Non-Traumatic Anterior Knee Pain Care Pathway

9. Treatment Considerations for Soft Tissue Shoulder Disorders

 

Report of Findings (ROF) and Informed Consent

The Report of Findings (ROF) and Informed Consent process is crucial to patient care and to the therapeutic relationship. It involves explaining the diagnosis, prognosis, and treatment plan to the patient. This ensures the patient understands their condition and the proposed management strategies and agrees to the treatment plan voluntarily.

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1. Review of Diagnosis and Prognosis:

• Clearly explain the diagnosis, results of examinations and tests, and the expected course of the condition using understandable language and visual aids if necessary.

 

2. Treatment Plan Overview:

• Discuss the recommended treatments and their rationale.

• Explain how each intervention aligns with the patient's goals and preferences.

 

3. Informed Consent:

• Explain the condition: Use clear and simple language to describe the patient's condition and how it affects their health.

• Discuss treatment options: Provide detailed information about each treatment option, including the potential benefits, risks, and alternatives.

• Address questions and concerns:

  1. Encourage the patient to ask questions and discuss any concerns they may have.

  2. Provide thorough and understandable answers to ensure the patient feels comfortable and informed.

• Obtain explicit consent:

  1. Review the diagnosis.

  2. Propose a plan of care that relates to the patient’s condition and circumstances.

  3. Contextualize the potential risks and benefits of the proposed treatments.

  4. Encourage the patient to ask questions or express any concerns they may have. Consider utilizing strategies such as “teach-back” to confirm patient understanding.

  5. Ensure that all questions and concerns are appropriately addressed before proceeding.

  6. Obtain explicit consent from the patient to proceed with the proposed treatment plan.

• Document the consent: Ensure the patient's consent is documented in their clinical record. Concisely record the information provided, questions asked by the patient, and the patient's understanding and agreement to the treatment plan.

• Adhere to jurisdictional standards: Ensure the practitioner is meeting their jurisdiction’s standards of practice for informed consent.

 

Essential Interventions:

Essential for managing anterior knee pain and applicable to all patients, focusing on optimizing function and participation in daily life.

 

Education and Reassurance:

• Rationale: Helps patients understand their condition, implement pain management strategies, and actively participate in the rehabilitation process.

• Advantages: Increases patient confidence and engagement in their care.

• Disadvantages: Requires time and effective communication skills.

• Key Points: Clarify pain's biopsychosocial dimensions and set realistic expectations. Tailor education strategies to individual patient needs and preferences (e.g., written, digital, visual). Regularly engage patients in the educational process and assess their understanding to ensure effective communication and knowledge retention.

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Address Yellow Flags:

• Rationale: Factors (fear of movement, anxiety, depression, and social or occupational stressors) can significantly influence the perception of pain, adherence to treatment, and overall recovery.

• Advantages: Promotes a more comprehensive approach to treatment, promotes active participation, improves recovery outcomes.

• Disadvantages: Requires time and resources; some people may resist addressing psychosocial factors; may require a multidisciplinary approach.

• Key Points: Screen for psychosocial factors using validated tools, such as the Fear-Avoidance Beliefs Questionnaire (FABQ), Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder (GAD-7), Opioid Risk Tool (ORT), or the Pain Catastrophizing Scale (PCS). Educate patients on how these factors influence their pain and recovery, and incorporate cognitive behavioral techniques (CBT) to help them manage fear, anxiety, and negative thoughts. Refer to mental health professionals when necessary, especially for significant distress or mental health disorders. Encourage support from family, friends, and support groups, and maintain open, empathetic communication to regularly discuss concerns and progress. Collaborate with other healthcare providers for an integrated, multidisciplinary approach.

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Maintain Activities of Daily Living:

• Rationale: Prevents deconditioning and promotes recovery.

• Advantages: Maintains function and reduces disability.

• Disadvantages: Patients may need guidance on safe activities.

• Key Points: Encourage normal activities and proper self-care. Use Brief Action Planning for self-management.

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Self-Care:

• Rationale: Supports long-term health.

• Advantages: Empowers patients.

• Disadvantages: May require continuous motivation and support.

• Key Points: Set SMART goals, prioritize a healthy diet, regular physical activity, good sleep habits, stress management, and avoid smoking/substance abuse. Implement ergonomics and behavior changes to reduce strain.

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Engage in Social and Work Activities:

• Rationale: Promotes well-being and independence.

• Advantages: Enhances mental health and maintains conditioning.

• Disadvantages: May be challenging for severe pain cases, may increase risk of symptom exacerbation, requires balanced activity.

• Key Points: Encourage gradual re-engagement. Modify activities to fit current functional levels. Educate on pacing and support workplace accommodations if needed to ensure a safe and productive environment for the individual. Additionally, consider ergonomic adjustments, flexible scheduling, and assistive devices to facilitate work performance while minimizing the risk of exacerbating the condition.

 

Optional Interventions: Tailored to patient needs and preferences through shared decision-making (SDM). These interventions have varying evidence levels.

 

Exercise Therapy:

• Rationale: Enhances strength, mobility, and fitness.

• Advantages: May improve short- and long-term pain and function.

• Disadvantages: Requires regular commitment and proper technique.

• Key Points:

  • Types of exercises: Includes hip- and knee-targeted exercises. Preference may be given to hip-targeted exercise over knee-targeted exercise in the early stages of rehabilitation. Exercise may consist of weight-bearing (resisted squats) or non-weight-bearing (resisted knee extension) exercise. Tailor to individual needs and preferences (i.e., supervised in-clinic, home-based, gym-based).

  • Psychological considerations: Challenging patients during exercise therapy (beyond psychotherapy) can have psychological implications. Watch for signs of increased anxiety, depression, or distress related to the exercise regimen. Be mindful if the person’s mental health condition worsens despite adherence to the exercise program or if the person expresses a strong aversion or fear of the exercises.

  • Referral threshold: Consider referral to the appropriate provider (physician, psychologist, psychiatrist, mental health professional) when the psychological burden of exercise therapy exceeds the patient’s coping capacity or falls outside of the scope (e.g., person exhibits significant psychological barriers or disorders such as severe anxiety or depression).

 

Manual Therapy:

• Rationale: May provide symptom relief and improves mobility.

• Advantages: Immediate pain relief.

• Disadvantages: Requires skilled practitioners; effects may be temporary.

• Key Points: Techniques include mobilization, manipulation, and soft tissue techniques.

 

Needling Therapies:

• Rationale: May provide pain relief.

• Advantages: Alternative pain management.

• Disadvantages: Mixed evidence; may cause discomfort.

• Key Points: Should be considered as supportive to essential interventions.

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Heat/Cold Therapy:

• Rationale: Helps manage pain, inflammation, discomfort.

• Advantages: Non-invasive, easy to apply.

• Disadvantages: Effects are often temporary and may require frequent application.

• Key Points: Heat therapy can help relieve pain and tension/stiffness. Cold therapy can help relieve pain and inflammation.

 

Electrotherapies (e.g., TENS, IFC, low-level laser):

• Rationale: May provide temporary relief.

• Advantages: Non-invasive. TENS may be self-administered.

• Disadvantages: Mixed evidence on benefits. Access to electromodalities.

• Key Points: Should be considered as supportive to essential interventions.

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Taping:

• Rationale: May help reduce pain.

• Advantages: Alternative simple, low-cost pain management strategy.

• Disadvantages: Mixed evidence on benefits (may be beneficial for patellofemoral pain syndrome). Requires proper application of tape. Potential skin irritation.

• Key Points: Should be considered as supportive to essential interventions, including exercise therapy.

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Prefabricated Foot Orthoses:

• Rationale: To provide support to individuals with patellofemoral pain and greater than normal pronation.

• Advantages: Alternative pain relief strategy.

• Disadvantages: Mixed evidence on benefits.

• Key Points: Should be considered as supportive to essential interventions.

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Medications:

• Rationale: Alleviates pain and inflammation.

• Advantages: Quick relief.

• Disadvantages: Potential side effects and risk of dependency.

• Key Points: Includes over the counter (OTC) pain relievers, muscle relaxants, NSAIDs. Use judiciously and combine with other treatments. If OTC/prescribed medication is out of practice scope for practitioners (e.g., chiropractors, physiotherapists) refer to the appropriate provider (e.g., medical physician, nurse practitioner, pharmacist).

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Example: Anterior Knee Pain

 

Patient Presentation: A patient presents with anterior knee pain persisting for 3 weeks. The patient does not report any trauma, but they report starting a new running program 5 weeks ago. Pain typically worsens with jumping and running, relief with rest.

 

Essential Interventions:

1. Education and Reassurance:

   • Frequency: Initial visit and reinforced in follow-up visits.

   • Protocol: Provide a clear explanation of the condition, expected course with treatment (may be 6-12 weeks), and encourage the patient to stay active. Use visual aids or pamphlets for better understanding.

2. Maintain Activities of Daily Living:

   • Frequency: Daily.

   • Protocol: Encourage the patient to continue with normal activities as much as possible. Provide specific instructions on safe movements and ergonomics.

3. Self-Care Practices:

   • Frequency: Daily.

   • Protocol: Recommend a home exercise program focused on stretching and strengthening exercises tailored to the patient's abilities and pain levels. Advise on proper nutrition, adequate sleep, and stress management techniques.

4. Address Yellow Flags (Psychosocial Factors):

   • Frequency: Regularly, integrated into each visit.

   • Protocol: Identify and address psychosocial factors such as fear of movement, depression, or anxiety. Use cognitive-behavioral strategies to modify negative beliefs about pain.

 

Optional Interventions:

1. Exercise Therapy:

   • Frequency: 2-3 times per week for 6-8 weeks.

   • Protocol: Include a combination of posterolateral hip exercises and knee-targeted exercises in either weight-bearing (e.g., resisted squats) or non-weight-bearing (e.g., resisted knee extension) environments. Sessions are supervised initially and then transitioned to the home-based program.

2. Manual Therapy:

   • Frequency: 2-3 times per week for 6-8 weeks.

   • Protocol: Manipulation/mobilization and soft tissue techniques to relieve pain and improve mobility. Adjust techniques based on the patient's response.

3. Needling Therapies:

   • Frequency:2-3 times per week for 6-8 weeks.

   • Protocol: Dry needling or intramuscular stimulation to relieve pain.

4. Heat/Cold Therapy:

   • Frequency: As needed.

   • Protocol: Typically applied for 15-20 minutes at a time.

5. Electrotherapies (e.g., TENS, IFC):

   • Frequency: 2-3 times per week.

   • Protocol: Utilize Transcutaneous Electrical Nerve Stimulation (TENS) or Interferential Current Therapy (IFC) to provide temporary pain relief and comfort. Use in conjunction with other interventions.

6. Prefabricated Foot Orthoses:

   • Frequency: May only reduce pain in the short-term (<6 weeks).

   • Protocol: There is insufficient evidence to recommend custom foot orthoses over prefabricated foot orthoses.

7. Medications:

   • Frequency: As needed.

   • Protocol: Over-the-counter NSAIDs or acetaminophen for pain relief, used judiciously and in combination with other treatments. Consider muscle relaxants if indicated.

 

Follow-Up:

• Frequency: Regular follow-up at each visit, and every 2-4 weeks to reassess pain levels, functional status, goal achievement and adjust the treatment plan as necessary.