Title: Physiotherapy for the management of anterior knee pain (AKP)
Funder: Department of Health (England)

Abstract: Research Question: What is the clinical and cost-effectiveness of physiotherapy in the management of anterior knee pain (AKP)? 1.Interventions: Physiotherapy (researchers to specify and justify in terms of intensity timing and method of delivery)2.Patient group: Adults aged 18 – 40 years with anterior knee pain (AKP) of more than 8 weeks duration excluding trauma related AKP. Researchers may consider identification of subgroups who may be more likely to respond to treatment 3.Setting: Outpatients or community rehabilitation4.Control: Usual care GP management – to be defined by researchers5.Study design: A Randomised Controlled Trial with internal pilot phase (to test equipoise of research community and willingness to recruit randomise and follow-up) of: i) Physiotherapy versus ii) Usual care GP management alone6.Important outcomes: Function measured using a validated functional score for example the Oxford Knee Score; Activities of daily living Other outcomes: Return to functional mobility; Cost effectiveness7.Minimum duration of follow-up: 12 monthsNHS decision problem to be addressed by this research: Anterior knee pain is currently poorly managed in the NHS due to unclear aetiology poorly investigated interventions and consequently lack of clear guidelines on treatment pathways and packages. Treatment of anterior knee pain has recently been given a very high priority in a Research Priorities exercise by the Chartered Society of Physiotherapy where it was ranked as 3rd out of 185 topics in the musculoskeletal section.Hence NIHR HTA programme is inviting applications to carry out research as outlined above.Source of topic The original Topic / Vig 15129: Mr Toby Smith University of East Anglia – original suggestion was for patellar dislocation. ED&PT Panel changed to AKP Following completion of the TIPPS study we have created this new topic to suggest a RCT – originally the intervention was ‘Targeted physio’ but was changed to ‘Physio researchers specify’.Note to panel: This was originally written as a vignette for ED&PT and seen at panel in October 2011. The decision was to put on hold awaiting outcome of the ARUK study TIPPS – this is due to close Nov 2013 – information from study PI in the ongoing research section on Pg. 6Patient group•Patients of any age with anterior knee pain (AKP) of unknown originDefinition of anterior knee pain (AKP): •This is a term used to encompass a whole range of painful conditions which affect the anterior aspect of the knee. It can affect the alignment of the leg causing immense pain and inflammation of the knee in the process. AKP is also known as patellofemoral pain. The symptoms include pain coming from the front of the knee usually caused by a problem at the back of the knee cap (patella). The pain usually gets worse during exercise or when climbing stairs. AKP is the most common diagnosis in outpatients presenting with knee pain (11 % of musculoskeletal complaints). It is most commonly seen in women. It may be present in any age but usually affects young and middle aged adults. AKP is the most common single diagnosis among runners (16-25% of all injuries in runners). (Patient.co.uk)•AKP is characterized by pain perceived in the anterior region of the knee. The pain is usually mechanical exacerbated by activity and relieved by rest. While no specific etiology has been defined signs and symptoms are variable and multiple tissue sources and etiologies exist (anteriorkneepain.com)NICE and other guidanceAt the time of writing we were unable to identify any NICE or alternative guidelines on physiotherapy for anterior knee pain.The only NICE information is here but gives no information on intervention options:http://cks.nice.org.uk/knee-pain-assessment#!management Current practice and proposed interventionCurrent practice:•The management for this condition is most commonly non-operative. Treatment strategies include physiotherapy pharmacotherapy orthoses and combinations of these.•An attempt to correct any other relevant factors in the limb that might be made:• Foot abnormalities ? orthotics• Lack of flexibility ? stretching•Eliminate overuse modify precipitating factors - • Assess training or activity program• Rest until the symptoms have settled for more than a week• A judicious and gradual return to sporting or training activities with ongoing strength and flexibility exercises•Medication: analgesics/anti-inflammatories: modify symptoms to make life more tolerableIf after 3-6 months of conservative management the patient has not substantially improved surgery can be an option.Proposed intervention:This intervention will be delivered by Physiotherapists but orthopaedic practitioners such as orthopaedic surgeons general practitioners with a special interest in orthopaedics and sports clinicians can deliver all or part of these treatments. The treatment would be delivered in an outpatients or community.Physiotherapy packages of care 2 levels: i)Supervised standard physiotherapy – may include additional treatments: taping bracing foot orthoses therapeutic ultrasound electromyographic feedback;ii)Standard home-based physiotherapy - specific instructions for strengthening and stretching exercises ice and adviceCost and implications for NHS spend This is a rough guide only.Patients would typically attend 3-5 sessions of physiotherapy. Tariffs for physiotherapy packages of care vary but are usually around £112-120 per session for a new patient appointment and 4 follow-up sessions of physiotherapy. It is worth noting that many research studies include 6 sessions of treatment.


Research activity codes: 6.7 PHYSICAL
Health categories: MUSCULOSKELETAL