The Power of Education for Managing Patellofemoral Pain
Having worked solely with patients with patellofemoral joint (PFJ) problems for the last 15 years, I have become increasingly aware of the importance of education, and have spent an increasing proportion of my consultation time on education. Some people might argue I should spend this time ‘doing’ – doing exercises, hands on treatment, taping, etc. This blog will explain why I think the education component is the most important part of my consultation.
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PFJ pain is normally insidious in onset, i.e. it creeps up on the patient. When someone conversely has a trauma such as a broken bone, there is normally an obvious cause, and path of events. Insidious onset leaves the patient bewildered as to why it has happened, especially as often there is no obvious change in lifestyle. The research on health beliefs show that conditions of insidious onset are more likely to cause a psychological block to engagement with treatment than those of an obvious cause. As such, we as clinicians must spend time explaining the reasons for the pain.
The confusion that patients feel is often heightened by a normal MRI scan. How can it be that a joint can hurt when the scan is normal? Once again, taking time to explain and educate about this will help the patient move forwards, and engage with their treatment.
My recent research has looked at patients’ beliefs about the noise in their knee and what they think it means, and how they alter their behaviour as a result (1). The results demonstrate often fearful inaccurate beliefs that lead to avoidance of certain functional tasks. Here is a perfect example of the need to educate, to restore appropriate health beliefs, and stop the cycle of fear avoidance.
A large proportion of treatment for patients with PFJ pain is based around exercise. Even in the most compliant patients it is quite an ask to do exercises regularly for what may be weeks on end. The literature clearly shows that people on average do less than asked, so we must do our best to help the patient remain engaged with their exercise programme. As a very minimum we should be educating as to why the patient should do an exercise, what it should feel like during and after (e.g. the sensation of fatigue, or permissible pain). The patient should be clear on the goals of the exercise and most certainly the realistic time frame, so they don’t lose heart and stop if they do not discern a change in the short-term.
Much of PFJ pain is driven by overloading the joint with insufficient conditioning. Activity modification is a vital part of education. The yo-yo effect must be avoided at all costs. A baseline of activity needs to be established and then small increments of increasing activity aimed for. Education about this is likely to help avoid the scenario whereby the patient feels better and so increases their activity by a large amount in one go!
Finally, most physiotherapy appointments last half an hour. How the patient moves, and what footwear they wear for the rest of the week is going to have a more profound effect than anything that can be done in half an hour. Therefore, education re appropriate movement retraining and footwear must take priority, as these are likely to have a positive impact.
To conclude, the next time you have a patient with PFJ pain, when they leave your clinic, ask yourself:
Do they know the cause of their pain, how much activity they should be doing, what the treatment is and why, what their exercises should feel like, and what realistic goals with time frames are?
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