LITERATURE REVIEW
The patient education lasted for about 30 minutes and was standardised and covered the following topics: n Why does it hurt? n Pain management n Information on how to modify physical activity
n How to return slowly to sport n How to cope with knee pain n Information on how to increase knee alignment during sit-to-stand, standing, walking, stair walking and bicycling
n Questions from the student or the parents.
After the patient education
session, the adolescents received the information in an 8-page leaflet. Exercise therapy consisted of both supervised and home-based exercises. The supervised group training sessions consisted of neuromuscular training of the muscles around the foot, knee and hip, strength training for the knee and hip, patellofemoral soft tissue mobilisation, and stretching of the muscles around the hip and knee. To progressively match the exercise level to the performance level of each participant, all exercises were available in multiple levels of difficulty (18). All adolescents started with exercises at level one and progressed from there. This was chosen to see how the adolescent responded to exercises and to avoid aggravating symptoms. The progression followed previously described rules (18,19): 1. Good quality of movement, as determined by the physiotherapist, was defined as being able to keep hip, knee and foot aligned during exercises with both extra-slow and slightly faster than normal movement speed.
2. Ability to perform the number of repetitions specified in the training protocol.
3. No increase in self-reported pain directly after the training session or in usual morning pain the next morning.
The unsupervised home-based
exercises consisted of approximately 15 minutes of quadriceps and hip muscle retraining and stretching. Instructions were given immediately after patient education together with
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a 5-page leaflet with pictures and descriptions of the exercises. The exercises were to be performed each day except on the days of supervised group training (20). The adolescents were instructed to incorporate the exercises into their normal daily routines.
In addition patellar taping was offered to the adolescents who benefitted from it (18). The patellar taping was based on the McConnell approach (21). We used non-rigid, hypoallergenic tape to reduce skin irritation while rigid zinc-oxide tape was used for the corrections of the patella. Taping corrections was applied in a predetermined order of anterior tilt, medial tilt, glide, and fat pad unloading until the participant’s pain was reduced by at least 50%. However, tape was only used if patients achieved a minimum of 50% reduction in pain measured by the visual analogue scale (VAS) during a two-leg squat immediately after application of the tape. Adolescents were taught to independently apply the taping corrections and were instructed to reapply the tape daily and wear the tape during all waking hours. We found that at all time points from 3 to 12 months, adolescents randomised to patient education combined with exercise therapy were more likely to have recovered compared to the adolescents randomised to patient education alone. Twenty-nine percent had recovered in the group who received patient education while 38% had recovered in the randomised patient education and exercise therapy. This is indeed a lower proportion of recovery than van Linschoten (62%) and Collins et al. (81%), which suggests that patient education and exercise therapy may be slightly less effective in adolescents with PFP compared to adults.
IS EXERCISE THERAPY INDICATED FOR ALL ADOLESCENTS WITH PFP? We previously showed that adolescents between 15 and 19 years of age with PFP were characterised by reduced strength of the quadriceps as well as altered neuromuscular control. This provides a strong rationale for using
a combination of strength training and neuromuscular control exercises. However, not all adolescents responded favourable to the exercise therapy and the effect was lower than what is seen among adults. This suggests that exercise therapy is effective for some, but not all. Interestingly, frequent sports participation is a risk factor for persistent knee pain among young adolescents (10,11). The activity level
AT ALL TIME POINTS FROM 3 TO 12 MONTHS, ADOLESCENTS RANDOMISED TO PATIENT EDUCATION COMBINED WITH EXERCISE THERAPY WERE MORE LIKELY TO HAVE RECOVERED COMPARED TO THE ADOLESCENTS RANDOMISED TO PATIENT EDUCATION ALONE
(a) 100%
75% 50% 25%
(b)
100%
75% 50% 25%
Figure 4: Modifying the physical activity level from (a) strenuous to (b) moderate may be key to successful treatment and to avoid recurrence of knee pain. (M.S. Rathleff, 2014)
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