A behind the Scenes Look at Reflective Practice In My Patellofemoral Pain Practice: An Open and Honest Account.

Introduction.

Reflective practice is often banded around with many reminded of student journals they were made to write. In this blog I explain how I use it in my practice and how the literature on this topic helps to inform us.

Experience

‘I pay attention to my ‘experience’ because I constantly strive to become a more effective practitioner and realise my vision of practice.’ (Johns, 2004). Is paying attention to the ‘experience’ enough? As a researcher and clinician I would hate to stop either component. For me there is a richness that comes from my clinical practice but this vast experience I now have of PFP, is devalued without reflection.

Throughout the last decade I have had a note pad which has now evolved into the notes section on my phone to jot down things to look up, give further thought to or even research myself. My crepitus work came out of my reflections on many patients talking about their crepitus.

Questioning

It is good to question and challenge yourself, and ask why did that patient not respond to treatment, why did a patient report an unusual symptom, why, why why…On those occasions where someone is looking to me as an expert in the field and they aren’t responding to treatment it’s imperative I ask why. This is not to beat myself up but learn from each and every patient through my questioning reflection.

Stages of Reflection

Kolb’s experiential learning cycle, (1984) reminds us of the stages of reflection. However, this doesn’t have to be a laboured process involving writing. This for me often occurs during practice so it is reflection in action as described by Schon (1983). So, for example, if I am about to ask a patient to do a single leg squat but I note their fear at the pain from getting out of a chair then I might reflect and in a second decide not to use a single leg squat.

Peer Support-Critical Friendships

‘All professionals are concerned with knowing and realizing desirable and effective practice, yet work in conditions where for one reason or another such realization is often difficult.’ (Johns, 2009). Peer support really can help with this. I am really fortunate that I work in a team that is passionate and friendly. When I’m stuck with a patient I will look to colleagues to reflect on the patient with them. Sometimes just verbalising in itself helps, and two brains knocked together is always better than one. As I have become more experienced I’ve been more comfortable to do this, accepting that we all have head scratchers! Critical friends to reflect with are valuable.

Feelings

Gibbs, (1998) work reminds us that we have feelings and this can impact on our interactions. These may be brought in to the consultation from home, eg anger, frustration about something, or induced by something in the consultation. For example, a spate of patients not progressing well will take the edge off my confidence that may subtly alter my communication style. To reflect on this and be self-aware is important to for me to add to the rich understanding of my practice.

Feedback

Patients’ give both formal, (e.g. questionnaires), and informal feedback. I have learnt so much off patients over the years especially ways in which they have innovatively found to do exercises at home. Apart from the patient who put his pedometer on his sausage dogs collar these will often be top tips that I ‘bank’ and pass on to future patients, leading to a richer experience for everyone. To listen well and reflect on patient’s experiences greatly aids this process.

Problematic Experience

We’ve all had them. Those consultations we’d rather forget about. But actually these are such useful sources of learning from reflection. Osterman and Kottkamp, (2004) refer to this as problem identification. As opposed to Kolb’s reflection they talk about analysis, so really breaking down the components of a negative experience. It is useful not to simply think of what didn’t go well and what you do differently next time, but reflect on the underlying assumptions that led you to act in a certain way. Just dealing with patients with PFP I need to be really careful with this. My inevitable strong pattern recognition with this patient group can lead to the wrong assumptions and reflecting on this helps guard against it!

Re-visiting a Reflection.

Ultimately we reflect and conceptualise with the information we have at any one moment in time. However when I reflect on a patient after a 6-month gap I am looking to see how my reflections have evolved due to six months of extra experience and reading. I often ask my course delegates to reflect on a patient in the light of my course and hope that their reflections will have evolved.

Beliefs

It is very easy to look for evidence to support a pre-existing belief. This can make us feel sure of our stance and avoid the discomfort of change. Argyris’s ladder of inference, (1982) neatly shows us how we easily select data to reinforce an assumption. This is something to be aware of when reading literature. The plethora of literature means that even the articles we select to read and their take-home messages may in itself be reinforcing assumptions. I try and make myself reflect on what literature I am choosing and why to ensure I keep evolving in my PFP practice and teaching.

Personal Mastery

‘People with a high level of personal mastery are acutely aware of their ignorance, their incompetence and their growth areas.’ (Senge, 2006). This really is very annoying at times as the more you know the more you realize you don’t know! However, it is also hugely exciting to be in a profession where I can learn, learn, learn, even if the ‘to read’ list gets a bit overwhelming at times.

To conclude

I feel hugely privileged to be in a career that is so rewarding and stimulating. When I reflect on my days as a student with faradism, slings and de Lorme boots I can see what a journey I’ve been on. Reflection has, and continues to be a vital part of that journey.

‘Reflective practice is the antidote to complacency, habit and blindness.’ (Johns, 2004)

 

Top Tips for ensuring you have a Reflective Practice:

  1. Keep a log or pop things on your phone to look up, give further thought to.
  2. Regularly make time to talk to a ‘critical friend’ and reflect on tricky cases or problematical scenarios.
  3. Ask yourself why you have chosen to read the papers you have.
  4. Try and be self-aware of your own beliefs and feelings.

References:

Argyris C (1982) Reasoning learning and action: Individual Organizational, San Francisco: Jossy-Bass

Gibbs G. (1998) Learning by Doing: a Guide to teaching and learning methods, Oxford: Further Education Unit, Oxford Polytechnic.

Johns C. (2004) Becoming a Reflective Practitioner, 2nd Ed, Oxford: Blackwell Publishing.

Johns C. (2009) Becoming a REflective Practitioner, 3rd Edition, Chichester: Wiley-Blackwell

Kolb D. (1984) Experiential Learning: experience as the source of learning and development, New Jersey: Prentice Hall

Ostermann KF, Kottkamp RB (2004) Reflective Practice for Educators,2nd edition, London: Kogan Page

Schon D. (1983) `the reflective practitioner, New York: Basic Books.

Senge P (2006) The fifth discipine, 2nd edition, London: Random House Business

 

 

 

 

42 year old female, right inferopatellar pain

Female, 42, describing intense pain sometimes burning, inferopatellar, worse laterally. Area swells up locally. Complains of intermittent giving-way associated with sharp pain. No locking.

Thoughts: Typical of inferopatellar fat pad but can’t discount patella tendinopathy or referral from PFJ. Giving way probably pain induced quads inhibition but can’t yet disqualify possibility of intra-articular pathology. Swelling sounds local to fat pad and not an effusion.

 

Agg. prolonged standing, kneeling.

Thoughts: Prolonged standing typical of fat pad-need to ascertain if type of shoe alters this. Kneeling could be fat pad/ PFJ or tendon.

 

Shoes. Worst in bare foot or very flat. Better in a slight heel.

Thoughts: Best clue so far that this is probably a fat pad problem. Unlikely to like a heel if PFJ or tendon.

 

Ease. Standing with knee flexed. Avoidance of kneeling.

Thoughts: Very unlikely to be PFJ if likes standing in flexion. Offloading her fat pad with this stance.

 

HPC. 4 months ago her 2 year old ran into her knee at speed and hit inferopatellar area. Very sore and swollen initially. Settled 70% over first 2 weeks but no further improvement. Anxious about her knee as she wants to try and get pregnant again but doesn’t know if that is a bad idea with her knee as it is. She comments she is very aware of her age and her declining fertility. Moving house out of area and very stressed about house hunting/ not knowing people/ moving away from family.

Thoughts: This lady has a lot on! She doesn’t know the meaning of her pain and how this should impact on her decision re getting pregnant. She sees this as a potential threat to something very important to her. Stress of moving and all associated with it has the potential to decrease her ability to cope with this current pain.

The blow to the front must also be considered for a potential PCL rupture as this can present as PFP as the PFJ gets overloaded by the posterior sag of the tibia.

 

PMH. Nil of note. Obese.

Thoughts: Obesity will increase the likelihood for catastrophic handling of her pain. The high BMI also increases her systemic inflammatory state as well as her inflammatory sate of her fat pad.

SH. Full time stay at home mum with one two year old. Spends a lot of the time on the floor playing with daughter and does not wear shoes at home.

Thoughts: A lot of kneeling going on here plus time bare foot, both of which are likely to stop an inflamed fat pad from settling.

 

O/E.

Obs: Stands with knees in hyperextension. Fat pad oedematous compared to the other side.

 

Thoughts. Constant position of hyperextension creating impingement of patella on fat pad. Need to feel passive hyperextension to check posterior capsule not been overstretched by blow from the front.

 

ROM. R=L. 30 degrees hyperextension. Right painful on passive hyperextension.

Thoughts. Capsule normal but fat pad painful when compressed.

 

Ligament testing: ACL & PCL normal.

 

Palpation: Patella tendon soft and non tendon. Fat pad just lateral to the tendon very tender.

 

Quads: Some subtle atrophy. In single stance unable to control 30 to zero degrees and snaps back into hyperextension.

Thoughts. Poor terminal extension control means that she is likely to accelerate into hyperextension which creates a microtrauma to the fat pad.

 

Other: Excessive pronation of foot visible by abduction of forefoot and rearfoot valgus. Correction in weight bearing visibly makes the lateral fat pad appear less impinged by the patella.

Thoughts: This foot posture closes down the space for the lateral fat pad.

 

Impression.

 

Inferopatellar fat pad inflammation initially started by a direct blow form toddler. A number of factors have meant that the fat pad is struggling to settle. These are:

  • Tendency to hyperextend.
  • Volume of kneeling.
  • Foot posture exacerbated by volume of time bare foot.

There is also a concern here that there is a real risk of catastrophising as the knee problem is perceived as a threat to her future pregnancy, happily moving house and coping with her daughter with reduced family support.

 

Plan.

 

  1. Reassure re the pain. Nothing serious and should be viewed as a nuisance but not a worry. She should not be considering delaying a second pregnancy because of this. Absolutely no need for surgery whatsoever.
  2. Calm the fat pad itself. Ice massage to oiled skin at end of day,(the ice-it-away is fantastic for this), fat pad tape offload and tape in the popliteal fossa to help educate re hyperextension.
  3. Indoor trainer with chunky rear foot sole to provide better foot position and help avoid hyperextension.
  4. One exercise only, (more may become a stressor in itself) to practice 30 to zero degrees in front of a mirror slowly, initially little and often. This must be done pain free,
  5. Avoidance of kneeling as a temporary measure. Sitting on her bottom not kneeling, and bathing daughter with a rolled up towel under knees on tiled floor.
  6. Gentle conversation re BMI stressing it should be viewed as a long-term plan and that she should turn her attention to it when the time is right for her, (ready for change).

 

 

 

 

 

 

 

GUEST BLOG: How should we explain patellofemoral pain to patients?

On a daily basis we face the challenge of explaining a patient’s pain to them. When this goes well it can reassure them, help them manage their condition and be a key starting point for treatment. Unfortunately, however, it doesn’t always go well and sometimes our words can have a negative impact if not chosen carefully. Patellofemoral pain can be particularly challenging issue to explain, so how should we approach it?

What are we trying to achieve?

First of all it’s worth considering what are our goals with this explanation? Broadly speaking our goals might be;

  • Reassure that pain doesn’t mean damage
  • Provide an explanation that the patient can understand and apply to their rehab
  • Be clear that movement is helpful not harmful
  • Help the patient find the right level of exercise to start with
  • Discuss a graded return to activity based on their goals
  • Change their attitude towards their joint and its response to exercise
  • Address any specific concerns and worries
  • Aim for physcological and physical resilience

So, not much then! Where do we start?..

…Before we talk, we listen! A good place to start is to ask the patient what they think is wrong with their knee. This can help highlight unhelpful beliefs that we might be able to change and identify specific concerns.

It’s also good to know what not to say! We know that our words can have a nocebo effect and certain words may be recieved more negatively than others by patients. Research in arthritis has suggested the terms, “wear and tear” and “degenerative changes” have an especially negative impact (see table below). How often have we said to patients, “it’s just a bit of wear and tear!”? Although I’m not aware of evidence on it I suspect the term, “mal-tracking” can be interpretted negatively too.

By contrast no negative impact was reported for the word, “inflammation”. The terms “irritated”, “sensitive” and “overworked” seem to be received quite well too. These might be good options to consider in our explanation. Pain specialist Mike Stewart also suggests talking about the distress that can accompany pain, thinking beyond the ‘ow factor’ and considering the broader impact pain has on people’s lives.

Source: Barker et al. (2014)

Changing perceptions

When you’re in pain it’s easy to see your body as damaged and fragile. We might hope to change this view and help people see that their bodies are amazing things that can adapt and strengthen in response to exercise. Combining this with the thoughts above we may try something like this,

We know that when we exercise muscles they strengthen. Did you know that a joint can strengthen in response to exercise too? It just needs the right amount of exercise and enough time. If we work it too hard or don’t give it the time to strengthen it can become a bit overworked and irritated. When this happens, everyday activities can become painful because the knee becomes sensitive. In time this sensitivity reduces and we can build back up to where you want to be. This usually needs to be done gradually though to give the joint enough time to adapt and strengthen.”

It can help to use a positive anecdote here for some patients. I talk about one particular, wonderful patient who could only manage 1 minute on a bike before his pain become too severe. He started with just under a minute and gradually built up… 6 months later he cycled London to Brighton! While we, as scientists, don’t put much stock in anecdotes as evidence, patients can find them helpful to illustrate a point.

Some patients might want a more detailed explanation. Where I’m based, for example, we sit between two universities and treat a lot of lecturers and students who may be interested in research. For them I talk about this amazing study which suggests some joints are able to adapt even in the middle of a multi-day ultra-marathon event! This helps to challenge the view that a joint is simple hinge that get’s ‘wear and tear’ and instead shows it’s an amazing, living tissue that constantly tries to adapt to the stresses placed upon it.

Goldilocks theory

A barrier to our idea that exercise is helpful is that, for many with patellofemoral pain, exercise hurts! The challenge is trying to find the right type of exercise at the right volume, intensity and frequency. Like Goldilocks’ stolen porridge we want exercise that’s not too hot, or too cold, but just right. Ideally we can achieve this without having to burgle bears!

In more scientific terms we don’t want to underload the tissues and create deconditioning, or overload the tissues and cause lasting symptom aggravation. We want to find the right level to improve load tolerance and reduce pain. It’s important to use the patient’s own experience as examples with this to help make it relevant to them. For example, if a runner tells you they can run 3 miles but 4 causes lasting irritation we can suggest that 3 sits at the right level but more might be overloading the tissues a little at the moment. In time we can build up to 4 (and beyond potentially) but we would start at around 3 miles and progress from there. This links in nicely with recent recommendations from the excellent work of Barton et al. (2015) who highlight that activity modification is a key component of managing patellofemoral pain.

Normalise pain

It’s unlikely for many for patellofemoral pain that their rehab is going to be completely painfree. We usually need to load sensitive tissue in order to help it to strengthen and adapt so it’s likely, at times, that this may hurt. We need to be clear that this pain isn’t creating damage and it’s a normal part of the process. A pain monitoring system can be a useful way to ensure that we aren’t creating lasting tissue irritation;

We also want to try to keep exercise as comfortable as we can for the patient. Pain can be a significant barrier to adherence to rehab (Jack et al. 2010) and may cause a level of quads inhibition (Rice and McNair 2010).

Message received?

Image source

Providing the right explanation is, in a way, only half of the process. We also need to see if the patient understands the message and is happy to apply it. A good question to ask is, “how would you explain your knee to a friend?” Or, “can you explain back to me what you’ll take from today’s session?”

Psycosocial factors like stress, anxiety or depression may influence how someone interprets your explanation and whether it provides sufficient ressurance for them. Fear is a very powerful emotion and not one that can always be talked away,

“I must say a word about fear. It is life’s only true opponent. Only fear can defeat life. It is a clever, treacherous adversary, how well I know. It has no decency, respects no law or convention, shows no mercy. It goes for your weakest spot, which it finds with unerring ease. It begins in your mind, always.” Life of Pi, Yann Martel

On the flip side, low levels of fear and positive perception of return to sport are associated with a greater likelihood of returning to pre-injury level (Ardern et al. 2013). Hopefully our explanation fosters a positive perception of return to activity as something that strengthens our bodies rather than damages it!

We should consider the impact of mental health on rehab and seek appropriate help for those need it. It can also be very helpful to try to assess the patient’s outlook towards they pain. A Pain Catastrophizing Scale can be a good way of doing this and might help us prioritise our treatment more towards education in those with an especially negative view of their pain.

Building ‘resilience’

A careful consideration of the key messages delivered in the right way can be a very powerful part of our treatment process and empower the patients to make informed decisions about their rehab. Considering the impact of mental health and providing a comprehensive rehab programme can help a patient with patellofemoral pain build both physical and psychological resilience. There are no recipes though! This will always need to be taylored to the individual and their specific goals.

Tom Goom is a Running Specialist and Clinical Lead at the Physio Rooms in Brighton. His website, running-physio.com has become a popular source of evidence-based information for runners and clinicians and he teaches around the UK on his Running Repairs Course. You can follow Tom on Twitter via @TomGoom.

35 year old male with PFP

Male 35, Pain vague distribution around patella. No swelling, no giving way.

Thoughts: typical of PFP. Nothing to make me suspicious of meniscal pathology.

Agg. Stair descent, prolonged sitting, turning with foot fixed.

Thoughts: stair descent and cinema sign typical, turning on foot fixed makes me suspicious of joint pathology, (tibiofemoral), or shallow trochlea.

Ease. No pain after cessation of aggravating movements.

Thoughts. No Inflammatory component here.

HPC. Insiduous onset 2 years ago after increasing volume of salsa dancing to 5 x2 hour sessions per week. No other exercise. Pain increased and forced him to stop. Sought physio who gave him squats and lunges. Pain worsened. Sleep disturbance but not through pain. Sought orthopaedic opinion and had an MRI. Mild superficial changes on retropatellar surfaces but shallow trochlea with small angle to slope of lateral edge of trochlea. Referred to me.

Thoughts. This is a lot of exercise with no s&c alongside. Unlikely to be weak in quads as no swelling and came on at a time of lots of exercise. Repeated loading of PFJ through squats and lunges have worsened pain. Sleep disturbance may be from stopping exercise. This is likely to feed the possibility of central sensitization.

PMH.x2 ankle arthroscopies on ipsilateral side 5 years ago. Great recovery from ankle and not aware of any ongoing issues.

Thoughts. Need to look at ankle ROM/stability and gluteal function as ankle problems can inhibit gluteus medius

SH. Office worker who drives to work. No issue with work/commute. No exercise for last 18 months. Has put on 8 kg.

Thoughts. This man has gone from being an intense exerciser to very sedentary. He has lowered self esteem, has lost a major part of his social life and is low in mood. He now cannot imagine getting back to dancing. We need to explore other avenues of exercise as a preliminary stage.

O/E.

Obs. Overweight, no effusion. Small patella.

Thoughts: small patella can indicate hypermobility.

ROM full, 20 degrees hyperextension. Little pain.

Beighton score: 9

Palpation. No tender areas. Patella highly mobile. Negative apprehension sign.

Thoughts. Patella easily becomes malaligned due to shallow trochlea and global hypermobility.

Quads: bulk reasonable, no obvious deficits.

Thoughts. Not going to be great as very sedentary but not convinced they are primary problem but will need improving as part of later stages of rehab before return to dance, especially with a shallow trochlea as dynamic stability more important.

Gluteal assessment. Poor firing and force generation of gluteus medius in frontal plane. Compensating massively through TFL.

Thoughts. Probably a legacy from the ankle problems as vey one-sided. Rotational strength fine.

Length. Modified Thomas test reveals pain provoked by hip adduction and a subluxing patella. Very tight. Tightness perceived by pt down lateral thigh and he comments that he often gets a sense of tightness in lateral thigh with walking.

Thoughts. Tightness through ITB complex, ie TFL shortening and immobility of ITB itself lateralizing the patella that will move easily due to trochlea shape and hypermobile patella. Comment re walking tightness suggests gross overuse in simple tasks.

Standing double stance swaying side to side. Huge bracing of lateral thigh and VL making ITB bow out.

Thoughts. Excess inappropriate tone on low level activities. Need more strength proximally and retrain VL to decrease in tone.

Ankle assessment normal.

Thoughts. Ankle itself may be fine but it’s left a legacy of gluteal inhibition.

 

Impression.

PFP from lateralizing patella creating excess contact pressures between trochlea and lateral patella. Cause is insufficient strength proximally, driven initially by ankle injury and compensation by TFL that has got tight, and overactive bracing from VL.

Plan:

  1. Stretches x2 daily to TFL.
  2. Firing work for glut med in frontal plane to be progressed to alternate day endurance training.
  3. Rolling to lateral thigh, STM and practicing initially swaying weight without massive tensing of VL.
  4. Medialising tape to help in short term with discomfort.
  5. Swimming x3/ week crawl or back stroke for min 20 mins to help with weight, self esteem and sleep.
  6. Graduated increase in exercise as proximal strength improves, and ITB complex softer and lateralizing patella less.
  7. Long term restoration of dance with appropriate stretches and conditioning alongside.