DOWNregulating Patellofemoral Pain

[gilbert thomson]

This one is a problem for me, so any ideas are very welcome.

I'm seeing a patient diagnosed with PF pain of 2.5 months duration, middle aged, overweight, her job involves a lot of walking. Also significant Hx of 'fibromyalgia' pain in the upper back and neck.

She keeps the knee locked in extension when walking, reluctantly flexes it to 90 in sitting when asked to, and is VERY sensitive to any palpation over the anterior knee (with allodynia to light touch). In addition she gets some pain behind the knee and up into the posterior thigh. Her symptoms look very neural to me, with a strong central component. The prone knee bend only gets to about 50 of knee flexion passively. It seems that almost EVERYTHING is interpreted as a threat. (My touch, any movement, any of the inevitable crepitus with flexion, etc.) She KNOWS it will hurt, and so it does! I tried a bit of light DNM type stretching over the anterior/medial knee and that was tolerated for a few minutes. I gave her some for homework since it is not as threatening for her to touch herself. I also tried to reinforce pain education about the neural sensitivity and the fact that hurt =/= harm.

Any other ideas how I can help her to down-regulate the pain and fear and get her moving more normally?

Thank you - Gilbert

[Diane]

her job involves a lot of walking.
May I ask what this job is?

[nari]

Have you tried a slump with her? The upper back/neck can be a significant association with knee pain.
Was there any particular event associated with the start of the pain?
Does she think there is something seriously wrong?

One of my favourite tests is PKB with down pressure (light to moderate, possibly moderate if she is O/W) over the TLJ. I then turn it into a brief (4-10 secs) treatment if it is positive for her pain.
Another possibility is to tape the anterior aspect of her knee (single piece, about 2-3 inches long) - provided, with her history, she isn't allergic to tape.
More later, if you can glean more from her.


Nari

[gilbert thomson]

Diane - Her work is bringing the food trolley around the Nursing Home. (breakfast, morning tea, lunch, afternoon tea, supper etc.)

Nari - slump test was negative, I'm doing a few active neural glides though.
I did try the PF taping for a week but it wasn't much help.
thanks -Gilbert

[emad]

May be light touch therapy , breathing , Somatics and distance neural mobilization help her . Try to find if She is doing something to keep that sensitivity e.g habits...

cheers
Emad

[Diane]

Diane - Her work is bringing the food trolley around the Nursing Home. (breakfast, morning tea, lunch, afternoon tea, supper etc.)

Oh, I see. Her head may well be full of images of pain and decrepitude in that case. And she may have financial stress. Yellow flag land. Nari's advice is good.

You'll have to spend some time just talking. I recommend getting a big picture (I use a letter size picture) of the Melzack neuromatrix model ready, and explaining pain to her, use her own life facts, and be absolutely non-judgmental. Make it like a story.

[Erica]

Hi Gilbert,
Not sure what tape you used, but I have had success with kinesio tape in situations such as this, extreme sensitivity etc. Just a thought.
Erica

[Diane]

While I was in a taping mood, I wouldn't just put tape on the knee. After you've gone through some pain ed., you could explain that because pain can be driven to anywhere from anywhere, that it might help if tape were applied to her upper back.

It's important to say to people, "This should feel immediately relieving. If it doesn't we'll take it straight off again. Sometimes we have to move the tape a bit this way or that until it feels "right" to you, like it's helping you move easier." This gives her that all-important locus of control that you'd like her to develop and retain.

Often a simple strip, stretched first then applied horizontally across the T2 dermatome, will bring considerable relief and effortlessly improved neck posture.

It's important to show people exactly how to get the dang stuff off after it's been on 5 days.

[Jason Silvernail]

I'm not putting together the knee pain and thoracic spine connection.
Little help?

[Diane]

I'm not putting together the knee pain and thoracic spine connection.
There is none, other than that the brain of the patient has decided to output pain to both at once, specifically to its maps of each, for whatever reason.

[nari]

Jason, if you think about what this woman is doing - walking, trudging, pushing and pulling, reaching...repetitive, mechanical movement with no novel input?
Yes, i am partly guessing on intuition, and it could be argued that both knees should hurt, and the lower back as well; but after all, what would we know? No-one knows what's actually going on in her brain.

I have come across quite a few patients who came in with CTJ and lower Tx pain plus a crook knee or two and found all mostly resolved with attention to the thoracic spine. The reverse may work, but I don't know.

Re taping: taping both areas sounds good. I thought of the knee first because of the apparent focus on that area in her CNS.

Nari

[ginger]

Gilbert, PFS is related to a stiff irritated L3 facet joint. At least I can say with confidence that should you mobilise L3 on the side of the painfull knee, till protective behaviour there is significantly reduced or eliminated , then the symptoms commonly known as PFS ( patellofemoral pain, poor vmo recruitmernt, puffiness , pain with hyperextension, going down stairs etc, ) all disappear and don't return. It can be established quite quickly wether any one case is or is not related to the irritations at L3 ( joint/nerve ) by applying gentle mobilisation effects to L3 for about five minutes and retest ( the knee ), continuous mobs for up to twenty minutes may be needed to fully "downregulate" , to use a term popular here, the protective spinal behaviour causing PFS.

[marcelk]

Mulligan techniques can resolve PF pain quickly.

Combined with some functional excercises even better.

[Diane]

No surprise here - this was just broadcast on a local TV station: Popular surgery does little for arthritis pain: study (http://www.ctv.ca/servlet/ArticleNews/story/CTVNews/20080910/knee_pain_080910/20080910?hub=TopStories) about arthroscopic knee surgery.

[Diane]

More about the uselessness of arthroscopic knee surgery for "arthritic" pain. (http://www.newswise.com/articles/view/544086/?sc=dwhn)

[EricM]

From the article in the last post:
... one physical therapy session per week for twelve weeks with a home physical therapy program,....
12 sessions!? What was done in each of these 12 sessions?

[Diane]

What was done in each of these 12 sessions?
:D
Probably estim, IFC, mobs to the spine, exercise - lots of exercise, maybe involving a Swiss ball and some core work....

Link (http://content.nejm.org/cgi/content/short/359/11/1097).

[Diane]

Link to Bas's thread, Always nice to see a confirmation (http://www.somasimple.com/forums/showthread.php?t=6101#post58846).

[Jon Newman]

From Gilbert's first post

Any other ideas how I can help her to down-regulate the pain and fear and get her moving more normally?

The folks at the BrainEthics blog express some thoughts with their post Two ways of reducing fear (http://brainethics.wordpress.com/2008/09/30/two-ways-of-reducing-fear/)

[kongen]

Neural Aspect to Patellofemoral Pain Syndrome : http://www.neurodynamicsolutions.com/research-scientific-PFPS.php

[gilbert thomson]

Thanks for all the great input and ideas on this.

Unfortunately the patient hasn't come back :( so I guess I wasn't very helpful to her.
I had been planning to try some more DNM, kinesiotape, continue the pain education, and incorporate more of those neurodynamic mobs.

If she ever does return I'll give an update.