Psychosocial Considerations in Patellofemoral Pain

Original Editor - Carin Hunter based on the course by Claire Robertson
Top Contributors - Carin Hunter, Jess Bell, Ewa Jaraczewska, Kim Jackson and Wanda van Niekerk

Pain and Movement Reasoning Model , (Jones & O’Shaughnessy,2014)

When considering the psychosocial factors affecting the patellofemoral joint, even though the pain and movement reasoning model was not designed for patellofemoral pain, the theory can be effectively applied.

Factors in the Pain and Reasoning Model

1. Local Stimulation
   1. Biomechanical Stimulation - Bone oedema, fat pad swelling, effusion, retinacular ischaemic changes, bone bruising, or anything local at the knee.
   2. Chemical Stimulation
2. Regional Influences
   1. Kinetic Chain - Excessively pronating foot, anteverted femoral neck or poor control of their hip abduction
   2. Patho-neuro-dynamics
   3. Convergence
3. Central Nervous System Modulation - Minimal research on this area
   1. Prolonged Afferent Input
   2. Predisposing Factors
   3. Cognitive - Emotive - Social state

Mindfulness

Wride's work shows two important correlations with regards to anxiety and depression

1. The prevalence of anxiety and/or depression is higher in the patellofemoral population than the normal population.
2. The prevalence of anxiety and/or depression is higher in young females
3. and we know that a lot of patellofemoral pain is in females, but given that still, the rates are much, much higher.

When patients had patellofemoral pain, many of them experienced a sense of loss of identity and a loss of social interactions. When an individual has patellofemoral pain which limits them from participating in their sport of choice, we need to consider that it is not only the activity they are suddenly unable to participate in. They also often loose the sense of wellbeing and social interaction that the sport offered.

A few patients have even been known the change career aspirations and housing choices because of their patellofemoral pain. These types of large lifestyle adaptations, due to a belief regarding their knee pain can

Patients can battle with their understanding of the causes of their knee pain, especially when it is of insidious onset. Unlike a traumatic injury, knee pain of insidious onset is not marked by an event which the pain can be attributed to. This can be influential to the incorrect assumption that exercise can worsen the pain. When a physical therapist then prescribes exercise based treatment, a patient can be hesitant and non-compliant due to their beliefs. The patient should be educated on the effects of load, repetitive volume, warm up, cool down, footwear, and many other facets vital to understanding exercise. Treatments that patients felt were of benefit to patellofemoral pain where often passive, primarily painkillers, knee supports, and rest. While these might help the pain temporarily, they will not be beneficial to the patient in the long term.

A study by Selhorst showed that a short educational video shown to a group of adolescents can reduce kinesiophobia, catastrophisation, pain scores, immediately and at two weeks. This shows the significance of education in patellofemoral pain.

Another factor to consider is the patients sleep. We should look at the only the quantity or duration of sleep but the quality as well. We should be asking questions such as, How many times does someone wake up in the night? How long does it take to get to sleep?

Bagheri's work showing that physical treatment, sort of standardised typical patellofemoral treatments, with mindfulness was more effective at pain reduction, catastrophisation, kinesiophobia than the same physical treatment. Mindfulness, that's great to see that paper. That's the first paper I've ever seen on, and I'm sure it is, on mindfulness and patellofemoral pain, but why not? It's all around stress reduction, being able to take control of the situation, stay in control, and not be overly alarmed by it

And, you know, the irony is if we do great physical treatments, maybe someone is more flexible or stronger, their foot sorted out with an orthotic or whatever it may be, we may think - and even their pain might be less - we might feel oh, you know, I've done a good job there. But if they leave your room and they still avoid the stairs because their belief is that it's harmful to them if their knee is noisy on the stairs, or if they still feel highly anxious about doing their sport, or they still avoid going back to their running club because they feel that running bought it on in the first place and that pain meant damage, we have not addressed those psychosocial considerations that really are absolutely as big an issue as any physical thing around the knee.

Ben Smith's fantastic qualitative work and Wride's work in 2018

Bagheri et al., 2021. PFP exs vs exs+mindfulness.

Mindfulness aimed at increasing awareness of thoughts, sensations, emotions all with an attitude of acceptance, curiosity and openness.

Better pain, less catastrophizing, less kinesiophobia w mindfulness.

There is little written about anxiety and depression in PFP but Wride et al., 2019 work in the UK reveals the following key facts regarding the prevalence of anxiety and depression in the PFP population, (n=400):

49.5% demonstrated anxiety.

20.8% indicated depressive symptoms.

When combined, 53% were living with anxiety +/or depression.

Patients with a high anxiety score were significantly younger.

Patients with a high anxiety score were more likely to be female.

Tampa Scale of Kinesiophobia

The original Tampa Scale of Kinesiophobia is (TSK) was first developed in 1991 by R. Miller, S. Kopri, and D. Todd. TSK is 17 items a self-reporting questionnaire based on evaluation of fear of movement, fear of physical activity, and fear avoidance. It was first developed to distinguish between non-excessive fear and phobia in patients with chronic musculoskeletal pain, specifically the fear of movement in patients with chronic low back pain then widely used for different parts of the body. The questionnaire using 4 points to assess that are based on; the model of fear-avoidance, fear of work-related activities, fear of movement, and fear of re-injury.

Links:

• Tampa Scale of Kinesiophobia
• Tampa Scale of Kinesiophobia (TSK) pdf
• MDApp, Tampa Scale of Kinesiophobia

Key Questions to ask and why

Question	Reason	Treatment Implication
Duration of symptoms	The longer the duration the more likely there will be central pain changes.	Assess for central changes
Alteration in sleep quality?	Serotonin (natural painkiller) production suppressed with poor sleep	Recommend re-establishing routine. Non-painful exercise. Decrease anxiety through education
Change in exercise profile?	Can affect sleep, mood, self-esteem, social interactions and conditioning.	Consider exercise programmes for non-painful body parts initially. Education to minimise fear-avoidance.
Can they tolerate the sense of clothing on their knee, eg skinny jeans/tights?	Some patients cannot bear the feeling of material on their knee. Highly suggestive of non-mechanical pain.	Graduated exposure. May need medical management to de-sensitise.