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Comparative effectiveness of treatments for patellofemoral pain: a living systematic review with network meta-analysis
  1. Marinus Winters1,
  2. Sinéad Holden1,2,
  3. Carolina Bryne Lura1,
  4. Nicky J Welton3,
  5. Deborah M Caldwell3,
  6. Bill T Vicenzino4,
  7. Adam Weir5,6,7,
  8. Michael Skovdal Rathleff1,2
  1. 1 Centre for General Practice at Aalborg University, Aalborg, Denmark
  2. 2 SMI, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
  3. 3 Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
  4. 4 School of Health and Rehabilitation Sciences: Physiotherapy, University of Queensland, Brisbane, Queensland, Australia
  5. 5 Sports Groin Pain Centre, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
  6. 6 Sports Medicine and Exercise Clinic Haarlem (SBK), Haarlem, Netherlands
  7. 7 Department of Orthopaedics, Erasmus MC University Medical Center for Groin Injuries, Rotterdam, Netherlands
  1. Correspondence to Dr Marinus Winters, Center for General Practice at Aalborg University, Aalborg, Denmark; marinuswinters{at}hotmail.com

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.

  • knee
  • sports and exercise medicine
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bjsports-2020-102819

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    Footnotes

    • Twitter @marinuswinters, @Sinead_Holden, @Bill_Vicenzino

    • Contributors MW, AW and MSR came up with the study idea. MW, SH, BTV, AW and MSR designed the study. MW, NJW, DMC, SH and MSR designed the statistical analyses plan. MW constructed the search with help of a research librarian. MW and CBL performed the search and selection process. MW, CBL, MSR, AW, SH, and Rebecca Mellor performed data extraction. MW, CBL and AW performed risk of bias assessments. MW and NJW performed all data analyses. MW and Arco van der Vlist performed Grading of Recommendations, Assessment, Development and Evaluation assessments. MW, SH and MSR drafted the first version of the manuscript. MW and MSR are the study guarantors. All authors provided feedback and gave important intellectual input. All authors read and consented to the content of the article.

    • Funding The Tryg Foundation is acknowledged for provided support for this project (Grant ID: 118547). The foundation had no role in the planning, conduct or reporting of this work.

    • Competing interests NJW lead a research project in collaboration with Pfizer plc. Pfizer part-funded a junior researcher. The projects is purely methodological, using historical data on treatments for pain relief. NJW has no other conflicts. All other authors report to have no conflicts of interest.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.