 101) had significant and clinically meaningful differences in pain and function favoring the intervention group, according to predefined subgroup analyses.
"Supervised exercise therapy resulted in less pain and better function at short term and long term follow-up compared with usual care in patients with patellofemoral pain syndrome in general practice," the study authors write. "Exercise therapy did not produce a significant difference in the rate of self reported recovery."
Limitations of this study include lack of blinding, small numbers of patients recruited by sports physicians, and protocol violation by 8 patients in the control group who received physical therapy.
"Further research should aim to elucidate the mechanisms whereby exercise therapy results in better outcome," the study authors conclude.
ZON-MW (the Netherlands organization for health research and development) supported this study. The study authors have disclosed no relevant financial relationships.
BMJ. 2009;339:b407.