Research Review By Dr. Jeff Muir©


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Date Posted:

March 2019

Study Title:

The effects of joint mobilization on individuals with patellofemoral pain: a systematic review


Jayaseelan DJ, Scalzitti DA, Palmer G, Immerman A & Courtney CA

Author's Affiliations:

Program in Physical Therapy, The George Washington University, Washington, DC, USA; Outpatient Rehabilitation Center, The George Washington University Hospital, Washington, DC, USA; Program in Physical Therapy, University of Illinois at Chicago, Chicago, IL, USA.

Publication Information:

Clinical Rehabilitation 2018; 32(6): 722-733. doi: 10.1177/0269215517753971.

Background Information:

Patellofemoral pain syndrome (PFPS) is a very common musculoskeletal condition, reported in between 25-40% of the population (1). More common in women than men in an adolescent population (2), PFPS is associated with significant decreases in functional ability, quality of life and increases in healthcare costs (3).

Characterized by a multifactorial etiology, current evidence suggests the use of exercise in the management of PFPS (5). However, up to 40% of patients have reported dissatisfaction with their treatment results at 1-year follow-up (6, 7), a potential consequence of the diversity in clinical presentation of PFPS (or, variation in exercise and general treatment approaches).

Manual therapy, while a mainstay of treatment for a variety of musculoskeletal disorders, may be an appropriate treatment option for patients with PFPS, although to date there has been no attempt at systematically reviewing the available data. The purpose of this study, therefore, was to systematically review the effects of joint mobilization (and manipulation) on patellofemoral pain syndrome.

Pertinent Results:

10 studies were identified as eligible from database searches, with an additional 2 studies identified from reference list searching. A total of 499 participants were included in these studies.

Pain was a recorded outcome in 11 of 12 studies, with all studies showing an improvement in pain in manual therapy groups. Joint mobilization was compared with a group not receiving manual therapy in 9 studies, of which 6 showed pain improvements in favour of mobilization.

Of the 12 eligible articles, 10 reported the effect of joint mobilization on self-reported function. Several scales were used, with 8 studies reporting within-group improvements in function from groups receiving joint mobilization. 4 studies found greater functional improvements in manual therapy groups vs. non-manual therapy.

5 studies utilized joint mobilization focused on the knee as the only manual therapy intervention in the intervention group, of which 4 demonstrated statistically significant improvements favouring manual therapy. Patellar taping and exercise were found to be more effective than low-grade patellar mobilization and exercise in 1 study.

5 studies evaluated proximally directed spinal thrust manipulation. 2 studies used lumbar manipulation, of which 1 showed superior results for the manipulation group. The remaining studies used manipulation alone or in combination with patellar mobilization and did not find an improvement.

The final 2 articles utilized joint mobilization with soft-tissue mobilization, noting improvement when these interventions were added to exercise.

Clinical Application & Conclusions:

In general, the existing data suggests that peripheral joint mobilization and spinal manipulation appear to be most effective for patients with patellofemoral pain syndrome when utilized in a multimodal approach. This isn’t surprising and likely mirrors what most clinicians do in practice – combining manual therapy with exercise and rehab, modalities, taping etc.

The authors also presented the following take-home messages:
  1. Positive within-group improvements in pain and function were noted; however, heterogeneity among studies made conclusions regarding the effect of joint mobilization for patellofemoral syndrome unclear.
  2. Relatively few articles evaluated joint mobilization for patellofemoral syndrome and those that did had weak design and were poorly reported.
  3. There was insufficient data to make any conclusions regarding the rate of adverse effects of joint mobilization.

Study Methods:

The authors worked in conjunction with librarians to search the CINAHL, Cochrane Central Registry, PubMed, Scopus and SPORTDiscus databases, using terms and combinations of synonyms related to patellofemoral pain and manual therapy.

Eligibility was limited to randomized, controlled trials published in English-language, peer-reviewed journals, where one treatment group received a joint thrust or non-thrust mobilization to address their patellofemoral pain. Comparison groups performing the same manual therapy technique(s) were excluded.

Two authors were randomly assigned to screen each article while two other authors were responsible for data extraction. Authors reviewing each article used the PEDro rating scale (14) to assess study quality.

Between-group effect sizes (Cohen’s d) were extracted from each study and calculated as the mean difference between the two comparison groups divided by the pooled standard deviation (15). Meta-analyses were not calculated due to limited data availability and study heterogeneity.

Study Strengths / Weaknesses:

  • Strong search criteria, devised in collaboration with librarian
  • Clinically relevant search criteria
  • Strong statistical analysis plan
  • Heterogeneity among studies limited pooling of data
  • Narrative analysis weakens strength of conclusions
  • Relatively low study quality limits conclusions

Additional References:

  1. Callaghan MJ and Selfe J. Has the incidence or prevalence of patellofemoral pain in the general population in the United Kingdom been properly evaluated? Phys Ther Sport 2007; 8: 37–43.
  2. Taunton JE, Ryan MB, Clement DB, et al. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 2002; 36: 95–101.
  3. Rothermich MA, Glaviano NR, Li J, et al. Patellofemoral pain: epidemiology, pathophysiology, and treatment options. Clin Sports Med 2015; 34: 313–327.
  4. Crossley KM, Van Middelkoop M, Callaghan MJ, et al. 2016 Patellofemoral pain consensus statement from the 4th international patellofemoral pain research retreat, Manchester. Part 2: recommended physical interventions (Exercise, Taping, Bracing, Foot Orthoses and Combined Interventions). Br J Sports Med 2016; 50: 844–852.
  5. Collins N, Crossley K, Beller E, et al. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial. Br J Sports Med 2009; 43: 169–171.
  6. Van Linschoten R, Van Middelkoop M, Berger MY, et al. Supervised exercise therapy versus usual care for patellofemoral pain syndrome: an open label randomised controlled trial. BMJ 2009; 339: b4074.
  7. Maher CG, Sherrington C, Herbert RD, et al. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther 2003; 83: 713–721.
  8. Cohen J. Statistical power analysis for the behavioral sciences. Amsterdam: Elsevier, 1988.