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PEDro systematic review update


This section features a recent systematic review that is indexed on PEDro, the Physiotherapy Evidence Database (www.pedro.org.au). PEDro is a free, web-based database of evidence relevant to physiotherapy.
MAIN OUTCOME MEASURES
The outcome measure was pain (eg, 11-point numeric rating scale or 100 mm visual analogue scale). For trials that reported outcomes on multiple pain scales, participant-reported worst pain intensity over the previous week was used.

Multimodal physiotherapy is effective for anterior knee pain relief


Efcacy of non-surgical interventions for anterior knee pain

STATISTICAL METHODS
Random effects meta-analysis was performed to pool results when homogeneity was found (ie, similar interventions, comparators and timing of follow-up) among included trials. Effect sizes were reported as standardised mean differences (SMDs) with 95% CIs. To calculate SMDs, mean change scores and SD were extracted from included papers or calculated by subtracting the follow-up score from the baseline score. Effect sizes were interpreted as being: nearly perfect (4), very large (24), large (1.22), moderate (0.61.2), small (0.20.6) and trivial (<0.2)3 with positive values favouring intervention. Sensitivity analyses were conducted to verify a high risk of bias of the excluded papers (ie, trials that fullled less than three of the six criteria on the modied PEDro scale). Spearmans correlation coefcients were used to investigate the association between risk of bias and effect sizes.

Collins NJ, Bisset LM, Crossley KM, et al. Efcacy of nonsurgical interventions for anterior knee pain: systematic review and meta-analysis of randomised trials. Sports Med 2012;42:3149.

BACKGROUND
Anterior knee pain is a prevalent musculoskeletal condition which often has a poor prognosis and can signicantly impact daily activities as well as participation in physical activity. Management of anterior knee pain involves consideration of each individuals presentation and the potential contribution of local (eg, patellar alignment and quadriceps strength), proximal (eg, hip) and distal (eg, foot) knee factors.1 Non-surgical interventions appear to be the primary treatment of choice for anterior knee pain;2 however, evidence to support these interventions is currently inconclusive.

RESULTS
Forty-eight trials were identied as eligible for the review, but twenty-one of these were excluded from further analysis owing to a high risk of bias assessed by the modied PEDro scale. Sensitivity analyses revealed a signicant association between risk of bias and effect size (r=0.328; p<0.01), indicating that studies with a high risk of bias were more likely to overestimate the effects of intervention. In the remaining 27 eligible trials, the number of randomised participants per group ranged from 6 to 66 with a mean age ranging from 19 to 62 years. Most trials evaluated chronic episodes of anterior knee pain (ie, pain duration over 1 year). There was minimal opportunity for statistical pooling because of heterogeneity between studies; however, meta-analysis of two studies (n=250) showed that multimodal physiotherapy (including lower limb exercise, patella taping, foot orthoses and manual therapy) had moderate effects compared with the control group (SMD 1.08; 95% CI 0.73 to 1.43) at short-term (6 weeks) follow-up ( gure 1). In addition, meta-analysis of two studies (n=86) showed no signicant benet of electromyography (EMG) biofeedback with exercise at 4 weeks (SMD 0.21; 95% CI 0.64 to 0.21), or at 812 weeks (SMD 0.22; 95% CI 0.65 to 0.20). There was some evidence from individual trials that lower limb exercise, foot orthoses and acupuncture are effective interventions for anterior knee pain compared with the control group, but manual therapy is not effective. Insufcient data was available for the one study investigating pharmacological interventions for anterior knee pain.

AIM
The aim of the systematic review was to evaluate the short-term and long-term efcacy of non-surgical interventions for anterior knee pain.

SEARCHES AND INCLUSION CRITERIA


Nine databases (ie, MEDLINE, EMBASE, CINAHL and PRE-CINAHL, PEDro, PubMed, SportDiscus, Web of Science, BIOSOS Previews and the full Cochrane library) were searched up to November 2009 for randomised controlled trials published in English. Trials were eligible if they investigated at least one non-surgical intervention for anterior knee pain compared with a control group with a follow-up of at least 2 weeks. Anterior knee pain was dened as an insidious onset of anterior or retropatellar knee pain aggravated by activities that load the patellofemoral joint such as running or jumping. Trials were excluded if they presented results reported in previous publication or if their focus was the chondromalacia patella veried by imaging or arthroscopy. A modied version of the Physiotherapy Evidence Database (PEDro) scale containing six criteria was used to assess the risk of bias of all included trials. Trials that fullled less than three of the six criteria were excluded from further analysis.

LIMITATION/CONSIDERATIONS
Despite a wide variety of interventions for anterior knee pain being identied by the review, heterogeneity among the published studies meant pooling was not possible in most cases, and most of the available evidence comes from individual randomised controlled trials. Further high-quality research is very likely to have an important impact on the estimate of these effects. In addition, limitations in study design and reporting contributed to the lack of evidence for most interventions studied. Almost half of the studies identied as eligible were excluded from further analysis because of a high risk of bias (n=21).
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INTERVENTIONS
Any non-surgical intervention designed to improve pain was included. Studies were grouped by their primary intervention of interest: multimodal physiotherapy, manual therapy, exercise, tape, foot orthoses, electrotherapy, acupuncture and pharmacotherapy.
Oliveira VC, et al. Br J Sports Med March 2013 Vol 47 No 4

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PEDro systematic review update


Figure 1 Standardised mean difference (SMD) for short-term (06 weeks) improvement in pain with multimodal physiotherapy (MMP). SMD >0 favours MMP, <0 favours comparator. HEP, home exercise programme; FO, foot orthoses (redrawn from Collins et al. 2012).4

High-quality research with larger sample sizes and reporting consistent outcome data are required. Future research should also full the gap in the evidence for other non-surgical interventions such as manual therapy, knee braces and pharmacology. Only six studies that were included in the nal analyses investigated treatment effects beyond 3 months. For a chronic condition such as anterior knee pain, studies with longer duration of follow-up are required to determine the intermediate-term to long-term efcacy of non-surgical interventions.

Correspondence to Vinicius Cunha Oliveira, Faculty of Health Sciences, University of Sydney, S Block, 75 East Street, Lidcombe, Sydney, New South Wales 2141, Australia; viniciuscunhaoliveira@yahoo.com.br Contributors VCO and NH selected the systematic review, interpreted the data and reviewed the drafts. Both authors accepted the nal version. Each authors contribution to the paper is according to the International Committee of Medical Journal Editors guidelines for authorship. http://www.icmje.org/ethical_1author.html. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed. To cite Oliveira VC, Henschke N. Br J Sports Med 2013;47:245246 Received 13 November 2012 Revised 13 November 2012 Accepted 18 November 2012 Published Online First 15 December 2012 Br J Sports Med 2013;47:245246. doi:10.1136/bjsports-2012-091986

CLINICAL IMPLICATIONS
Multimodal physiotherapy, including exercise, can improve anterior knee pain intensity in the short term. EMG biofeedback with exercise was found to be ineffective for anterior knee pain in the short to intermediate term. The current evidence for other non-surgical interventions for anterior knee pain is inconclusive. This evidence suggests that the inclusion of interventions that target specic proximal factors in conjunction with local interventions may be the key to ensuring success in reducing anterior knee pain symptoms.

REFERENCES
1 Barton CJ, Levinger P, Menz HB, et al. Kinematic gait characteristics associated with patellofemoral pain syndrome: a systematic review. Gait Posture 2009;30:40516. Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-based managementof acute musculoskeletal pain. National Health and Medical Research Council, 2003. http://www.nhmrc.gov.au/guidelines/publications/cp94-cp95 (accessed 14 Nov 2012). Hopkins W. A new view of statistics. Internet Society for Sport Science, 2000. http:// www.sportsci.org/resource/stats/ (accessed 14 Nov 2012). Collins NJ, Bisset LM, Crossley KM, et al. Efcacy of nonsurgical interventions for anterior knee pain: systematic review and meta-analysis of randomised trials. Sports Med 2012;42:31 49.

Vinicius Cunha Oliveira,1 Nicholas Henschke2


1

3 4

Faculty of Health Sciences, University of Sydney, Sydney, New South Wales, Australia 2 Institute of Public Health, University of Heidelberg, Heidelberg, Germany

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Oliveira VC, et al. Br J Sports Med March 2013 Vol 47 No 4

Downloaded from bjsm.bmj.com on April 23, 2013 - Published by group.bmj.com

Multimodal physiotherapy is effective for anterior knee pain relief


Vinicius Cunha Oliveira and Nicholas Henschke Br J Sports Med 2013 47: 245-246 originally published online December 15, 2012

doi: 10.1136/bjsports-2012-091986

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