I think there's one really useful question, and that is if they mention crepitus, I just say the following. What do you think it means? And if they say, oh, I don't know, I don't think about it, fine, right. But they will often go, well, obviously it means my knee's arthritic or my knee's wearing away or it means it's bone on bone. And that's your moment to say, this person has an inaccurate belief that is quite catastrophic and leading to fear avoidant behaviour. And it's warranted to spend time in my consultation addressing this inaccurate belief.
SPEAKER_00:what has changed in patella femoral joint pain quite a lot today we spoke to claire robertson for the second time on our podcast this is actually also known as claire patella she's a physiotherapist and she's done a ton of research in this space she also runs her own postgraduate course and website for pfj specific issues today we covered a lot of the qualitative data the correlation with anxiety and depression how people have a lot of kinesophobia and fear of movement when it Also some practical tips for young therapists about how they can keep the fire going in their career and how something seemingly simple like patella femoral joint pain can actually be quite complex and how we need to sharpen our skill set in other areas, particularly the interview and particularly around the qualitative impact that simple injuries can have on the whole human's life. Really, really thought-provoking episode. Please enjoy it. My name is Michael Risk and this is Physio Explained. All right. Welcome, Claire. Thank you for joining us again.
SPEAKER_01:Thank you. Nice to be here.
SPEAKER_00:We did an amazing episode on the fat pad, the Hoffa's fat pad, to be specific. But today we're talking about PFJ pain. And we're going to start with just quite simply, what's coming up for you as new or different in this space at the moment?
SPEAKER_01:Yeah, well, it's been really housed in biomechanics for years and decades and decades. So first of all, it was all everything about the VMO and then it was kind of proximal stuff and then it was the foot. And look, there's a place for all of that. But there was an absolute total silence on the qualitative front. And gradually, gradually, we're just seeing the beginnings of some qualitative work coming through. I published my qualitative work on craptis. And then more recently, we've had Ben Smith's lovely work looking at kind of the impact on people's lives, you know, and really quite significant impact he's shown on things, even things like career aspirations, people feeling a real sense of social isolation. So understanding the kind of the meaning of living with patella femoral pain and how important it is for us to understand that and take time to educate around that and I guess leading on possibly leading off that but certainly in parallel has been work on kinesiophobia as well so showing and actually interestingly approaching quite a biomedical way in the sense of looking at people's jump down technique with camera systems so that's very much kind of how patella femoral pain has been addressed but then actually correlating it with schools of kinesiophobia And looking at actually how when people jump and land badly, often it's more linked with kinesiophobia than it is a weakness. So that whole side of, yes, sort of fear, fear avoidance, catastrophization, and just the beginnings of some work on treatment for that. So what's the role of education or cognitive therapies? There was a paper last year on mindfulness. I was like, wow, this is great. So, you know, I mean, I'm not saying I want to dis the by biomedical or the biomechanical work, there's a total utter place for that. I'm not swinging away from that, but I think we can totally look at that in the light of the whole person. For me, that's how it should be approached.
SPEAKER_00:That's a beautiful merging of the biomechanical sciences, the qualitative literature, the mindfulness. That to me says that the research is actually trying to be more BPS, if I use that term bluntly. What came up for you in the qualitative research? What were you surprised about or what did you find?
SPEAKER_01:In my own research or any of it?
SPEAKER_00:Yeah, in any of it. I'm a newbie to it, so talk to me about it.
SPEAKER_01:Yeah, so really just the extent of the findings. I mean, I wasn't surprised they were finding that people had kinesiophobia or catastrophizing, but the extent of it. And actually, there was another nice paper where they looked at prevalence of anxiety and depression in patellofemoral pain sufferers and compared that with the normal population. And again, found really, really heightened rates of anxiety and depression. Now, they weren't looking at causation, so you can't say If you're anxious and depressed, are you more likely to get knee pain or the other way around? That wasn't the remit of the paper. But I think ultimately, it'd be very easy to always be a bit flippant and go, oh, it's just a bit of pressure pain, pressure and knee pain. But actually, the extent that it seems to be affecting people and people's lives is something that we have to consider. And I guess looking at it in a more chronic pain umbrella, in a sense. And I think, you know, actually... Most of these patients, by the time they seek treatment, actually have had the problem for a long time. And we know that in any area in the body, the longer the duration of symptoms, the more complex the belief systems, the more likely they are to have central change, et cetera. So it makes sense intuitively to me, totally, that we should be looking at this. But I think the extent of it was really quite shocking or is quite shocking. And I think that's probably what surprised me the most.
SPEAKER_00:It is. I've got a few things that are coming up for me. With young physios potentially feeling a bit confused and lost when they're more biomedical trained and they come out of uni and then they're learning about this whole inactive approach, the web of determinants, the BPS lens, it can be quite hard and quite complex and quite scary simultaneously. The levels you're describing kind of show how impactful we are on someone's life when we're treating just a knee. And I do see people get to about third and fifth year and they get a little stale and a little bit bored. And they might say something like that, like, I'm just treating a lot of knees. And I think what this research is highlighting is like how impactful we are on people's lives when we really consider that whole thing. Do you have any thoughts on that? Is that exciting or more scary?
SPEAKER_01:Yeah, I think. People go to me all the time, like, how can you just assess and treat patella femoral pain? Doesn't it completely do your head in? And I'm like, no, it's so interesting because it's all about the patient's narrative. And there's some really interesting work that's actually come from the psychiatry world, the concept of not knowing. So the concept is basically that you as the clinician know nothing. and the start of the consultation. And you're listening to the patient's narrative and you're listening. The thing is, it's harder because it's inductive. So I think as a student, it's really nice to be hypothetical deductive. So I've got my hypothesis and I could deduct that. It's this, this or this. Yeah, that gives you a really neat framework to work. But actually, when you're exploring someone's narrative, you have to go... Okay, so they used to exercise an awful lot in the evening and now they're talking about sleep deprivation. And actually, I need to explore that sleep deprivation a bit more because we know from the emerging literature, again, the role of sleep on pain modulation. So actually, I'm going to have a 15-minute conversation about what we can do to help their sleep strategies. And that's actually much more important than assessing their muscle length for this patient.
SPEAKER_00:Yeah, that's beautiful, exciting information. our Sherlock Holmes-ness of like being an explorer and a true scientist, it's just expressed differently. Whereas when we leave uni, I feel like the expression of what we do, our genius is like finding the biomechanical fault. It's just shifted, but it's no less exciting to me. And it's really cool that the research is reflecting that. You mentioned earlier as well about something on mindfulness. Did that come through in your research or just the qualitative research you've read?
SPEAKER_01:No, this was another paper that came out last year where they looked at a very standardized treatment for patellofemoral pain, mainly around graduated strength. It was at RCT, so it was a strength group versus strength plus mindfulness. And they taught them some mindfulness skills, and then they had to go away and do independent mindfulness work as well. Both groups improved, but the group with the mindfulness had much better scores in the end on things like the catastrophization of fear avoidance. And if you can lower those, then generally I find with patients, then they're more likely to be more active, to move better because it's got the confidence. And then that kind of takes over.
SPEAKER_00:I'm such a hippie at heart. Like that really excites me. Right at the start, you mentioned crepitus and how that might also link with kinesiophobia. Yeah. Can you tell me more about that? And then I'm keen to know what you actually do with patients who present with a bit of that.
SPEAKER_01:Yeah, sure. So I wrote an editorial, it got in 2010, basically just saying, I think patients get really agitated about this. I think they really focus on it. I think they really worry about it. And it was interesting because the feedback informally from that editorial was like other people saying, yeah, I agree. Patients talk about this a lot. And so I then was fortunate enough to be awarded a research grant to look at it, much to the amusement of my academic colleagues doing a whole research trial on noisy knees. I was like, yep. And I did semi-structured interviews using thematic analysis to basically look at the emerging things. And I did it to data saturation. So there wasn't until nothing new was coming through. And I did it non-arthritic. So that's important. They had a normal MRI, but the presence of patellofemoral pain and crepitus. And it was really interesting. So for example, I asked every patient, if a physio gave you an exercise and whilst you're doing the exercise, it made your knee make its noise, what would you do? Every single patient said, oh, I wouldn't do the exercise. That's
SPEAKER_00:amazing, isn't it? Because we don't think that anymore.
SPEAKER_01:Yeah, we need to know that. And certainly, again, high levels of fear avoidance. And I thought, so it's interesting. We might get to the point with a patient where they're pain-free, they're nice and strong. We think we've done a great job. They leave our room and they still avoid the stairs because on the stairs, their knee makes this noise and they think that means their knee is wearing away.
SPEAKER_00:Yeah.
SPEAKER_01:And I even had a 26-year-old who said, so remember, this is someone with a normal MRI. He said, I'm house hunting at the moment and I'm so tired. perturbed by the noise in my knee, I've decided to just look at ground floor properties.
SPEAKER_00:Yeah, that's literally changing someone's life. So what do you say to a patient? Did your research reveal how to de-threaten that?
SPEAKER_01:So, well, not my research, but my clinical experience. And to put that into context, I've recently gone past my 10,000 per telephone patient. So it's a fair few to draw on.
SPEAKER_00:That's a study in itself.
SPEAKER_01:Playing around with dialogue what phrases what words questions that's so important and over the years I sort of kind of modified how I approach this and I think there's one really useful question and that is if they mention crepitus I just say the following what do you think it means and if they say oh I don't know I don't think about it fine right but they will often go well obviously it means my knee's arthritic or my knee's wearing away or it means it's bone on bone and That's your moment to say, this person has an inaccurate belief that is quite catastrophic and needing to fear avoidant behavior. And it's warranted to spend time in my consultation addressing this inaccurate belief. So I then explain what it is. So very quickly, so it's either bubbles of gas releasing, like when people crack their knuckles. It's sometimes a clunk as the patella just sort of rattles into the trochlea. That's okay. That's not a problem. Or the one that probably creates the most alarm is the fine grating noise that people get on the stairs, for example. And that is something we can look to the engineering world to help us explain that. And there's a phenomenon called slip stick, which simply means the noise that arrives when fluid moves through an uneven surface. So what I say to patients is, right, If I take a really thick carpet and the thick carpet is like your nice thick cartilage that's there, it's a reinforcement, lots of cartilage there. I said, but the top of it's just really slightly fluffed up. If I pour some water on that cartilage and go like that, on that carpet and go like that, I'll get a noise. That's what's going on your knee. But it's fine because you've got that nice thick cartilage, this carpet there, that's cushioning. We don't need to worry. We need to separate out pain and noise. Don't put them together. And I manage their expectation from session one. And I say, look, your pain is the abnormality. We're looking to change that and get rid of it, lower it. But the noise may remain. So I'm telling you now, we're not going to worry about that because that's OK if that's there long term. Whereas if you get to the end of the treatment and then they're pain free, but the noise is still there, it sounds like you're trying to kind of get rid of them again. I don't worry about that. That's all right.
SPEAKER_00:And
SPEAKER_01:that was something else that came up actually in my research is that patients felt that they'd been treated with, it had been a bit flippant at times the way clinicians, I remember one lady, she said, I've told my GP, I've told my surgeon, I've told my physio and everyone goes, oh, don't worry about that. And she said, I remember it so clearly. She said, it might not matter to them, but it matters to me. And I thought, yeah, so we need to be careful that through our attempts to de-alarm that we don't actually just sound like we're disinterested.
SPEAKER_00:It's a fine line. It
SPEAKER_01:is a fine line. So it's about taking the time out to explain what it is and explain that it's not linked in with sort of pathology. And luckily, the phrase chondromalacia patellae has been given out less and less now, thank goodness, which helps because that's another... diagnostic term that brings about a loss of alarm. And then if combined with correctors, people can get in a real state about it.
SPEAKER_00:You touched on something really important then is that potentially the timing of that question and when it comes up in the consult. So getting to questions like that, what does it mean to you much earlier? Because if you get into that with a minute or two to go in your consult and you're rushed or you're back to back, it could really easily lead to the patient feeling kind of apathy, I guess.
SPEAKER_01:Yeah. And it's really powerful. You know, I had one patient who I saw and then I sent them off to a treating physio and then the physio called me and said, this patient's not come. And I said, all right, so I'll ring them. And I rang the patient and he said, do you know what? After that conversation we had about the noise in my knee, he said, I just thought, oh, okay. And he said, I just, I've just got on with it and I'm absolutely fine.
SPEAKER_00:Easy.
SPEAKER_01:And it was just that light bulb moment. Yeah. If only it was always like that. But it was interesting, just that change of perspective on it had just changed it. You know, he was avoiding going to the gym, he was avoiding all forms of exercise. And then he was like, oh, I don't need to avoid this. It's fine. I can just crack on.
SPEAKER_00:And he's got an apartment with no views because he bought ground floor.
UNKNOWN:Yeah.
SPEAKER_00:So Claire, I've got one more question for you with a minute to go. What other strategies do you find are helpful to reduce someone who's highly anxious or that kind of phobia of say jump landing or squatting down? Is there anything else that you're finding either through the research or your experience that has been quite helpful other than graded loading? Or is that still like the go-to for you? I
SPEAKER_01:think graded loading is really helpful and actually doing exercises that are pain-free and but similar. So say someone is worried and anxious and pain coming down the stairs, but they can manage a reverse step down. They can see the relevance of that. They can see that this is a similar action. And again, it's just building that confidence and not overloading people with too many exercises. That's the other thing that happens a lot in patellofemoral pain. When people go for a coverall basis, I've given some glutes, quads, a few stretches, maybe an orthotic, something might work. Well, hang on a minute. Their list now is like hugely long and it overwhelming and it almost increases alarm because I think oh my god I need all this to get sorted oh god it must be really bad so good education keep it short really try and no more than three exercises I would say and keep the exercises feeling relevant for the patient
SPEAKER_00:I like that so less is more and a more contextual exercise where they can see it's really close to the thing they're trying to do and or sometimes linking the steps so this exercise will get you to that thing that you're struggling with or the thing that you would love to do
SPEAKER_01:yeah or say I've got a badminton player or a squash player I might get doing like a really really mini lunge but still shadowing the stroke of a forehand or backhand whatever so that again it I'm doing that more just to sort of subliminally message to them. I've listened to you. I know your badminton is really important to you. And I've got that in my mind. That's where we're heading.
SPEAKER_00:It's a beautiful strategy.
SPEAKER_01:And they then are more likely to do it.
SPEAKER_00:Yeah, I like that. Claire, where is the best place for people to read more about this specific resource or your website? Could you remind us?
SPEAKER_01:yeah so it's claire with an i and an e so claire patella.com and there's resources for clinicians and there's resources for patients as well i've got a forum on there for patients and lots and lots of blogs articles webinars all sorts
SPEAKER_00:we were joking off air that you're getting lots of consults from around the world because you dominate the first 10 pages of google when someone types in fat pads so that's how good your website is check it out thank you so much for joining us Claire?
SPEAKER_01:It's a pleasure. Thank you for having me.