Patellofemoral Pain in Adolescence and Adulthood: Same Same, but Different?

The mainstay of patellofemoral pain (PFP) treatment is exercise therapy, often in combination with adjunct treatments such as patient education, orthoses, patella taping and stretching, making the intervention multimodal in nature. The vast majority of randomised controlled trials among patients with PFP have investigated the effect of treatment among adults (>18 years of age). So, while systematic reviews and meta-analyses provide evidence-based recommendations for treating PFP, these recommendations are largely based upon the trials in adults. In the present article, we have summarised the findings on the efficacy of multimodal treatment (predominantly exercise) from the three largest trials concerning patients with PFP, focusing on the long-term success-rate 1 year after receiving multimodal treatment, and with a particular focus on the success rate across the different age groups, including both adolescents, young adults and adults. The results of this paper show that there appears to be a difference in the success rate between adolescents and adults, despite providing similar exercise treatment and having similar exercise compliance. While PFP may present in a similar fashion in adolescence and adults, it may not be the same underlying condition or stage, and different treatments may be required. Collectively, this highlights the importance of increasing our understanding of the underlying pathology, pain mechanisms and why treatment may-or may not-work in adolescents and adults with PFP.

Cost-utility of exercise therapy in adolescents and young adults suffering from the patellofemoral pain syndrome.

The objective of this paper was to determine the cost effectiveness of exercise therapy (intervention group) compared with "usual care" (control group) in adolescents and young adults with the patellofemoral pain syndrome in primary care. This multicenter prospective randomized clinical trial with cost-utility analysis was conducted at 38 general practices and three sport medical advice centers in the Netherlands for 2007. A total of 131 patients were included. The annual direct medical costs per patient were significantly higher for the intervention group (euro 434) compared with the control group (euro 299) mainly caused by additional physiotherapy visits. The average annual societal costs per patient were significantly lower in the intervention group (euro 1011 vs euro 1.166). Productivity costs were the largest cost component, in particular costs due to reduced efficiency at paid work which were responsible for 47% and 56% of the total costs in the intervention and control group respectively. Patients in the intervention group experienced a slightly, but not significantly, higher quality of life (0.8722 vs 0.8617). With a cost effectiveness ratio of -euro 14,738 per quality adjusted life year, exercise therapy appears to be cost effective as compared with "usual care."

Supervised exercise therapy versus usual care for patellofemoral pain syndrome: an open label randomised controlled trial.

OBJECTIVE: To assess the effectiveness of supervised exercise therapy compared with usual care with respect to recovery, pain, and function in patients with patellofemoral pain syndrome. DESIGN: Open label randomised controlled trial. SETTING: General practice and sport physician practice. PARTICIPANTS: Patients with a new episode of patellofemoral pain syndrome recruited by their general practitioner or sport physician. INTERVENTIONS: The intervention group received a standardised exercise programme for 6 weeks tailored to individual performance and supervised by a physical therapist, and were instructed to practise the tailored exercises at home for 3 months. The control group were assigned usual care, which comprised a "wait and see" approach of rest during periods of pain and refraining from pain provoking activities. Both the intervention group and the control group received written information about patellofemoral pain syndrome and general instructions for home exercises. MAIN OUTCOME MEASURES: The primary outcomes were self reported recovery (7 point Likert scale), pain at rest and pain on activity (0-10 point numerical rating scale), and function (0-100 point Kujala patellofemoral score) at 3 months and 12 months follow-up. RESULTS: A total of 131 participants were included in the study: 65 in the intervention group and 66 in the control group. After 3 months, the intervention group showed better outcomes than the control group with regard to pain at rest (adjusted difference -1.07, 95% confidence interval -1.92 to -0.22; effect size 0.47), pain on activity (-1.00, -1.91 to -0.08; 0.45), and function (4.92, 0.14 to 9.72; 0.34). At 12 months, the intervention group continued to show better outcomes than the control group with regard to pain (adjusted difference in pain at rest -1.29, -2.16 to -0.42; effect size 0.56; pain on activity -1.19, -2.22 to -0.16; effect size 0.54), but not function (4.52, -0.73 to 9.76). A higher proportion of patients in the exercise group than in the control group reported recovery (41.9% v 35.0% at 3 months and 62.1% v 50.8% at 12 months), although the differences in self reported recovery between the two groups were not statistically significant. Predefined subgroup analyses revealed that patients recruited by sport physicians (n=30) did not benefit from the intervention, whereas those recruited by general practitioners (n=101) showed significant and clinically relevant differences in pain and function in favour of the intervention group. CONCLUSION: Supervised exercise therapy resulted in less pain and better function at short term and long term follow-up compared with usual care in patients with patellofemoral pain syndrome in general practice. Exercise therapy did not produce a significant difference in the rate of self reported recovery. TRIAL REGISTRATION: ISRCTN83938749.

[Guideline 'Chronic Achilles tendinopathy, in particular tendinosis, in sportsmen/sportswomen']. / Richtlijn 'Chronische achillestendinopathie, in het bijzonder de tendinosis, bij sporters'.

--Chronic Achilles tendinopathy in sports often leads to various therapeutic strategies, medical shopping and frequently to inability to perform at the desired level. --Although it is clear that this chronic tendinopathy is not an inflammatory disease of the tendon, the cause of the degeneration of the tendon fibres is not understood. --The main therapeutic measure--based on scientific evidence--is eccentric calf-muscle training for at least 3 months. --Recent therapies such as sclerotherapy ofneovascularizations in and around the Achilles tendon appear to be promising, but more studies are required. --About 20% of the patients tend to be refractive to conservative measures. --In selected cases surgery can be undertaken, with percutaneous longitudinal tenotomy proving effective in 75-80% of the cases.

[Diagnostic image (172). A man with blisters after the use of a cold pack. Cryotrauma caused by frozen cold pack]. / Diagnose in beeld (172). Een man met blaren na gebruik van een diepgevroren pakking. Cryoletsel door een diepgevroren pakking.

A 19-year-old soccer player developed cryotrauma after the prolonged application of a cold pack to a sprained ankle.

Epilepsy and sports.

Millions of healthy people participate in sport on a regular basis. Moreover, in the last decade patients with chronic disorders have been encouraged to take part in sporting activities as a part of their rehabilitation. Can epileptic patients freely participate in sport or whether they are restricted to a certain extent by their disorder? An important factor is freedom from seizures. If seizures have been controlled for over 2 years the risk of relapse is the same as the risk of a first seizure. The risk of patients drowning or falling, or their epilepsy worsening because they are engaged in sport is thought to be low. Clinical data suggest that the incidence of seizures during sports and exercise is reduced. In the cooling down period, however, seizures tend to occur more frequently. Physicians should encourage epileptic patients to participate in sporting activities to enhance their physical fitness, self-esteem, and social integration. Before giving advice about the most suitable type of sport, the physician should known the patient's medical history, have a good insight into the different types of sport and be able to judge the role and function of sport to the particular patient. With certain precautions virtually all sports are suitable for most epileptic patients and should therefore be encouraged. However, a small minority of hospitalised patients with severe epilepsy need the supervision of qualified trainers, coaches and volunteers.

No effect of doxapram during enflurane-nitrous oxide anesthesia.

Doxapram was administered to 50 spontaneously breathing patients receiving enflurane and nitrous oxide for surgical anesthesia. A similar group acted as control. Significant depression of ventilation did not occur in the control group of patients, nor did doxapram produce a reduction of end tidal CO2 concentrations. It is suggested that surgical stimulation and concomitant nitrous oxide administration reduced the ventilatory depressant effect of enflurane and that the effect of doxapram was attenuated by the actions of enflurane on the peripheral chemoreceptors.