Systematic review

Br J Sports Med: first published as 10.1136/bjsports-2024-108145 on 18 June 2024. Downloaded from http://bjsm.bmj.com/ on October 13, 2024 by guest. Protected by copyright.
Are adjunct treatments effective in improving pain
and function when added to exercise therapy in
people with patellofemoral pain? A systematic review
with meta-­analysis and appraisal of the quality
of interventions
Larissa Rodrigues Souto ,1 Danilo De Oliveira Silva ,2,3 Marcella F Pazzinatto,2
Malu Santos Siqueira ,1 Roberta Fátima Carreira Moreira,1 Fábio Viadanna Serrão1

►► Additional supplemental Abstract

material is published online Objective To compare the effectiveness of adjunct WHAT IS ALREADY KNOW
only. To view, please visit the ⇒⇒ Patellofemoral pain is one of the most prevalent
journal online (https://​doi.​ treatments combined with exercise to exercise alone
org/​10.​1136/​bjsports-​2024-​ in people with patellofemoral pain (PFP) and explore conditions in general practice, orthopaedic and
108145). the quality of intervention descriptions in randomised sports settings.
controlled trials (RCTs). ⇒⇒ Exercise therapy is widely recognised as a key
1
Departament of Physiotherapy, intervention for patellofemoral pain.
Design Systematic review.
Universidade Federal de Sao
Data sources Seven databases were searched in ⇒⇒ Clinical experts and international consensus
Carlos, Sao Carlos, São Paulo,
Brazil November 2023. statements recommend adding adjunct
2
La Trobe Sport and Medicine Eligibility RCTs that evaluated the effectiveness of any interventions (eg, taping) to exercise therapy as
Research Centre (LASEM), La adjunct treatment combined with exercise to exercise best management for patellofemoral pain.
Trobe University, Bundoora/
Melbourne, Victoria, Australia alone on self-­reported pain and function in people with WHAT ARE THE NEW FINDINGS
3
Discipline of Physiotherapy, PFP.
School of Allied Health, Human Results We included 45 RCTs (2023 participants), ⇒⇒ Very low-­certainty evidence suggests that in the
Services and Sport, LaTrobe with 25 RCTs (1050 participants) contributing to meta-­ short-­term, neuromuscular electrical stimulation
University, Melbourne, Victoria,
analyses. Pooled analysis indicated very low-­certainty or monopolar dielectric diathermy, combined
Australia with exercise, improves self-­reported pain in
evidence that neuromuscular electrical stimulation or
monopolar dielectric diathermy combined with exercise people with patellofemoral pain compared to
Correspondence to exercise alone, with a small and large effects,
Larissa Rodrigues Souto, leads to small and large improvements in self-­reported
Departament of Physiotherapy, pain when compared with exercise alone (standardised respectively.
Federal University of São Carlos, mean difference (95% CI)=−0.27 (−0.53 to −0.02) and ⇒⇒ Very low-­certainty evidence suggests
São Carlos, São Paulo, Brazil;
−2.58 (−4.59 to −0.57), respectively) in the short-­term. that knee taping, whole-­body vibration,
​larissasouto@​live.​com electromyographic biofeedback and knee brace
For self-­reported pain and function, very low-­certainty
evidence indicates that knee taping, whole-­body may not be effective adjunct treatments.
DDOS and FVS are joint senior ⇒⇒ Most interventions are poorly described limiting
authors. vibration, electromyographic biofeedback and knee
brace combined with exercise do not differ from exercise knowledge translation and implementation in
Accepted 22 May 2024 alone. Interventions are poorly described in most RCTs, clinical practice.
adjunct treatments scored on average 14/24 and HOW THIS STUDY MIGHT AFFECT RESEARCH,
exercise therapy 12/24 in the Template for Intervention PRACTICE OR POLICY
Description and Replication checklist.
⇒⇒ Our findings provide level 1 evidence that
Conclusion Neuromuscular electrical stimulation and
challenges current clinical practice guidelines
monopolar dielectric diathermy combined with exercise
and international consensus statements,
seem to improve self-­reported pain in people with PFP
which recommend that biophysical agents (eg,
compared with exercise alone. Knee taping, whole-­body
electrical stimulation, monopolar dielectric
vibration, electromyographic biofeedback and knee brace
diathermy) should not be used in people with
do not offer additional benefits to exercise alone. Most
patellofemoral pain.
interventions are poorly described, which is detrimental
to translating research knowledge into clinical practice.
PROSPERO registration number CRD42020197081.
© Author(s) (or their
and sports settings, with an annual prevalence of
employer(s)) 2024. No 23% in adults and 29% in adolescents.6 PFP has
commercial re-­use. See rights a poor prognosis, with only one-­third of patients
and permissions. Published Introduction recovering 1-­year post-­treatment,7 and 57% still
by BMJ. Patellofemoral pain (PFP) is a complex multifac- not recovered 8 years post-­treatment.8
To cite: Souto LR, De Oliveira torial condition1 characterised by pain around or Exercise therapy is recognised as a key treatment
Silva D, Pazzinatto MF, behind the patella during activities that load the for PFP,2 as a standalone or embedded in multi-
et al. Br J Sports Med patellofemoral joint.2 PFP is one of the most prev- modal approaches.1 Clinical guidelines recommend
2024;58:792–804. alent conditions in general practice,3 orthopaedic4 5 combining exercise therapy with adjunct treatments

792    Souto LR, et al. Br J Sports Med 2024;58:792–804. doi:10.1136/bjsports-2024-108145

 Systematic review

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such as patellar taping and biofeedback to improve clinical Inclusion and exclusion criteria
symptoms in this population.1 9 Previous reviews explored the Trial selection criteria were established a priori using the Popu-
effect of adjunct treatments in improving PFP.10–17 However, lation, Intervention, Comparison, Outcome framework.22 RCTs
most reviews are limited to exploring only individual adjunct providing a full-­text report were considered for inclusion. Editorials,
treatments, and do not explore their effect when combined comments, letters, abstracts, review articles, theses and dissertations
with exercise therapy—the cornerstone of PFP management were excluded. Trials that met the following criteria were included:
and most likely application in clinical practice. These system- (1) participants diagnosed with PFP and its synonyms (eg, anterior
atic reviews10–17 were published between 2001 and 2017 (latest knee pain, chondromalacia pattelae) according to the international
update: May 2017). Since then, 30 new randomised clinical consensus statement on PFP definition,2 (2) trials comparing an inter-
trials (RCTs) have explored the effects of adjunct treatments vention group (consisting of one adjunct treatment combined with
combined with exercise therapy compared with exercise therapy exercise therapy) with a control group (placebo adjunct treatment
alone. No recent systematic review has synthesised the effects of combined with exercise therapy or exercise therapy alone), (3) trials
individual adjunct treatments combined with exercise therapy to had to provide the same exercise therapy intervention to the exper-
guide clinicians in managing PFP. imental and control groups, with the adjunct intervention being the
A review of RCTs summarising the effectiveness of various only difference between them. We considered strength, stretching,
adjunct treatments added to exercise therapy is needed to inform endurance, aerobic or resistance training, power and proprioception
upcoming PFP clinical practice guidelines and international exercises as exercise therapy interventions, (4) the following inter-
consensus statements. Additionally, appraising the quality of ventions were considered adjunct treatments: non-­pharmacological
intervention description in RCTs is crucial to ensure knowledge interventions including patellofemoral knee orthoses (bracing),
translation and appropriate implementation in clinical practice. visual and electromyographic (EMG) biofeedback, taping, foot
Our systematic review aimed to evaluate the effectiveness of orthoses, manual therapy (mobilisation/manipulation), needling
adjunct treatments combined with exercise therapy compared therapies (acupuncture and dry needling), behavioural/psycholog-
with exercise therapy alone in people with PFP. Our secondary ical therapy and biophysical agents such as shortwave, ultrasound,
aim was to appraise the quality of the intervention description phonophoresis, iontophoresis, neuromuscular electrical stimulation
in PFP RCTs. (NMES) and laser therapy and any other complementary thera-
pies, (5) assessed outcome measures of self-­reported pain and/or
function (eg, Visual Analogue Scale (VAS), Numerical Pain Rating
Methods Scale (NPRS), Anterior Knee Pain Scale (AKPS)). Trials exploring
Our review was guided by the Methodological Expectations knee conditions other than PFP (eg, patellar dislocation, patellar
of Cochrane Intervention Review standards,18 Preferred subluxation, patellofemoral osteoarthritis, patellar tendinopathy,
Reporting Items for Systematic Reviews and Meta-­ Analyses Osgood-­Schlatter disease, iliotibial band syndrome, Sinding-­Larsen-­
(PRISMA) 2020 checklist19 and the implementing PRISMA in Johansson syndrome or clinical evidence of meniscal injury, liga-
Exercise, Rehabilitation, Sport medicine and SporTs science.20 ment instability or joint effusion), or including participants who
The systematic review protocol was prospectively registered have undergone surgery, have reported pain from the lumbar spine,
with the International Prospective Register of Systematic hips, ankles or feet, and those with symptomatic osteoarthritis in any
Reviews (PROSPERO) on 5 August 2020 (registration number: lower limb joint were excluded.
CRD42020197081) and has been published elsewhere.21 We
did not involve patients or the public when designing our
research question. Literature search strategy
The search strategy for each of the data sources was developed
by two authors (LRS and RFCM) and was published elsewhere.21
Deviations from protocol We did not apply any restrictions on settings, language or year of
Detailed deviations from protocol are described in online supple- publication. We searched the following databases from inception
mental file 1. A summary of the changes is described below: to November 2023: PubMed (via MEDLINE), Cochrane Central
1. Bayesian network meta-­analysis was deemed unfeasible. Register of Controlled Trials (CENTRAL), Embase (via Elsevier),
PEDro, Cumulated Index to Nursing and Allied Health Literature
2. The grey literature was excluded.
(CINAHL) (via EBSCO), SPORTDiscus (via EBSCO) and Web of
3. The Revised Cochrane Risk of Bias 2 tool (RoB 2) for ran-
Science (via Clarivate Analytics). As a final step, we screened the
domised trials was used instead of the Physiotherapy Evi-
reference lists of included trials and relevant systematic reviews to
dence Database (PEDro) tool.
identify potentially relevant trials that could not have been captured
4. The second aim was changed to assess the quality of inter-
by our electronic search—no RCTs were identified. The complete
vention descriptions in the RCTs instead of determining the
search strategy of all databases is presented in the online supple-
relative efficacy of different types of adjunct treatments plus
mental file 2.
exercise therapy.

Declaration of equity, diversity and inclusion Trial selection

The author group consists of four women and two men. Two First, two authors (LRS and MSS) independently assessed the titles
PhD students, three early career to mid-­career researchers and and abstracts of all identified trials to determine potential eligibility.
one senior researcher; four members of the author group are Second, both authors retrieved the potentially eligible full-­text trials
affiliated in a university from a non-­English speaking low-­income and independently assessed them against the eligibility criteria. Trials
and middle-­income country, and two members are affiliated in deemed eligible by both authors at this stage were included in the
a university from an English speaking high-­income country. Our review. Any disagreements at either step were resolved through
search was inclusive and not restricted to gender, nationality, consensus with a third author (DOS). When the full text of a trial
cultural background, language or age. was unavailable, a member of the team (LRS) contacted the authors

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(three contact attempts were made, if the authors did not reply, the the following groups of interventions combined with exercise
trial was excluded). therapy: (1) NMES (2) monopolar dielectric diathermy, (3) knee
taping, (4) whole-­body vibration, (5) knee brace and (6) EMG
Data extraction biofeedback. All interventions had exercise therapy alone as the
One author (LRS) independently extracted data from included trials comparator.
into a prepiloted data extraction form. A second author (MSS) inde- Standardised mean differences (SMDs) were calculated using
pendently audited all extracted data for accuracy. Any disagreement Review Manager statistical software (RevMan V.5, Copenhagen;
was resolved through consultation between the two authors. If the The Nordic Cochrane Centre, The Cochrane Collaboration, 2014)
two authors could not agree, a third author (DOS) was available. with 95% CIs to allow for pooling and data comparison of outcomes
We made three contact attempts to request data that were either in individual trials. Where trials reported 95% CIs only, we calcu-
missing or published in graphical form. Where the authors could not lated the SD according to Cochrane guidelines.18 SMDs were inter-
be contacted, we used Web Plot Digitizer software (Ankit Rohatgi, preted as: minimal <0.2, small 0.2–0.49, medium 0.50–0.79 and
California, USA; available at https://automeris. io/WebPlotDigi- large >0.8. Interpretation of effect estimates and Grading of Recom-
tizer) to extract eligible data from graphical form.23 Trials that could mendations, Assessment, Development and Evaluations (GRADE)
not be extracted using Web Plot Digitizer software were excluded findings followed published recommendations.29 The self-­reported
from the analysis. Information regarding the trials where authors function outcome values were inverted to negative to ensure consis-
were contacted can be found in the online supplemental file 3. The tent reporting. As a result, when computing SMDs for pain and
following data were extracted from eligible trials: function outcomes, negative values represent improved pain and
►► Trial characteristics: sample size, author and year of function, favouring the adjunct treatment groups. Where there were
publication. two or more trials that were sufficiently similar, random-­ effects
►► Participant characteristics: age, sex, population and body meta-­analysis with the inverse variance method was performed using
mass index (BMI). Review Manager.30 The random-­effects model was used as hetero-
►► Intervention and comparator characteristics: type of treat- geneity was expected in the intervention, comparator and popula-
ment, frequency and duration. tion. Statistical heterogeneity was assessed by visually inspecting
►► Outcomes: all available data on self-­reported measures of forest plots and examining the χ² test for heterogeneity. I² values
pain and function outcome from each trial’s intervention and of 30%, 50% and 75% were considered moderate, substantial and
comparator arm were extracted, including the point estimate considerable statistical heterogeneity, respectively.18 31 Assessment of
and the corresponding measure of variability (SD, p value or publication bias was not possible as there were <10 trials in each
95% CI). Data were extracted for all evaluated timepoints meta-­analysis.18
and divided into short-­ term (<3 months), medium-­ term For trials with two or more comparator groups where
(3–12 months) and long-­term (>12 months).24 data pooling was undertaken, we combined groups receiving
similar interventions 32 33 to create a single pairwise compar-
Risk of bias assessment ison in order to prevent a unit-­o f-­a nalysis error as recom-
Two authors (LRS and DOS) independently assessed the risk mended by the Cochrane Handbook. 18 Data from studies
of bias for each trial outcome using the RoB 2 for RCTs. 25 that applied taping in areas other than the knee (eg, femur,
We considered five domains: (1) bias arising from the rando- tibia or foot) were not included in our analyses.
misation process, (2) bias due to deviations from intended
interventions, (3) bias due to missing outcome data, (4) Certainty of evidence
bias in measurement of the outcome, (5) bias in selection We used the GRADE framework29 34 to assess the certainty of evidence
of the reported result. The authors independently rated for each pooled analysis. One author (LRS) used GRADEpro soft-
each domain as either low risk, some concerns or high risk ware (McMaster University, 2015, developed by Evidence Prime,
of bias. A third author (MFP) was available to solve any available from ​gradepro.​org) to assess the certainty of evidence for
disagreements. each outcome independently. Evidence started as high certainty but
was downgraded if there was a concern with the risk of bias, indi-
Quality of intervention descriptions rectness, inconsistency or imprecision. The GRADE was assessed
The Template for Intervention Description and Replication (TIDieR)
by one author (LRS) and audited by a second author (DOS). Any
checklist and guideline26 27 was applied to evaluate how well both
discrepancies were solved by consensus. Full details of upgrade and
adjunct treatment and exercise-­therapy interventions are described in
downgrade criteria for all GRADE categories can be found in the
the RCTs. This tool was developed to improve the reporting of inter-
online supplemental file 4.
ventions across different trial designs.26 The TIDieR checklist has 12
items and was adapted to the purpose of our review. Each item was
assessed on a 3-­point Likert scale, with the following categories: not Results
reported (0), partially reported (1) and adequately reported (2), sepa- Trial selection characteristics
rately for each intervention, adjunct treatment and exercise therapy. The PRISMA flow chart for trial selection is outlined in figure 1.
The overall score was calculated by summing the score (0, 1 or 2) for We identified 11 106 records through database searches, 5823 titles
each of the 12 items, with a final score ranging from 0 to 24 points.27 and abstracts were screened, 111 potential full texts were assessed
Based on a previous review,28 we rated the description of the interven- using eligibility criteria and 45 trials were included in the review.
tions as good (≥21/24), moderate (18–20/24) or poor (≤17/24). The Online supplemental file 5 provides the reasons for the exclusion of
TIDieR checklist was completed by one author (LRS) and audited by full texts. From the 45 trials, 25 were included in the quantitative
a second author (DOS). Any discrepancies were solved by consensus. analysis. Online supplemental file 6 describes the reasons why trials
could not be pooled.
Data synthesis and analysis Of these 45 trials, 13 (n=590 participants) investigated the effect
We pooled data across trials that were sufficiently similar by of biophysical agents,35–47 12 (n=426 participants) investigated the
intervention. After assessing the available evidence, we created effect of taping,32 33 48–57 4 (n=144 participants) investigated the effect

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Figure 1 Flow chart.

of whole-­body vibration,58–61 3 (n=148 participants) investigated respectively. Mostly, the participants were adults (aged 18–40 years)
the effect of dry needling,62–64 3 (n=256 participants) investigated from the general population,32 33 35–41 43–48 52–54 56–58 60 62 65–70 72–74
the effect of knee brace,65–67 3 (n=115 participants) investigated the with five trials involving sedentary patients.49–51 61 71 Additionally,
effect of manual therapy,68–70 2 (n=139 participants) investigated three trials included army recruits,42 55 64 one trial involved adoles-
the effect of blood flow restriction,71 72 2 (n=86 participants) inves- cents77 and four trials included athletes.59 63 75 76 Characteristics
tigated the effect of EMG biofeedback,73 74 1 (n=70 participants) of the 45 trials are provided in online supplemental table 1. The
investigated the effect of internal and external attentional focus,75
specifics of all interventions and comparators are described using the
1 (n=29 participants) investigated the effect of mindfulness76 and
TIDieR26 checklist in online supplemental file 7.
1 (n=20 participants) investigated the effect of foot orthoses.77
Measurement outcomes included pain evaluated through the
VAS,32 33 35–40 42–47 49 50 52–58 60–62 67 68 71 72 74–77 NPRS,51 59 63 64 69 70 pain
Risk of bias
severity scale,73 numerical analogue scale65 and verbal pain scale,66 and
functionevaluatedwiththeAKPS,323335364041434446484951535860–6669717275 Results from risk of bias can be found in figure 2. We
kneefunctionscale,67 functionalindexquestionnaire,5574 kneeoutcome rated 10 outcomes as ‘some concerns’ 39 41 43 64 72 76 and 67
survey,76 lower extremity functional scale,68 70 Knee Injury and Osteo- outcomes as ‘high risk of bias’. 32 33 35–38 40 42 44–63 65–71 73–75 77
arthritis Outcome Score—Activities of Daily Living52 and the Western The risk of bias was largely consistent between the trials
Ontario and McMaster Universities Osteoarthritis Index.56 Partici- and was mostly due to bias arising from measurement of the
pants’ mean age and BMI ranged from 14 to 63 years and 22–29 kg/m², outcome and selection of the reported result.

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Souto LR, et al. Br J Sports Med 2024;58:792–804. doi:10.1136/bjsports-2024-108145

Risk of bias for included trials.
Systematic review

Figure 2

796
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Table 1 Summary of adjunct treatments pooled in the short-­term (<3 months)
Adjunct treatment No. of participants Certainty of the
outcomes SMD (95% CI) (trials) evidence (GRADE) Comments
Self-­reported pain
 Neuromuscular electrical SMD 0.27 lower (0.53 lower 238 (5) ⨁◯◯◯VERY LOW Downgrade because of risk of bias within studies,
stimulation to 0.02 lower) indirectness (outcome measures used, timepoints when
outcome assessed and differences between interventions)
and imprecision (wide CI)
 Monopolar dielectric diathermy SMD 2.58 lower (4.59 lower 140 (2) ⨁◯◯◯VERY LOW Downgrade because of risk of bias within studies, high
to 0.57 lower) statistical heterogeneity, indirectness (difference between
interventions) and imprecision (wide CI)
 Knee taping SMD 0.17 higher (0.07 lower 276 (8) ⨁◯◯◯VERY LOW Downgrade because of risk of bias within studies,
to 0.41 higher) indirectness (outcome measures used, timepoints when
outcome assessed and differences between interventions)
and imprecision (wide CI)
 Whole-­body vibration SMD 1.10 lower (2.34 lower 144 (4) ⨁◯◯◯VERY LOW Downgrade because of risk of bias within studies, high
to 0.14 higher) statistical heterogeneity, indirectness (difference between
interventions) and imprecision (wide CI)
 EMG biofeedback SMD 0.34 higher (0.08 lower 86 (2) ⨁◯◯◯VERY LOW Downgrade because of risk of bias within studies,
to 0.77 higher) indirectness (outcome measures used, timepoints when
outcome assessed and differences between interventions)
and imprecision (wide CI)
Self-­reported function
 Neuromuscular electrical SMD 0.44 lower (1.08 lower 154 (4) ⨁◯◯◯VERY LOW Downgrade because of risk of bias within studies, high
stimulation to 0.20 higher) statistical heterogeneity, indirectness (outcome measures
used, timepoints when outcome assessed and differences
between interventions) and imprecision (wide CI)
 Monopolar dielectric diathermy SMD 0.93 lower (2.11 lower 140 (2) ⨁◯◯◯VERY LOW Downgrade because of risk of bias within studies, high
to 0.26 higher) statistical heterogeneity, indirectness (difference between
interventions) and imprecision (wide CI)
 Knee taping SMD 0.02 higher (0.22 lower 275 (8) ⨁◯◯◯VERY LOW Downgrade because of risk of bias within studies,
to 0.26 higher) indirectness (outcome measures used, timepoints when
outcome assessed and differences between interventions)
and imprecision (wide CI)
 Whole-­body vibration SMD 0.87 lower (1.80 lower 120 (3) ⨁◯◯◯VERY LOW Downgrade because of risk of bias within studies, and
to 0.06 higher) indirectness (difference between interventions)
 Knee brace SMD 0.18 lower (1.48 lower 100 (2) ⨁◯◯◯VERY LOW Downgrade because of risk of bias within studies, high
to 1.13 higher) statistical heterogeneity, indirectness (difference between
interventions) and imprecision (wide CI)
GRADE Working Group grades of evidence:

High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.

Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is
a possibility that it is substantially different.

Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.

Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of
effect.

SMD of <0.2, 0.2–0.49, 0.50–0.79 and >0.8 represents a minimal, small, medium and large effect, respectively.

Significant values are in bold.

EMG, electromyographic; GRADE, Grading of Recommendations, Assessment, Development and Evaluations; SMD, standardise mean difference.

Data synthesis Biophysical agents

Results from pooled analyses and certainty of the evidence are Neuromuscular electrical stimulation
summarised in table 1. The pooled analyses were performed Six trials (n=265 participants) compared electrical muscle
considering the outcomes evaluated at short-­ term. Summary stimulation combined with exercise therapy with exer-
GRADE tables for all pooled comparisons are presented in the cise therapy alone in the short-­ t erm. 36 37 41 42 46 47 Data
online supplemental file 4. Results for outcomes in trials ineli- from five trials (n=238 participants) were pooled for
gible for pooling are presented in the online supplemental file 8, analysis, 36 37 42 46 47 and the results indicate there is very
including their SMD, 95% CI and a narrative synthesis. low-­c ertainty evidence with low statistical heterogeneity

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Figure 3 Effects of neuromuscular electrical stimulation combined with exercise (A, B) and monopolar dielectric diathermy combined with exercise
therapy (C, D) compared with exercise therapy alone for self-­reported pain and function at short-­term (IV, inverse variance; MDD, monopolar dielectric
diathermy; NMES, neuromuscular electrical stimulation). The self-­reported function values were inverted to negative to ensure consistent reporting. All
self-­reported measures of pain and function were assessed using the Visual Analogue Scale and the Anterior Knee Pain Scale, respectively.

(I ²=0%) to suggest that electrical muscle stimulation analysis indicates there is very low-­c ertainty evidence with
combined with exercise therapy leads to small improvement considerable statistical heterogeneity (I ²=73%) to suggest
(SMD (95% CI)=−0.27 (−0.53 to −0.02), p=0.04) in self-­ that electrical muscle stimulation combined with exercise
reported pain when compared with exercise therapy alone therapy is not significantly different from exercise therapy
(figure 3A). For self-­r eported function, data from four trials alone (SMD (95% CI)=−0.44 (−1.08 to 0.20), p=0.18)
(n=154 participants) were pooled, 36 37 41 46 and the pooled (figure 3B).

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Monopolar dielectric diathermy Knee brace
Data from two trials (n=140 participants) compared monop- Two trials (n=100 participants) compared knee brace combined
olar dielectric diathermy combined with exercise therapy with with exercise therapy with exercise therapy alone in the short-­
exercise therapy alone in the short-­term.35 40 The pooled analysis term.66 67 Pooled analysis indicates there is very low-­certainty
indicates there is very low-­certainty evidence with considerable evidence with considerable statistical heterogeneity (I²=89%)
statistical heterogeneity (I²=95%) to suggest that monopolar to suggest that knee brace combined with exercise therapy does
dielectric diathermy combined with exercise therapy leads to a not differ from exercise therapy alone in improving self-­reported
large improvement (SMD (95% CI)=−2.58 (−4.59 to −0.57), function (SMD (95% CI)=−0.18 (−1.48 to 1.13), p=0.79)
p=0.01) in self-­ reported pain when compared with exer- (figure 5A).
cise therapy alone (figure 3C). For self-­reported function, the
pooled analysis indicates there is very low-­certainty evidence EMG biofeedback
with considerable statistical heterogeneity (I²=91%) to suggest Two trials (n=86 participants) compared EMG biofeedback
that monopolar dielectric diathermy is not significantly different combined with exercise therapy with exercise therapy alone in
from exercise therapy alone (SMD (95% CI)=−0.93 (−2.11 to the short-­term.73 74 Pooled analysis indicates there is very low-­
0.26), p=0.13) (figure 3D). certainty evidence with low statistical heterogeneity (I²=0%) to
suggest that EMG biofeedback combined with exercise therapy
does not differ from exercise therapy alone in improving self-­
Knee taping reported pain (SMD (95% CI)=0.34 (−0.08 to 0.77), p=0.12)
Nine trials (n=315 participants) compared knee taping (figure 5B).
combined with exercise therapy with exercise therapy alone
in the short-­ term.32 33 48 49 51–53 56 57 Data from eight trials Quality of intervention descriptions
(n=276 participants) were pooled for analysis.32 33 49 51–53 56 57 The mean quality of intervention descriptions scored using
Five trials used knee taping for patellar medialisation (three the TIDieR checklist was 14 out of 24 for adjunct treatment
trials with rigid tape and two trials with kinesio tape), while descriptions and 12 out of 24 for exercise therapy descriptions,
two trials used patellar taping (one trial with rigid tape and with scores ranging from 1 to 20 points and 2 to 22 points,
one trial with kinesio tape). Additionally, one trial used knee respectively. A detailed assessment of the quality of the inter-
vention description can be found in online supplemental file
kinesio tape for muscle stimulation. The results indicate there
10. From 45 trials, 35 had a poor description of their adjunct
is very low-­ certainty evidence with low statistical hetero-
treatments,32 33 35–42 44 47–50 52–59 61–64 66–70 73 74 77 while 10 trials
geneity (I²=0%) to suggest that knee taping combined with
had a moderate description.43 45 46 51 60 65 71 72 75 76 Regarding
exercise therapy is not significantly different from exercise
exercise therapy descriptions, 39 trials had a poor descrip-
therapy alone in improving self-­ reported pain (SMD (95%
tion,32 33 35–42 44 45 47–59 61–70 73–75 77 5 trials had a moderate
CI)=0.17 (−0.07 to 0.41), p=0.16) (figure 4A). For self-­
description43 46 60 72 76 and 1 trial had a good description.71 The
reported function, data from eight trials (n=275 participants)
most prevalent lacking items for adjunct treatments and exercise
were also pooled.32 33 48 49 51–53 56 Five trials used knee taping
therapy were items: 10 (45/45 trials for adjunct treatment and
for patellar medialisation (three trials with rigid tape and two
43/45 trials for exercise therapy) (modifications: if the interven-
trials with kinesio tape), while two trials used kinesio tape for
tion was modified during the course of the study), 11 (39/45
patellar stabilisation and one trial used kinesio tape for muscle
trials for adjunct treatment and 34/45 trials for exercise therapy)
stimulation. The pooled analysis indicates there is very low-­ (how well planned: if the intervention adherence or fidelity was
certainty evidence with low statistical heterogeneity (I²=0%) assessed, how and by whom and if any strategies were used to
to suggest that knee taping combined with exercise therapy is maintain or improve fidelity) and 12 (40/45 trials for adjunct
not significantly different from exercise therapy alone (SMD treatment and 40/45 trials for exercise therapy) (how well: if
(95% CI)=0.02 (–0.22 to 0.26), p=0.88) (figure 4B). Find- the intervention adherence or fidelity was assessed, describe the
ings of sensitivity analyses exploring the effect of each taping extent to which the intervention was delivered as planned).
technique do not differ from the findings of all knee taping
techniques combined (online supplemental file 9). Discussion
Summary of findings
We identified 11 adjunct treatment categories; however, pooled
Whole-body vibration analyses were only feasible for 6 adjunct treatments due to the
Four trials (n=144 participants) compared whole-­body vibra- heterogeneity among treatments within these categories. Very
tion combined with exercise therapy with exercise therapy alone low-­certainty evidence indicates that, in the short-­term, NMES
in the short-­term.58–61 The pooled analysis indicates there is very or monopolar dielectric diathermy combined with exercise
low-­certainty evidence with considerable statistical heteroge- leads to small and large improvements in self-­ reported pain
neity (I²=91%) to suggest that whole-­body vibration combined compared with exercise alone, respectively. For self-­ reported
with exercise therapy is not significantly different from exer- pain and function, very low-­certainty evidence indicates that
cise therapy alone in improving self-­reported pain (SMD (95% knee taping, whole-­body vibration, EMG biofeedback and knee
CI)=−1.10 (−2.34 to 0.14), p=0.08) (figure 4C). For self-­ brace combined with exercise do not differ from exercise alone
reported function, data from three trials (n=120 participants) in the short-­term. Interventions are poorly described in most
were pooled,58 60 61 and the pooled analysis indicates there is RCTs, adjunct treatments scored on average 14/24 and exercise
very low-­certainty evidence with considerable statistical hetero- therapy 12/24 in the TIDieR checklist.
geneity (I²=83%) to suggest that whole-­body vibration combined
with exercise therapy is not significantly different from exer- NMES and monopolar dielectric diathermy
cise therapy alone (SMD (95% CI)=−0.87 (−1.80 to 0.06), Despite providing additional benefits when combined with exer-
p=0.07) (figure 4D). cise therapy, neither NMES nor monopolar dielectric diathermy

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800
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Figure 4 Effects of knee taping combined with exercise therapy (A, B) and whole-­body vibration (WBV) combined with exercise therapy (C, D)
compared with exercise therapy alone for self-­reported pain and function at short-­term (IV, inverse variance). The self-­reported function values were
inverted to negative to ensure consistent reporting. Akbaş et al53, Clark et al56, Ghourbanpour et al52, Günay et al33, Şahan et al32, Songur et al49,
Tunay et al57, Corum et al61, Wu et al58 and Yañez-Álvarez et al60 assessed the self-­reported measure of pain using the Visual Analogue Scale (VAS)
while Arrebola et al51 and Rasti et al59 assessed it using the Numerical Pain Rating Scale (NPRS) and Numerical Rating Scale (NRS), respectively. Akbaş
et al53, Arrebola et al51, Günay et al33, Lee et al48, Şahan et al32, Songur et al49, Corum et al61, Wu et al58 and Yañez-Álvarez et al60 assessed the self-­
reported measure of function using the Anterior Knee Pain Scale (AKPS), while Clark et al56 and Ghourbanpour et al52 assessed it using the Western
Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Knee Injury and Osteoarthritis Outcome Score - Activities of Daily Living
(KOOS-A ­ DL), respectively.

is recommended by PFP clinical practice guidelines or interna- and translational movement on the anterior surface of the knee).
tional consensus statements.9 78 Our findings should be used to To the best of our knowledge, these are the only trials evalu-
update current recommendations from these documents against ating monopolar dielectric diathermy in people with knee pain,
biophysical agents for people with PFP. However, caution should making it challenging to compare our results with other knee
be taken when proposing recommendations because the very conditions or other parameters.
low-­certainty evidence indicates further high-­quality RCTs may The limited number of trials and the different parameters used
change our findings. for both adjunct treatments, NMES and monopolar dielectric
The NMES trials displayed large variability in the parameters diathermy, limit our ability to provide direct recommendations
applied. The majority used a 50 Hz pulse frequency36 37 41 42 and for clinical practice. Further RCTs with larger sample sizes and
a pulse amplitude ranging from 0 to 99 mA.36 42 46 Additionally, comparing different biophysical agent parameters are necessary
most employed a pulse duration of 400 µs36 41 42 and applied to inform clinical practice.
intensity close to the maximum tolerable for patients.36 37 46 47
The lack of consensus in the literature regarding NMES parame-
ters reflects the difficulty in drawing definitive conclusions in our Taping does not provide additional benefit to exercise
systematic review and in previous reviews evaluating the effects therapy
of NMES on patients with PFP16 and knee osteoarthritis.79–81 As a standalone intervention, knee taping has short-­term effective-
Only two trials35 40 evaluating the effectiveness of monopolar ness in reducing self-­reported pain during descending stairs,82 83
dielectric diathermy were included in our review, both from the walking84 and single-­leg squatting85 86 when compared with not
same research group. Conducting a similar RCT in different using knee taping. However, knee taping in isolation is not consid-
geographic locations and settings would be beneficial to improve ered the best care for PFP9 78 as it does not address key impairments
external validity. Pulsed emission used for monopolar dielectric of this population (eg, hip and quadriceps muscle weakness).87 Our
diathermy varied slightly across trials (ie, 640 kHz35 and 840 findings suggest knee taping does not provide additional benefits
kHz40), while the application technique and time were the same to people with PFP when combined with exercise therapy. This is
(ie, 12 min of dynamic application with a continuous rotation irrespective of knee taping technique (eg, patellar medialisation,

Figure 5 Effects of knee brace combined with exercise therapy (A) and electromyographic (EMG) biofeedback combined with exercise therapy (B)
compared with exercise therapy alone for self-­reported function and pain, respectively, at short-­term (IV, inverse variance). The self-­reported function
values were inverted to negative to ensure consistent reporting. Denton et al66 assessed the self-­reported measure of function using the Anterior
Knee Pain Scale, while Lun et al67 assessed it using the Knee Function Scale. Dursun et al74 assessed the self-­reported measure of pain using the Visual
Analogue Scale, while Qi et al73 assessed it using the Pain Severity Scale.

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patellar taping, kinesio taping), as evidenced by our sensitivity inclusion of only RCTs and the summary of the certainty of the
analyses (online supplemental file 9). evidence using the GRADE approach. Our review was designed
Previous systematic reviews11 15 have advocated for taping in to be comprehensive with a robust search strategy. As limitations,
the management of PFP. Barton et al11 found moderate evidence no trials were rated as low risk of bias. Each pooled analysis was
for patellar taping and recommended its use in exercise reha- based on a limited number of trials, and the interventions exhib-
bilitation to improve functional capacity. Additionally, Logan et ited inherent differences (eg, multiple taping techniques were
al15 concluded that taping can complement traditional exercise applied across the studies) that might make it difficult to draw
therapy. However, these reviews did not evaluate the effective- definitive conclusions about the effectiveness of specific adjunct
ness of taping combined with exercise therapy, and based their treatments. There is a lack of comparator to control for placebo
conclusion on only a few trials. Findings from new trials32 33 48–52 effects, particularly for biophysical agents and knee taping, such
and the inclusion of appropriate comparators generated by our as sham interventions.98 Additionally, all pooled analyses were
review should be used to update clinical practice guidelines and conducted solely in the short-­term. Some trials included popu-
international consensus statement recommendations.9 78 lations with a wide age variation, and this should be considered
when interpreting our findings.
Other adjunct interventions
Whole-­body vibration: in contrast to our findings, evidence Implication for clinicians
suggests that combining whole-­ body vibration with exercise Our findings suggest that NMES and monopolar dielectric
therapy has improved self-­ reported pain and knee function diathermy, combined with exercise therapy, may improve self-­
in people with knee osteoarthritis88–90 compared with exer- reported pain. However, knee taping, when used with exercise
cise therapy alone. There are only a limited number of trials therapy, does not appear to improve self-­reported pain or function.
exploring whole-­body vibration in people with PFP, with the These results are based on short-­term effects and are supported by
first trial published in 2018.61 The considerable methodological evidence of very low certainty. Additionally, NMES trials exhib-
heterogeneity among the pooled trials may also be a confounder ited a wide variety of parameters, making it challenging to draw
to our findings (eg, vibratory platform frequency, intervention definitive conclusions. Although trials using monopolar dielectric
duration, small sample size). Therefore, further trials with larger diathermy had slight variations in parameters, the fact that the
samples and low risk of bias may change our findings. two trials were from the same author group presents challenges in
Knee brace: our result is supported by previous systematic extrapolating their results to the PFP population. Despite a wide
reviews,14 17 91 which did not find additional benefits to self-­ variety of knee taping techniques across the trials, the lack of knee
reported pain and function of patellar bracing compared with taping effects remained consistent across different techniques, as
exercise therapy alone. Additionally, the pooled analysis, with evidenced by our sensitivity analyses. These recommendations
considerable statistical heterogeneity (I²=89%), included only are based on very low-­certainty evidence, highlighting the need
two trials exhibiting a high risk of bias. Despite our results not for high-­quality research on this topic with interventions that are
supporting wearing a knee brace to improve self-­reported pain better described to facilitate knowledge translation.
and function, wearing a knee brace seems to reduce fear of
movement in people with PFP, which could facilitate exercise Conclusion
therapy in fearful patients.92 93 There is very low-­certainty evidence that NMES and monop-
EMG biofeedback: the pooled analysis included only two trials olar dielectric diathermy combined with exercise improve self-­
with high risk of bias, and its results align with other systematic reported pain in people with PFP compared with exercise alone.
review,94 where the quality of evidence does not conclusively Very low-­certainty evidence suggests that knee taping, whole-­
support its effectiveness for people with PFP. The efficacy of EMG body vibration, EMG biofeedback and knee brace do not offer
biofeedback has been assessed in various populations, including additional benefits to exercise alone in improving self-­reported
those who underwent knee surgery, with conflicting findings.95 96 pain and function. Most interventions are poorly described,
Consistent with our findings, a recent systematic review97 found which is detrimental to translating research knowledge into clin-
no significant difference in self-­reported pain or function when ical practice.
comparing the combination of EMG biofeedback with exercise
with exercise alone in individuals with knee osteoarthritis in the Correction notice This article has been corrected since it published Online First.
short-­term. The use of EMG biofeedback has not been recom- The correct figure 4 has now been replaced.
mended by clinical practice guidelines for PFP management.9 78 X Larissa Rodrigues Souto @LarissaRSouto, Danilo De Oliveira Silva @DrDanilo_Silva
and Marcella F Pazzinatto @M_Pazzinatto
Quality of the interventions’ description Acknowledgements The authors acknowledge the Coordination for the
Except for five trials,43 46 60 72 76 which had moderate-­ quality Improvement of Higher Education Personnel (CAPES)—finance code 001. The
authors would like to thank Dr Fereshteh Pourkazemi and Juanita Low for their
descriptions for both interventions, and one trial,71 which had
assistance in translating articles that were not published in English. The authors
moderate-­quality and good-­quality descriptions for adjunct treat- would like to thank the corresponding authors of the included trials for their
ment and exercise therapy, respectively, the overall quality of assistance in data retrievement.
intervention descriptions was generally poor. Poor intervention Contributors LRS, DOS, RFCM and FVS designed the study. LRS wrote the first
description limits the ability of clinicians to translate the findings draft of the manuscript and all authors provided critical feedback. LRS ran the
of RCTs into clinical practice. This highlights the need for future searches. LRS and MSS conducted the study screening and data extraction. LRS, DOS
trials to improve the description of whether the intervention was and MFP conducted the risk of bias assessment and grading of evidence. LRS and
DOS conducted the data analysis and synthesis. All authors have read and confirmed
modified, how it was delivered and how adherence was assessed. that they meet ICMJE criteria for authorship. All authors read and approved the final
manuscript. LRS is the guarantor of the manuscript.
Strength and limitations Funding The authors have not declared a specific grant for this research from any
The strengths of our review include the use of a prespecified funding agency in the public, commercial or not-­for-­profit sectors.
protocol with no language and date restriction criteria, the Competing interests None declared.

802 Souto LR, et al. Br J Sports Med 2024;58:792–804. doi:10.1136/bjsports-2024-108145

 Systematic review

Br J Sports Med: first published as 10.1136/bjsports-2024-108145 on 18 June 2024. Downloaded from http://bjsm.bmj.com/ on October 13, 2024 by guest. Protected by copyright.
Patient consent for publication Not applicable. 21 Souto LR, Borges MS, Marcolino AM, et al. Effectiveness of Adjunctive treatment
combined with exercise therapy for patellofemoral pain: a protocol for a systematic
Ethics approval Not applicable.
review with network meta-­analysis of randomised controlled trials. BMJ Open
Provenance and peer review Not commissioned; externally peer reviewed. 2022;12:e054221.
Data availability statement All data relevant to the study are included in the 22 Counsell C. Formulating questions and locating primary studies for inclusion in
article or uploaded as supplementary information. systematic reviews. Ann Intern Med 1997;127:380–7.
23 Burda BU, O’Connor EA, Webber EM, et al. Estimating data from figures with a
Supplemental material This content has been supplied by the author(s). It web-­based program: considerations for a systematic review. Res Synth Methods
has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have 2017;8:258–62.
been peer-­reviewed. Any opinions or recommendations discussed are solely those 24 Lack S, Barton C, Sohan O, et al. Proximal muscle rehabilitation is effective for
of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and patellofemoral pain: a systematic review with meta-­analysis. Br J Sports Med
responsibility arising from any reliance placed on the content. Where the content 2015;49:1365–76.
includes any translated material, BMJ does not warrant the accuracy and reliability 25 Sterne JAC, Savović J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in
of the translations (including but not limited to local regulations, clinical guidelines, randomised trials. BMJ 2019;366:l4898.
terminology, drug names and drug dosages), and is not responsible for any error 26 Hoffmann TC, Glasziou PP, Boutron I, et al. Better reporting of interventions: template
and/or omissions arising from translation and adaptation or otherwise. for intervention description and replication (TiDieR) checklist and guide. BMJ
2014;348:g1687.
ORCID iDs 27 Yamato TP, Maher CG, Saragiotto BT, et al. Rasch analysis suggested that items from
Larissa Rodrigues Souto http://orcid.org/0000-0003-0968-4835 the template for intervention description and replication (TiDieR) checklist can be
Danilo De Oliveira Silva http://orcid.org/0000-0003-0753-2432 summed to create a score. J Clin Epidemiol 2018;101:28–34.
Malu Santos Siqueira http://orcid.org/0000-0001-8051-7525 28 Briani RV, Ferreira AS, Pazzinatto MF, et al. What interventions can improve quality of
life or psychosocial factors of individuals with knee osteoarthritis? A systematic review
with meta-­analysis of primary outcomes from randomised controlled trials. Br J Sports
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804 Souto LR, et al. Br J Sports Med 2024;58:792–804. doi:10.1136/bjsports-2024-108145