Comparative effectiveness of treatments for patellofemoral pain: a living systematic review with network meta-analysis

Marinus Winters; Sinéad Holden; Carolina Bryne Lura; Nicky J Welton; Deborah M Caldwell; Bill T Vicenzino; Adam Weir; Michael Skovdal Rathleff

doi:10.1136/bjsports-2020-102819

Comparative effectiveness of treatments for patellofemoral pain: a living systematic review with network meta-analysis

Br J Sports Med. 2020 Oct 26;55(7):369-377. doi: 10.1136/bjsports-2020-102819. Online ahead of print.

Authors

Marinus Winters¹, Sinéad Holden^{2

3}, Carolina Bryne Lura², Nicky J Welton⁴, Deborah M Caldwell⁴, Bill T Vicenzino⁵, Adam Weir^{6

7

8}, Michael Skovdal Rathleff^{2

3}

Affiliations

¹ Centre for General Practice at Aalborg University, Aalborg, Denmark marinuswinters@hotmail.com.
² Centre for General Practice at Aalborg University, Aalborg, Denmark.
³ SMI, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.
⁴ Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
⁵ School of Health and Rehabilitation Sciences: Physiotherapy, University of Queensland, Brisbane, Queensland, Australia.
⁶ Sports Groin Pain Centre, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar.
⁷ Sports Medicine and Exercise Clinic Haarlem (SBK), Haarlem, Netherlands.
⁸ Department of Orthopaedics, Erasmus MC University Medical Center for Groin Injuries, Rotterdam, Netherlands.

Abstract

Objective: To investigate the comparative effectiveness of all treatments for patellofemoral pain (PFP).

Design: Living systematic review with network meta-analysis (NMA).

Data sources: Sensitive search in seven databases, three grey literature resources and four trial registers.

Eligibility criteria: Randomised controlled trials evaluating any treatment for PFP with outcomes 'any improvement', and pain intensity.

Data extraction: Two reviewers independently extracted data and assessed risk of bias with Risk of Bias Tool V.2. We used Grading of Recommendations, Assessment, Development and Evaluation to appraise the strength of the evidence.

Primary outcome measure: 'Any improvement' measured with a Global Rating of Change Scale.

Results: Twenty-two trials (with forty-eight treatment arms) were included, of which approximately 10 (45%) were at high risk of bias for the primary outcome. Most comparisons had a low to very low strength of the evidence. All treatments were better than wait and see for any improvement at 3 months (education (OR 9.6, 95% credible interval (CrI): 2.2 to 48.8); exercise (OR 13.0, 95% CrI: 2.4 to 83.5); education+orthosis (OR 16.5, 95% CrI: 4.9 to 65.8); education+exercise+patellar taping/mobilisations (OR 25.2, 95% CrI: 5.7 to 130.3) and education+exercise+patellar taping/mobilisations+orthosis (OR 38.8, 95% CrI: 7.3 to 236.9)). Education+exercise+patellar taping/mobilisations, with (OR 4.0, 95% CrI: 1.5 to 11.8) or without orthosis (OR 2.6, 95% CrI: 1.7 to 4.2), were superior to education alone. At 12 months, education or education+any combination yielded similar improvement rates.

Summary/conclusion: Education combined with a physical treatment (exercise, orthoses or patellar taping/mobilisation) is most likely to be effective at 3 months. At 12 months, education appears comparable to education with a physical treatment. There was insufficient evidence to recommend a specific type of physical treatment over another. All treatments in our NMA were superior to wait and see at 3 months, and we recommend avoiding a wait-and-see approach.

Prospero registeration number: PROSPERO registration CRD42018079502.

Keywords: knee; sports and exercise medicine.

Publication types

Review