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

The Pain and Movement Reasoning Model

Figure 1. Pain and Movement Reasoning Model.

The Pain and Movement Reasoning Model is designed to improve clinical reasoning. It aims to "capture the complexity of the human pain experience by integrating these multiple dimensions into a decision making process." As is shown in Figure 1, this model includes three categories.

1. Local stimulation
   1. Biomechanical stimulation
   2. Chemical stimulation
2. Regional influences
   1. Kinetic chain
   2. Patho-neuro-dynamics
   3. Convergence
3. Central nervous system modulation
   1. Prolonged afferent input
   2. Predisposing factors
   3. Cognitive - emotive - social state

Clinicians use the model to identify the most important category for each patient. Once identified, it can help to direct treatment. The model also enables clinicians to identify when there are changes in presentation and, thus, if a new / different treatment approach should be adopted.

While the pain and movement reasoning model was not designed for patellofemoral pain, the theory can be effectively applied for patients with this condition. Local stimulation in patellofemoral pain consists of factors such as bone oedema, fat pad swelling, effusion, retinacular ischaemic changes, bone bruising, or anything local at the knee. Regional influences include excessively pronating feet, an anteverted femoral neck or poor hip abduction control. There is not, however, much available research to show the role played by the central nervous system.

Psychosocial Factors and Patellofemoral Pain

There is a general lack in research on the impact of psychosocial factors on patellofemoral pain, but they should not be ignored.

Depression and Anxiety

Research by Wride and Bannigan highlights important correlations between anxiety and depression and patellofemoral pain:

1. The prevalence of anxiety and / or depression is higher in the patellofemoral population than the general population
2. The prevalence of anxiety and / or depression is higher in young females
3. Individuals with high anxiety scores were more likely to be female
4. The rate of patellofemoral pain is higher in females

Loss, Confusion and Fear-Avoidance Associated with Patellofemoral Pain

Smith et al. conducted a qualitative study on the experience of living with patellofemoral pain and the associated sense of loss, confusion and fear-avoidance. The full article is available here: The experience of living with patellofemoral pain-loss, confusion and fear-avoidance: a UK qualitative study.

Many patients with patellofemoral pain reported experiencing a loss of identity and a decrease in their social interactions. For example, if an individual has patellofemoral pain which limits them from participating in their sport of choice, we need to remember that it is not only the activity / sport they are suddenly unable to participate in. They may also lose the sense of well-being and social interaction normally offered by the sport.

Figure 2. Pain experience.

Thus, patellofemoral pain can have wide ranging effects and an individual's beliefs about their knee pain can cause them to make significant lifestyle adaptations. For example, some individuals have reported feeling they might need to change their career aspirations or their housing choices.

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 a specific event to which the pain can be attributed. This can lead to the confusion, uncertainty and the incorrect assumption that exercise or activity worsens their pain. When a physiotherapist then prescribes exercise-based treatment, a patient might be hesitant and / or non-compliant due to their belief that exercise actually caused their pain. Thus, the patient should be educated on the effects of load, repetitive volume, warm up, cool down, footwear, and the many other facets that are vital to understanding exercise.

When study participants discussed treatments or coping strategies, many focused on the idea of rest and postural adjustments, such as avoiding flexion in sitting. They also felt that passive treatments, such as pain medication and knee supports, would be of benefit. While these might help the pain temporarily, they will not be beneficial to the patient in the long term.

Psychologically-Informed Treatments

A study by Selhorst et al. offers insight into how psychologically-informed treatments may be beneficial for adolescents with patellofemoral pain. The study group were shown an educational video which focused on pain-related fear and pain catastrophising. Compared to the control, the study group showed a reduction in kinesiophobia, catastrophisation and pain scores, immediately and at two weeks. This highlights the significance of education in patellofemoral pain.

Sleep

In patients with patellofemoral pain, it is also important to consider their sleep patterns, including the quantity / duration of sleep as well as the quality of sleep. When conducting an assessment, we should consider asking questions such as, "how many times do you wake up in the night? How long does it take to get to sleep?"

Mindfulness

Research carried out by Bagheri et al. showed that when mindfulness was included with physical treatments, there was a greater improvement in pain reduction, catastrophisation and kinesiophobia in female runners with patellofemoral pain. Mindfulness is aimed at increasing awareness of thoughts, sensations and emotions, with an attitude of acceptance, curiosity and openness. The focus of mindfulness is to reduce stress, take control of the situation, stay in control, and not be overly alarmed by it.

Rehabilitation therapists often focus on reducing pain. But if a patient is discharged from treatment with incorrect beliefs about their knee pain, they could continue fear avoidance behaviours and experience anxiety while playing sport. Thus, it is important to address both psychosocial and physical factors.

Tampa Scale of Kinesiophobia

The Tampa Scale of Kinesiophobia (TSK) can be a useful measure in patellofemoral pain. The TSK was first developed in 1990 by R. Miller, S. Kopri, and D. Todd. It is a 17 item self-report questionnaire which evaluates 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 chronic low back pain. It is now widely used for different parts of the body.

Links:

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

Addressing Psychosocial Factors

Psychosocial Factors

• Depressive symptoms
• Higher levels of anxiety
• Fear avoidance
• Lifestyle changes
• Kinesiophobia
• Catastrophisation

Questions to ask

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 - this is highly suggestive of non-mechanical pain	Graduated exposure; May need medical management to de-sensitise