Is Postural Control Affected in People with Patellofemoral Pain and Should it be Part of Rehabilitation? A Systematic Review with Meta-analysis

Abstract

Background Growing evidence supports that exercise therapy is effective for patellofemoral pain (PFP) rehabilitation. Nevertheless, the improvements have been reported not to be sustained in the long term, suggesting that the current protocols may not comprehend all required functional factors to provide a consistent recovery. A potential neglected factor in treatment protocols for PFP is postural control. However, it is unclear whether this population presents balance impairments or the influence of postural control on pain and function during rehabilitation programmes. Objective To investigate whether (Q1) balance is impaired in people with PFP compared to controls, (Q2) conservative interventions are effective to improve balance in people with PFP, and (Q3) balance exercises are effective to improve pain and function in people with PFP. Data sources Medline, Embase, CINAHL, SPORTDiscus, Web of Science and Cochrane Library, supplemented by hand searching of reference lists, citations and relevant systematic reviews in the field. Methods A systematic review with meta-analysis was conducted according to the Cochrane recommendations and reported according to the PRISMA statement recommendations. We included cross-sectional studies comparing balance between people with and without PFP; and randomised controlled trials verifying the effect of conservative intervention on balance and the effect of balance intervention on pain and function in people with PFP. The risk of bias was assessed using the Epidemiological Appraisal Instrument for cross-sectional studies and the Physiotherapy Evidence Database scale for randomised controlled trials. Results From 15,436 records, 57 studies (Q1 = 28, Q2 = 23, Q3 = 14) met the eligibility criteria. Meta-analyses indicated that people with PFP have worse anteroposterior (very low grade evidence, standardised mean difference [SMD] = 1.03, 95% CI 0.40–1.66) and mediolateral (moderate grade evidence, SMD = 0.87, 95% CI 0.31–1.42) balance compared to controls. Moderate grade evidence indicated that overall balance is not affected in people with PFP (SMD = 0.38, 95% CI − 0.05–0.82). Low to very low grade evidence indicates that interventions are ineffective for mediolateral (SMD = 0.01, 95% CI − 0.51–0.53) and overall (SMD = 0.49, 95% CI − 0.14–1.11) balance improvements, and low grade evidence indicates that interventions are effective to improve anteroposterior balance (SMD = 0.64, 95% CI 0.04–1.23). Moderate to low grade evidence indicated that balance interventions are effective to reduce pain (SMD = 0.82, 95% CI 0.26–1.38) and improve function (SMD = 0.44, 95% CI 0.09–0.80) when measured using questionnaires; and very low grade evidence indicated no efficacy for function measured via functional tests (SMD = 0.73, 95% CI − 0.16–1.61). Conclusion People with PFP likely present balance deficits compared to asymptomatic people. There was insufficient evidence to support the efficacy of interventions to improve or modify balance in people with PFP. Also, there was insufficient evidence to support the efficacy of balance exercises to improve pain and function in people with PFP. Trial Registration The present systematic review was registered in PROSPERO (CRD42018091717).

The effect of chronic low back pain on postural control during quiet standing: A meta-analysis

“…The ratings for those categories were ‘No serious’, ‘Serious’, and ‘Very serious’. The level of evidence certainty was downgraded if the meta-analysis (i) included 25% of studies with poor quality assessed by QAT (1 level of Risk of bias) or all studies with poor quality (2 level of Risk of bias), (ii) showed higher than 50% of I 2 (1 level of Inconsistency)—I 2 values have been used previously to evaluate inconsistency in CoP outcomes 34 , 35 —(iii) did not include direct evidence related to the main question (1 level of Indirectness), (vi) included less than the optimal sample size (n = 244) calculated based on 5% of margin of error, 95% confidence intervals, and total sample size (n = 663; 1 level of Imprecision), and (v) showed publication bias resulting from Egger’s regression and trim and fill test (1 level of Publication bias). Combining all the ratings, the certainty of the evidence in meta-analyses were interpreted based on four levels: ‘High’, ‘Moderate’, ‘Low’, and ‘Very low certainty’.…”

Relationship between Functional and Laboratory Balance Assessment in Females with Patellofemoral Pain Syndrome

“…This syndrome can limit functional performance and intensively affect the quality of life (6). Also, some studies showed balance impairments in PFPS (7)(8)(9)(10)(11)(12)(13), but the recent systematic review study indicated that there is a controversy between studies about balance deficits in these patients (14). Dynamic balance is defined as the ability to do a task while maintaining a stable position (15) and is a basic need for independent activities of daily living (16)(17)(18).…”