Summary of high-quality systematic review findings and associated expert opinion themes and subthemes
| Quantitative findings (high-quality systematic reviews) | Related qualitative findings (expert opinion) | |
|---|---|---|
| Findings supporting the intervention | Other findings related to the intervention | Related themes/subthemes (see online supplementary file link) identified from interview transcripts |
| 3.1 Multimodal interventions | ||
| ▸ Based on pooled data from two studies, a 6-week program of multimodal physiotherapy has a significant moderate effect compared to placebo intervention (flat inserts or physiotherapy) over a 6-week period (SMD 1.08; 95% CI 0.73 to 1.43).30 ▸ A 6-week programme of multimodal physiotherapy combined with prefabricated foot orthoses has a significant large effect at 6 weeks (SMD 1.45; 95% CI 0.96 to 1.94), moderate effect at 12 weeks (SMD 0.86; 95% CI 0.40 to 1.33) and moderate effect at 1 year (SMD 0.77; 95% CI 0.33 to 1.21) compared to placebo (flat inserts).30 ▸ A 6-week programme of multimodal physiotherapy has a significant moderate effect compared to placebo intervention at 12 weeks (SMD 0.69; 95% CI 0.23 to 1.14).30 ▸ A 6-week programme of multimodal physiotherapy has a significant small effect compared to placebo intervention at 1 year (SMD 0.44; 95% CI 0.01 to 0.88).30 ▸ An 8-week multimodal programme consisting of manual therapy, stretches, vasti retraining and patellar taping has a significant moderate effect compared to no treatment (SMD 0.63; 95% CI 0.00 to 1.26).30 ▸ The addition of a 6-week program of multimodal physiotherapy to prefabricated foot orthoses has a significant moderate effect compared to foot orthoses alone at 6 weeks (SMD 0.87; 95% CI 0.42 to 1.32), 12 weeks (SMD 0.63; 95% CI 0.16 to 1.07) and 1 year (SMD 0.70; 95% CI 0.27 to 1.14).30 32 ▸ Multimodal physiotherapy involving patellar taping and vasti retraining has small significant effect compared to supervised strengthening and stretching exercise at 4 weeks (SMD 0.56; 95% CI 0.00 to 1.12).30 | ▸ An 8-week multimodal programme consisting of manual therapy, stretches and general lower limb exercises is not more effective than no treatment.30 ▸ Exercise, patellar taping and education is not more effective than education alone at 12 weeks or 1 year.30 ▸ One review reported a 6-week program of multimodal physiotherapy has a significant small effect compared to foot orthoses at 6 weeks (SMD 0.51; 95% CI 0.07 to 0.95) and 12 weeks (SMD 0.45; 95% CI 0.01 to 0.88),30 while another reported no significant difference at these time points (MD 7.60 mm; 95% CI −1.77, 16.97).34 ▸ A 6-week program of multimodal physiotherapy does not improve outcomes compared to foot orthoses at 1 year.30 34 ▸ Multimodal physiotherapy involving patellar taping and vasti retraining is not more effective than supervised or unsupervised strengthening and stretching exercise at 12, 26 and 52 weeks.30 | Considering PFP as a multifactorial condition (see online supplementary file 2.1) ▸ PFP as a multifactorial condition ▸ On the importance of tailoring intervention programs |
| 3.2 Exercise (active interventions) | ||
| ▸ A 6-week programme of CKC exercise has a very large effect compared to no treatment (SMD 3.02; 95% CI 1.93 to 4.11).30 ▸ A 6-week programme of OKC exercise has a large effect compared to no treatment (SMD 1.82; 95% CI 0.95 to 2.69).30 ▸ An 8-week programme of standard leg press has a moderate effect compared to control (SMD 1.01; 95% CI 0.43 to 1.59).30 ▸ An 8-week programme of leg press with hip adduction has a moderate effect compared to control (SMD 0.83; 95% CI 0.26 to 1.40).30 ▸ Supervised exercise has a small effect compared to control at 12 weeks (SMD 0.44; 95% CI 0.09 to 0.78) and 1 year (SMD 0.49; 95% CI 0.14 to 0.83).30 | ▸ Contrasting findings exist comparing open to closed kinetic chain exercise in the short term, with one study showing a significant moderate effect favouring CKC at 6 weeks (SMD 1.01; 95% CI 0.25 to 1.78), but another showing no difference at 5 weeks. Additionally, one study showed a small effect favouring OKC at 5 years (SMD −0.57; 95% CI −1.14 to 0.00).30 ▸ Based on two studies, the addition of hip exercises to standard quadriceps exercise does not improve outcomes.30 ▸ Findings from one study indicate there is no difference between supervised and unsupervised exercise.30 ▸ The addition of exercise to education does not improve outcomes compared to education alone at 12 and 52 weeks.30 ▸ The addition of exercise to patellar mobilisation/manipulation does not improve outcomes over 5 weeks.30 ▸ The addition of exercise to foot orthoses does not improve outcomes over 8 weeks.30 | Closed and open chain exercises (see online supplementary file 2.2) ▸ The link between CKC exercises and restoration of normal function ▸ The perceived value, or otherwise, of using OKC exercises Supervised or unsupervised exercise (see online supplementary file 2.2) ▸ Preferences for open or closed chain ▸ Importance of supervision ▸ Practicality of supervised exercise Quadriceps exercise (see online supplementary file 2.3) ▸ The importance of quadriceps strengthening ▸ The combination of VMO exercise with quadriceps exercises Gluteal/hip exercise (see online supplementary file 2.3) ▸ Importance of gluteal/hip strengthening ▸ Using functional exercise to facilitate gluteal strengthening ▸ Balancing strength and control at the hip |
| 3.3 Biofeedback (active interventions) | ||
| ▸ Pooled data from 2 studies indicates combining EMG biofeedback with exercise does not improve outcomes at 4 weeks (SMD −0.21; 95% CI −0.64 to 0.21) or 8–12 weeks (SMD −0.22; 95% CI −0.65 to 0.20).30 | Biofeedback (see online supplementary file 2.3) ▸ Using electromyographic biofeedback, or not, to retrain VMO | |
| 3.4 Patellar taping (passive interventions) | ||
| ▸ Pooled data from 5 studies indicates a trend that medially directed patellar taping reduces pain greater than sham tape in the immediate term (9.1 mm; 95% CI −1.8 to 19.9; p=0.10).31 ▸ Pooled data from 6 studies indicate medially directed patellar taping reduced pain greater than no tape in the immediate term (14.7 mm; 95% CI 6.9 to 22.8).31 | ▸ There are conflicting conclusions from three high-quality reviews regarding the effectiveness of patellar taping. Specifically, one review35 reported pooled data from 4 studies indicate patellar taping does not provide any benefits at the end of treatment (1 week to 3 months) (SMD −0.15; 95% CI −1.15 to 0.85); one review33 reported conflicting evidence for combining patellar taping with exercise compared with exercise alone in the short term (4–12 weeks); and one review30 reported the addition of patellar taping to exercise has a very large positive effect compared to exercise alone (SMD 2.47; 95% CI 1.25 to 3.70), and large positive effect compared to exercise and placebo tape (SMD 1.35; 95% CI 0.36 to 2.35) at 4 weeks. ▸ Findings from one study indicate the addition of patellar taping to education, or exercise and education does not improve outcomes at 12 and 52 weeks.30 ▸ There is moderate evidence that combining patellar taping with exercise is no more effective than exercise alone in the long term (1 year).33 | Patellar taping (see online supplementary file 2.5) ▸ Taping use and effects |
| 3.5 Patellar bracing (passive interventions) | ||
| ▸ Pooled data from 3 studies indicates a medially directed patellar brace reduces pain greater than no brace in the immediate to short term (14.6 mm; 95% CI 3.8 to 25.5).31 | ▸ Moderate evidence indicates that the addition of knee braces (various) to exercise compared to exercise alone in not effective in reducing pain in the short term.33 ▸ There is conflicting evidence regarding the effects of combining knee braces (various) with exercise compared with exercise alone on function in the short term | Patellar bracing (see online supplementary file 2.5) ▸ Bracing use and effects |
| 3.6 Foot orthoses (passive interventions) | ||
| ▸ Prefabricated foot orthoses provide greater global improvement compared to placebo (flat inserts) at 6 weeks (RR 1.48; 95% CI 1.11 to 1.99).32 34 | ▸ Prefabricated foot orthoses do not provide greater global improvement compared to placebo (flat inserts) at 1 year.32 34 ▸ At 6 weeks, one review reported prefabricated foot orthoses have small positive effect on pain (SMD 0.59; 95% CI 0.15 to 1.04),30 while two others reported they do not provide a statistical or clinically meaningful pain reduction compared to placebo (flat inserts; MD 8.20 mm; 95% CI −1.27 to 17.67).32 34 ▸ Prefabricated foot orthoses do not improve outcomes at 12 or 52 weeks compared to placebo (flat inserts).30 32 34 ▸ There is conflicting evidence regarding the effects of combining foot orthoses with exercise compared to exercise alone in the short term (4–8 weeks),30 33 34 but related research appears to be underpowered.30 34 ▸ Prefabricated foot orthoses combined with multimodal physiotherapy does not produce better outcomes compared to multimodal physiotherapy alone at 6, 12 or 52 weeks.30 32 34 ▸ Moderate evidence indicates the addition of foot orthoses does not improve outcomes compared to exercise alone in the long term (1 year).33 | Foot orthoses (see online supplementary file 2.5) ▸ When foot orthoses prescription is considered ▸ Prescription specifics for foot orthoses |
| 3.7 Adjunctive interventions (passive interventions) | ||
| ▸ Findings from one study indicate acupuncture produces a moderate positive effect compared to control at 5 months (SMD 0.65; 95% CI 0.13 to 1.16) | ▸ 2 weeks of medial glide and tilt mobilisations and lateral retinacular massage did not improve outcomes compared to no intervention.30 ▸ 2 weeks of PFJ manipulation did not improve outcomes compared to no intervention.30 ▸ Knee manipulation or full lower limb kinetic chain manipulation does not improve outcomes when added to exercise and soft tissue treatment at 6 or 14 weeks.30 ▸ The addition of spinal manipulation to patellar mobilisation does not improve outcomes over 4 weeks.30 ▸ The addition of high-voltage pulsed galvanic stimulation to exercise did not improve outcomes at 6 weeks | Acupuncture or dry needling (see online supplementary file 2.6) ▸ Using acupuncture/dry needling, or not ▸ Acupuncture and dry needling use and effects on soft tissue structures PFJ mobilisation (see online supplementary file 2.6) ▸ The use, or otherwise, of PFJ mobilisation ▸ Indications for PFJ mobilisation |
CKC, closed kinetic chain exercise; EMG, electromyography; OKC, open kinetic chain exercise; PFP, Patellofemoral pain; PFJ, patellofemoral joint; VMO, vastus medialis oblique.