Exercise therapy for patellofemoral pain syndrome

 

Characteristics of included studies [ordered by study ID]

Clark 2000

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Methods	RCT Computer generated randomisation High quality: Delphi score 6
Participants	AKP/PFPS, median duration >12 months (<3 to >12) Patients referred from orthopaedic/rheumatology consultants/GPs 81 patients, 56% male Age 26.0 ± 7.4 (15-40) 1) n=20 2) n=20 3) n=19 4) n=22
Interventions	Duration 3 months, 6 sessions 1) education, exercise, tape 2) education, exercise 3) education, tape 4) education Education: background of PFPS Exercise: 3 months 6 sessions and training at home: eccentric/isotonic strengthening exercises: bicycle warm-up, wall squats gradually lengthened up to 3 min., sit to stand, proprioceptive balance, exercise gluteus muscles, progressive step down, Tape: first three sessions, thereafter optional
Outcomes	VAS pain: baseline, 3 months, 12 months 1) 75.6 ±32.6, 35.9 ±28.7, 35.1±45.1 2) 77.1 ±44.4, 30.0 ±39.9, 37.8 ±43.4 3) 83.9 ±39.8, 57.8 ±38.7, 77.3 ±62.8 4) 77.0 ±41.8, 41.8 ±40.6, 51.9 ±53.8 WOMAC: baseline, 3 months, 12 months 1) 25.2 ±12.5, 11.5 ±10.5, 14.8 ±18.0 2) 23.7 ±12.9, 10.0 ±11.8, 15.6 ±16.2 3) 33.4 ±16.8, 20.9 ±15.5, 27.6 ±22.7 4) 28.7 ±15.4, 13.8 ±15.8, 22.0 ±21.3 Patient satisfaction expressed as N discharged: 3 months 1) 19=95% 2) 20=100% 3) 8=42% 4) 13=59% Patient recovery expressed as N still troubled: 12 months 1) 6=60% 2) 7=58% 3) 9=75% 4) 13=87% Patient recovery expressed as N continuing therapy: 12 months 1) 2=10% 2) 2=10% 3) 3=16% 4) 5=23%
Notes	Drop-outs: 1) 3 months: 4 patients 12 months: 10 patients 2) 3 months: 4 patients 12 months: 8 patients 3) 3 months: 1 patient 12 months: 7 patients 4) 3 months: 1 patient 12 months: 7 patients
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Colón 1988

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Methods	RCT Quasi random, matching for age, physical findings and disability Low quality: Delphi score 3
Participants	PFPS, mild or moderate Recreational athletes 29 patients, 66% male Age (15-24) 1) n=13 2) n=16
Interventions	Duration 6-8 weeks, Stretching*, ice application after exercise 1) Pogo stick bounces (isometric exercise + endurance training), incremental increase from 250 bounces twice daily up to 10 minutes 2) Conservative isometric exercises: straight leg raises with increasing weights, bicycling
Outcomes	Baseline, 6-8 weeks: N >50% improved on 11-point pain scale: 1) 9 (82%) 2) 13 (93%)
Notes	1) 2 withdrawals: 1 female increased pain, 1 male vacation interruptions, 2) 2 female withdrawals, no description
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

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Dursun 2001

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Methods	RCT Randomisation method not specified Low quality: Delphi score 4
Participants	PFPS, all unilateral, duration: 10 ± 8 months Outpatient clinic of university medical faculty physical medicine and rehabilitation 60 patients, 20% male Age: 37 ± 10 (17-50) 1) n=30 2) n=30
Interventions	Conventional exercise program: 4 weeks 5 days/week supervised, total duration not stated. Biofeedback 4 weeks, 3 times per week. Stretching*, proprioception training, endurance training with bicycle 1) conventional open and closed kinetic chain exercise with electromyographic feedback 2) conventional open and closed kinetic chain exercise (n=30)
Outcomes	VAS pain: baseline, 1, 2, 3 months 1) 7.5 ±1.6, 4.3 ±1.4, 2.2 ±1.8, 1.2 ±0.6 2) 7.3 ±1.5, 3.7 ±1.7, 2.0 ±1.2, 0.7 ±1.1 FIQ: baseline, 1, 2, 3 months 1) 8.3 ±1.8, 12.0 ±1.7, 13.4 ±2.0, 15.1 ±1.4 2) 7.9 ±1.8, 12.8 ±2.0, 14.3 ±1.5, 15.2 ±1.2
Notes	No drop outs
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

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Gaffney 1992

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Methods	RCT Randomisation method not specified Low quality: Delphi score 3
Participants	PFPS/chondromalacia, 50% bilateral Duration of complaints 40.7 months 72 patients, 65% male Age: 34 (11-65) 1) n=36 2) n=36
Interventions	Duration 6 weeks, weekly visits to check correct performance all groups, stretching retinaculum before taping 1) pain free eccentric and isometric exercise with taping (squats, steps with gradually increasing speed, height of step and weights (hand/rucksack)) 2) concentric isometric exercise (quadriceps setting, straight leg raises and knee extensions)
Outcomes	VAS pain baseline, 6 weeks: 1) 6.07, 2.86 2) 5.81, 2.64 Function grade 6 weeks: 1) improved=18, no change=4, variable=6 2) improved=15, no change=7, variable=10 Clarke's test positive baseline, 6 weeks: 1) 20 (28%), 8 (14%) 2) 28 (39%), 11 (17%) Individual's opinion of success 6 weeks: 1) 25 (89%) 2) 24 (75%)
Notes	1) 8 withdrawals 2) 4 withdrawals Descriptions: 1: too far to attend 2: another injury 2: work commitments/travel 7: unknown
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

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Gobelet 2001

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Methods	RCT Randomisation method not specified Low quality: Delphi score 1
Participants	Chondropathy, type Wyberg I or II (not III), with or without dysplasia of the patella 40 patients per group were included, analysed were following numbers: 1) n=28 2) n=40 3) n=26
Interventions	Duration 4 weeks, All groups ice application 1) at home electro stimulation of quadriceps with memory card for compliance, 4 hours a day 2) pain free isokinetic training at 30°/s and 300°/s, 3 times a week 25-30 minutes 3) proprioceptive static exercise, stretching* all structures, 3 times a week 30-45 minutes
Outcomes	Arpège function scale: baseline, 4 weeks 1) 11.1 ±3.9, 14.4 ±2.69 2) 12.8 ±3.1, 15.5 ±2.6 3) 10.8 ±3.7, 15.1 ±2.3
Notes	Drop out reasons: 10 incomplete 4 non compliance with instructions 12 stopped because of ineffectiveness of treatment.
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	D - Not used

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Harrison 1999

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Methods	RCT Random number table, application not specified Low quality: Delphi score 3
Participants	PFPS, 54% bilateral, 15% of patients limitations in activities referred from GPs and orthopaedic surgeons 112 patients, 40% male, Age: 22.2 ± 8.2 (12-35) 1) n=42 2) n=34 3) n=36
Interventions	Duration 4 weeks, All groups ice application after exercise, stretching 1) conservative home exercise: straight leg raises with progressive weights, knee extensions, education on background PFPS 2) similar program monitored by physiotherapist, education background PFPS, supervision 3 times weekly 3) exercises with patellar taping and biofeedback progressive exercises: stride standing, standing with foot supination, step downs, plié squats, wall squats, optional adductor strengthening supervision 3 times weekly, home exercise
Outcomes	VAS 3 days average of worst pain: baseline, 1, 3, 6, 12 months 1) 4.58 ±2.51, 2.96 ±2.28,2.62 ±2.95, 3.11 ±3.45, 2.01 ±3.18 2) 4.68 ±2.48, 3.60 ±2.31, 2.40 ±2.53, 2.20 ±2.58, 2.21 ±2.83 3) 4.39 ±2.39, 1.99 ±2.06, 2.93 ±2.49, 1.65 ±1.77, 1.80 ±2.83 FIQ (0 worst, 16 best score) number of patients with score 0-4, 5-8, 9-12, 13-16: 1) baseline: 0,7,15,12 1 month: 0,1,10,13 12 months: 0,3,4,12 2) baseline: 3,10,7,10 1 month: 1,5,12,8 12 months: 0,0,2,11 3) baseline: 0,6,10,14 1 month: 0,3,8,17 12 months: 0,2,4,14 PFS (0 worst -100 best): baseline, 1, 3, 6, 12 months 1) 54 ±15, 64 ±19, 65±18, 73 ±19, 75 ±17 2) 54 ±13, 58 ±16, 65 ±15, 71 ±16, 82 ±11 3) 51 ±12, 68 ±16, 68 ±16, 73 ±19, 81 ±17 Perceived change in condition at 1 month: none/worse, some improvement, significant improvement 1) 6, 14, 9, 2) 10, 13, 6 3) 2, 6, 17 Seconds of step test until pain: baseline, 1, 3, 6, 12 months 1) 106 ±110, 169 ±126, 188 ±121, 224 ±117, 211 ±123 2) 120 ±105, 154 ±117, 235 ±105, 231 ±115, 260 ±94 3) 131 ±106, 206 ±106, 235 ±95, 236 ±108, 265 ±90
Notes	In particular patients with good results at 1 month dropped out Number of patients 0, 1, 3, 6, 12 months: 1) 33 23 22 14 18 2) 31 26 20 15 13 3) 29 25 20 23 18
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

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McMullen 1990

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Methods	CCT Geographical location dictated group assignment Low quality: Delphi score 3
Participants	Chondromalacia, all unilateral, Duration of complaint: 4.07 ± 2.52 (1-8 months) 29 patients, 55% male Age: 28.12 ± 9.96 1) n=9 2) n=11 3) n=9
Interventions	Duration 4 weeks 1) waiting list control, weekly telephone contact 2) static exercise, stretching hamstrings, 12 sessions in 4 weeks 3) isokinetic exercise, 12 sessions in 4 weeks
Outcomes	CRS, overall activity level: 4 weeks 1) 10.92 2) 14.82 3) 13.86
Notes	No drop-outs
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	D - Not used

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Stiene 1996

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Methods	CCT Treatment assigned by investigator with attempts to balance for functional rating and patellar dislocation Low quality: Delphi score 1
Participants	PFPS, Sports Medicine Center 33 patients included, characteristics stated of 23 patients: 39 % male Age: 19 ± 6 1) n=11 duration symptoms 13.1 ± 12.2 months, 4 luxations 2) n=12 duration symptoms 31.9 ± 31.8 months, 3 luxations
Interventions	Duration 8 weeks Week 1: stretching only, from week 2 exercise three days per week 1) joint isolation isokinetic exercise: velocity spectrum from 180º/s to 360º/s with 30º/s increments 2) closed kinetic chain exercise: squats, lateral and retro step-ups with increasing dumbbell resistance, progression to stair-master exercise
Outcomes	Retro step repetitions until intolerance of symptomatic leg (including patients with luxations): baseline, 8, 52 weeks 1) 2.5 ±2.3, 4.3 ±1.7, 6.7 ±3.5 2) 3.2 ±2.4, 18.6 ±11.9, 27.3 ±12.5 Questionnaire (without patients with luxations): baseline, 6 months, 1 year 1) excellent 0, 0, 0 good 2, 1, 2 fair 5, 5, 4 poor 0, 1, 1 2) excellent 0, 1, 6 good 1, 4, 1 fair 6, 4, 2 poor 2, 0, 0
Notes	1) 6 drop-outs 2) 4 drop-outs due to <70% of training sessions attended
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	D - Not used

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Thomee 1997

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Methods	RCT Odd-even number treatment allocation Low quality: Delphi score 3
Participants	PFPS, 27% bilateral, 75% pain with sports, Duration: 43 ± 31.2 (6-108) months Referred by orthopaedic surgeons 40 female patients, Age: 20.2 ± 3.2 (15-28) 1) n=20 2) n=20
Interventions	Duration: 3 sessions to familiarise with training, 12 weeks training, 3 days per week during week 1 and 2, thereafter 2 days per week 1) isometric exercise 2) eccentric exercise
Outcomes	Number of patients participating in sports with/without pain: 0, 3, 12 months 1) 13/0, 3/9, 1/17 2) 17/0, 5/11, 1/17 Number of subjects experiencing pain: 0, 3, 12 months 1) Jogging 16 (80%),12 (60%), 6 (30%) Heavy loading 17 (85%), 11(55%), 5 (25%) At rest after activity 18 (90%), 7 (35%), 1 (5%) 2) Jogging 18 (90%), 9 (45%), 4 (20%) Heavy loading 17 (85%), 12 (60%), 5 (25%) At rest after activity 16 (80%), 6 (30%),1 (5%)
Notes	No drop-outs reported
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

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Timm 1998

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Methods	RCT Odd-even number treatment allocation Low quality: Delphi score 3
Participants	PFPS, all unilateral, duration: 12.5 ± 5 weeks (5-19) Referred from orthopaedic surgeons 100 patients, 60% male Age: 30 ± 6 (24 - 44) 1) n=50 2) n=50
Interventions	4 weeks duration, daily use of Protonics® device 1) Protonics® device: high volume submaximal concentric contractions of quadriceps and hamstrings 2) no treatment
Outcomes	VAS pain: baseline, 4 weeks 1) 6.50 ±1.07, 3.54 ±0.97 2) 6.54 ±0.97, 6.74 ±1.05 KPFS: baseline, 4 weeks 1) 41.72 ±4.21, 86.76 ±6.65 2) 41.42 ±3.87, 41.20 ±3.95
Notes	No drop-outs reported
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

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Wijnen 1996

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Methods	RCT Randomisation by independent person in blocks of 4 persons, prestratified for gender and duration of symptoms (< or < 1 year) High quality: Delphi score 6
Participants	PFPS, Duration: 32 (4 - 96) Orthopaedic outpatient clinic 18 patients, 28% male Age: 22 (16-37) 1) n=7 2) n=8
Interventions	Duration 6 weeks: group 1 group 2 home exercise intensity not specified 1) McConnell regimen with individual exercise program. 12 sessions twice weekly and twice daily home training 2) Coumans bandage with standard home exercise schedule
Outcomes	11-point pain scale walking stairs, mean (min-max): baseline, 6 weeks 1) 6.3 (1-10), 4.4 (1-7) 2) 5.3 (0-8), 4.1 (0-9) 11-point pain scale sitting with knees bent, mean (min-max): baseline, 6 weeks 1) 6.3 (1-10), 1.9 (0-6) 2) 5.3 (0-8), 4.3 (0-10) 11-point pain scale squatting, mean (min-max): baseline, 6 weeks 1) 6.3 (1-10), 5.1 (0-10) 2) 5.3 (0-8), 6.0 (0-10) KPFS: baseline, 6 weeks 1) 58.3 (28-84), 84 (60-96) 2) 64.6 (39-84), 74.1 (43-89) Ranawat function score: baseline, 6 weeks 1) 74.4 (38-97), 95 (81-100) 2) 79.0 (58-97), 85.3 (58-100) 11-point scale patient satisfaction with therapy: 6 weeks 1) 7.6 (6-9) 2) 4.3 (0-9) 11-point scale patient satisfaction with recovery: 6 weeks 1) 6.1 (4-9) 2) 3.4 (0-8)
Notes	Drop-outs 1) 1 patient did not show up, 1 patient found quadriceps contraction too painful 2) 1 patient could not tolerate Coumans bandage
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Witvrouw 2000

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Methods	RCT Randomisation using sealed envelopes High quality: Delphi score 6
Participants	PFPS, 45% bilateral, duration: 15.1 (0.5 - 28) months Physical therapy department of hospital 60 patients Age: 20.3 (14-33), 1) n=30 2) n=30
Interventions	Duration: 5 weeks, three days per week 1) open kinetic chain exercise: maximal static quadriceps muscle contractions in full extension, straight leg raises in supine position, short arc terminal knee extensions, leg adductions in lateral decubitus position 2) closed kinetic chain exercise: seated leg presses, one-third knee bends on one and both legs, stationary bicycling, rowing-machine exercises, step-up and step-down, progressive jumping
Outcomes	VAS pain during daily activity: baseline, 5 weeks, 3 months 1) 5.4 ±2.2, 3.7 ±1.6, 3.9 ±1.5 2) 5.5 ±2.3, 4.0 ±1.6, 3.0 ±1.0 VAS pain during triple jump test: baseline, 5 weeks, 3 months 1) 2.5 ±7, 1.4 ±4, 0.9 ±2 2) 2.4 ±6, 1.3 ±4, 1.0 ±3 KPFS: baseline, 5 weeks, 3 months 1) 68 ±35, 83 ±37, 87 ±40 2) 68 ±34, 80 ±37, 84 ±39 N without symptoms during functional tests: Unilateral squat: baseline, 5 weeks, 3 months 1) 6 (20%), 11 (37%), 16 (53%) 2) 6 (20%), 13 (43%), 17 (57%) Step-up: baseline, 5 weeks, 3 months 1) 11 (37%), 23 (77%), 22 (73%) 2) 8 (27%), 18 (60%), 22 (73%) Step-down: baseline, 5 weeks, 3 months 1) 8 (27%), 19 (63%), 23 (77%) 2) 5 (17%), 12 (40%), 20 (67%)
Notes	No drop-outs
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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 *stretching exercises usually focus on knee flexors and extensors and iliotibial band, sometimes patellar retinaculum
ABBREVIATIONS AND ACRONYMS
AKP: anterior knee pain
PFPS: patellofemoral pain syndrome
GP: General Practitioner
RCT: randomised controlled trial
CCT: concurrent controlled trial
VAS: visual analogue scale
WOMAC: osteoarthritis index, measuring pain, disability and stiffness of the knee or hip
FIQ: functional index questionnaire
KPFS: Kujala patellofemoral function scale
CRS: Cincinnati rating scale

 

Characteristics of excluded studies [ordered by study ID]

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Study	Reason for exclusion
Beetsma 1996	Publication was not full text article, contact with third author did not yield data.
Eburne 1996	Description of results insufficient.
Kowall 1996	The contrast between both exercising treatment groups existed of taping of the patella, which is not the aim of this review.
Roush 2000	Number of patients with plica syndrome, Osgood Schlatter and tendinitis not mentioned, no subgroups reported. The results were too poorly reported.

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Comparison 1. Exercise versus no exercise

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Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

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 1 Pain, continuous data

2

Mean Difference (IV, Random, 95% CI)

Totals not selected

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1.1 VAS: 1 month

1

Mean Difference (IV, Random, 95% CI)

Not estimable

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1.2 VAS: 3 months

1

Mean Difference (IV, Random, 95% CI)

Not estimable

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1.3 VAS: 12 months

1

Mean Difference (IV, Random, 95% CI)

Not estimable

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 2 Function, continuous data

3

Mean Difference (IV, Random, 95% CI)

Totals not selected

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2.1 Cincinnatti overall activity level: 1 month, static exercise versus no exercise

1

Mean Difference (IV, Random, 95% CI)

Not estimable

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2.2 Cincinnatti overall activity level: 1 month, isokinetic exercise versus no exercise

1

Mean Difference (IV, Random, 95% CI)

Not estimable

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2.3 Kujala Patellofemoral Scale: 1 month

1

Mean Difference (IV, Random, 95% CI)

Not estimable

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2.4 100 - WOMAC = inversed WOMAC scale: 3 months

1

Mean Difference (IV, Random, 95% CI)

Not estimable

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2.5 100 - WOMAC = inversed WOMAC scale: 12 months

1

Mean Difference (IV, Random, 95% CI)

Not estimable

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 3 Recovery, dichotomous data

1

Risk Ratio (M-H, Random, 95% CI)

Totals not selected

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3.1 Number of patients discharged from therapy because of patient's satisfaction, 3 months

1

Risk Ratio (M-H, Random, 95% CI)

Not estimable

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3.2 Number of patients no longer troubled by symptoms, 12 months

1

Risk Ratio (M-H, Random, 95% CI)

Not estimable

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3.3 Number of patients discontinuing therapy after 12 months

1

Risk Ratio (M-H, Random, 95% CI)

Not estimable

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Comparison 2. Closed kinetic chain versus open kinetic chain

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Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

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 1 Pain, continuous data

3

Mean Difference (IV, Random, 95% CI)

Totals not selected

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1.1 VAS: 6 weeks

1

Mean Difference (IV, Random, 95% CI)

Not estimable

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1.2 VAS walking stairs: 6 weeks

1

Mean Difference (IV, Random, 95% CI)

Not estimable

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1.3 VAS sitting with knees bent: 6 weeks

1

Mean Difference (IV, Random, 95% CI)

Not estimable

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1.4 VAS bending knees: 6 weeks

1

Mean Difference (IV, Random, 95% CI)

Not estimable

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1.5 VAS during triple jump test: 5 weeks

1

Mean Difference (IV, Random, 95% CI)

Not estimable

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1.6 VAS during daily activity: 5 weeks

1

Mean Difference (IV, Random, 95% CI)

Not estimable

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1.7 VAS during triple jump test: 3 months

1

Mean Difference (IV, Random, 95% CI)

Not estimable

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1.8 VAS during daily activity: 3 months

1

Mean Difference (IV, Random, 95% CI)

Not estimable

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 2 Pain, dichotomous data

1

Risk Ratio (M-H, Random, 95% CI)

Totals not selected

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2.1 >50% improvement: 6-8 weeks

1

Risk Ratio (M-H, Random, 95% CI)

Not estimable

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 3 Function, continuous data

3

Mean Difference (IV, Random, 95% CI)

Totals not selected

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3.1 Kujala Patellofemoral Scale: ± 6 weeks

2

Mean Difference (IV, Random, 95% CI)

Not estimable

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3.2 Kujala Patellofemoral Scale: 3 months

1

Mean Difference (IV, Random, 95% CI)

Not estimable

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3.3 Number of retro-step repetitions until painful: 8 weeks

1

Mean Difference (IV, Random, 95% CI)

Not estimable

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3.4 Number of retro-step repetitions until painful: 1 year

1

Mean Difference (IV, Random, 95% CI)

Not estimable

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 4 Function, dichotomous data

2

Risk Ratio (M-H, Random, 95% CI)

Totals not selected

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4.1 Overall assessment of function - number of patients improved: 6 weeks

1

Risk Ratio (M-H, Random, 95% CI)

Not estimable

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4.2 Asymptomatic patients in unilateral squat test: 5 weeks

1

Risk Ratio (M-H, Random, 95% CI)

Not estimable

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4.3 Asymptomatic patients in step up test: 5 weeks

1

Risk Ratio (M-H, Random, 95% CI)

Not estimable

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4.4 Asymptomatic patients in step down test: 5 weeks

1

Risk Ratio (M-H, Random, 95% CI)

Not estimable

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4.5 Asymptomatic patients in unilateral squat test: 3 months

1

Risk Ratio (M-H, Random, 95% CI)

Not estimable

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4.6 Asymptomatic patients in step up test: 3 months

1

Risk Ratio (M-H, Random, 95% CI)

Not estimable

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4.7 Asymptomatic patients in step down test: 3 months

1

Risk Ratio (M-H, Random, 95% CI)

Not estimable

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 5 Function, categorical data

Other data

No numeric data

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5.1 Function Index Questionnaire: 6 months

Other data

No numeric data

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5.2 Function Index Questionnaire: 12 months

Other data

No numeric data

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 6 Global assessment, 11-point scale, continuous data

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

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6.1 Satisfaction with therapy: 6 weeks

1

Mean Difference (IV, Random, 95% CI)

Not estimable

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6.2 Satisfaction with recovery: 6 weeks

1

Mean Difference (IV, Random, 95% CI)

Not estimable

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 7 Global assessments, dichotomous data

1

Risk Ratio (M-H, Random, 95% CI)

Totals not selected

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7.1 Treatment success: 6 weeks

1

Risk Ratio (M-H, Random, 95% CI)

Not estimable

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Analysis 2.5 Comparison 2 Closed kinetic chain versus open kinetic chain, Outcome 5 Function, categorical data.
Function, categorical data

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Study	Months	Rating	Closed kinetic chain	Open kinetic chain
Function Index Questionnaire: 6 months
Stiene 1996	6	poor (0-4) fair (5-8) good (9-12) excellent (13-16)	0 4 7 1	1 8 2 0
Stiene 1996
Function Index Questionnaire: 12 months
Stiene 1996	12	poor (0-4) fair (5-8) good (9-12) excellent (13-16)	0 2 3 7	1 6 4 0
Stiene 1996

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Table 1. Quality assessment tool

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Item	Score	Notes
D1. Was a method of randomisation performed?	2 = yes, clearly described method of randomisation 1 = unclear whether treatment allocation was truly random 0 = no, prospective study or other design without (quasi-)random assignment	Cochrane code (Clarke 2003b): Clearly yes = A; Not sure = B; Clearly no = C
M-A. (D2) Was the assigned treatment adequately concealed prior to allocation?	2 = method did not allow disclosure of assignment 1 = small but possible chance of disclosure of assignment or unclear 0 = quasi-randomised or open list/tables
M-B. (D9) Were the outcomes of patients who withdrew described and included in the analysis (intention-to-treat)?	2 = withdrawals well described and accounted for in analysis 1 = withdrawals described and analysis not possible 0 = no mention, inadequate mention or obvious differences and no adjustment
M-C. (D5) Were the outcome assessors blinded to treatment status?	2 = effective action taken to blind assessors 1 = small or moderate chance of unblinding of assessors 0 = not mentioned or not possible
M-D. (D3) Were the treatment and control group comparable at entry?	2 = good comparability of groups, or confounding adjusted for in analysis 1 = confounding small; mentioned but not adjusted for 0 = large potential for confounding, or not discussed
M-E. (D7) Were the participants blind to assignment status after allocation?	2 = effective action taken to blind participants 1 = small or moderate chance of unblinding participants 0 = not possible, or not mentioned (unless double-blind), or possible but not done
M-F. (D6) Were the treatment providers blind to assignment status after allocation?	2 = effective action taken to blind treatment providers 1 = small or moderate chance of unblinding of treatment providers 0 = not possible, or not mentioned (unless double-blind), or possible but not done
M-G. Were care programmes, other than the trial options, identical?	2 = care programmes clearly identical 1 = clear but trivial differences 0 = not mentioned or clear and important differences in care programmes
M-H. (D4) Were the inclusion and exclusion criteria clearly defined?	2 = clearly defined 1 = inadequately defined 0 = not defined
M-I. Were the interventions clearly defined?	2 = clearly defined interventions are applied with a standardised protocol 1 = clearly defined interventions are applied but the application protocol is not standardised 0 = intervention and/or application poorly or not defined
M-J. Were the outcome measures used clearly defined?	2 = clearly defined 1 = inadequately defined 0 = not defined
M-K. Were diagnostic tests used in outcome assessment clinically useful? (by outcome)	2 = optimal 1 = adequate 0 = not defined, not adequate
M-L. Was the surveillance active and of clinically appropriate duration?	2 = active surveillance and appropriate duration (>three weeks) 1 = active surveillance, but inadequate duration (<three weeks) 0 = surveillance not active or not defined
D8. Were point estimates and measures of variability presented for the primary outcome measures?	2 = point estimates and measures of variability presented 1 = point estimates, but no measures of variability presented 0 = only vague descriptions of outcome measures presented
T. Was the compliance rate in each group unlikely to cause bias?	2 = compliance well described and accounted for in analysis 1 = compliance well described but differences between groups not accounted for in analysis 0 = compliance unclear
X. Was a predefined set of diagnostic criteria provided for the included participants?	2 = clear description of diagnosis as well as diagnostic criteria were provided, or clear diagnostic exclusion criteria were provided (e.g. 'chondromalacia', defined by the presence of lesions in patellar cartilage determined at arthroscopy) 1 = only diagnosis without criteria was provided (e.g. 'chondromalacia') and no clear diagnostic exclusion criteria were provided 0 = neither clear diagnosis nor criteria or symptoms were provided (e.g. 'anterior knee pain')

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 In this Table, items beginning with 'D' denote items from the Delphi-list, while those beginning with 'M' denote items taken from the Cochrane Bone, Joint and Muscle Trauma Group methodological quality assessment tool and 'T' denotes the item from the Maastricht-Amsterdam consensus list for Methodological Quality Assessment. In view of the diversity of diagnostic terms used for PFPS, one more item was added for scoring whether a predefined set of diagnostic criteria was provided in the study. This criterion is denoted with 'X'.

 

Table 2. Exercise versus no exercise

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Study ID	Outcome measure	Instrument	Weeks	N exercise	Change (%) or N	N no exercise	Change (%) or N	Mean diff. (95% CI)	Stat. sign.?
Clark 2000	Pain	VAS (0-100 mm)	13	32	-34.4 ±41.6 (45%)* individual changes averaged by author	39	-26.8 ±43.8 (43%)* individual changes averaged by author	-7.6 (-28 - 12.9)	no
			52	22	-39.8 (52%)* as calculated from means	27	-17.0 (21%)* as calculated from means	Not reported significance stated	yes
	Function	WOMAC	13	32	-11.7 ±12.4 (48%)* individual changes averaged by author	39	-13.4 ±14.2 (33%)* individual changes averaged by author	1.7 (-4.7 - 8.1)	no
			52	22	-9.4 (38%)* as calculated from means	27	-6.4 (21%)* as calculated from means	Not reported no significance mentioned	no
	Patient satisfaction	Discharge from therapy	13	40	39*	31	21*	OR = 1.90 (1.41 - 2.58) NNT=3(1.6-3.3)	yes
	Recovery	No longer troubled	52	22	9	27	5	OR = 2.21 (0.87 - 5.64)	no
	Recovery	Discontinuing therapy	52	22	18	27	19	OR = 1.16 (0.85 - 1.59)	no
McMullen 1990	Pain	VAS (0-10 cm)	4		"No change"		"No change"		no
	Function	Overall activity level (CRS) static vs control)	4	11	Medium effect size	9	Small effect size		yes
		Isokinetic vs control	4	9	Medium effect size				yes
Timm 1998	Pain	VAS (0-10 cm)	4	50	-2.96 (47%)*	50	+0.20 (0.03%)	-3.16	yes
	Function	KPFS	4	50	+45.04 (108%)*	50	-0.22 (0.01%)	45.26	yes
* = significant change from baseline NS = not significant = significant difference between therapies		VAS=Visual Analog Scale KPFS=Kujala Patellofemoral Function Scale CRS=Cincinnatti Rating Scale					RR=Relative Risk NNT=Number needed to treat

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Table 3. Open versus closed kinetic chain exercise

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Study ID	Outcome	Instrument	Weeks	N open chain	Change (%)	N closed chain	Change (%)	Mean diff. (95% CI)	Stat. sign.?
Witvrouw 2000	Pain	VAS (0-100 mm) triple jump test	5	30	-11.5 (-46%)*	30	-11.0 (-46%)*	0.5	no
			13	30	-16.1 (-64%)*	30	-13.3 (-56%)*	2.8	no
		VAS (0-100 mm) daily activity	5	30	-17.0 (-31%)*	30	-15.0 (-27%)*	2	no
			13	30	-15.0 (-28%)*	30	-25.0 (-45%)*	-10	no
	Function	KPFS	5	30	+12 (18%)*	30	+15 (22%)*	3	no
			13	30	+16 (24%)*	30	+19 (28%)*	3	no
		N asymptomatic unilateral squat	5	30	+5 (83%)*	30	+7 (117%)*	RR = 1.52 (0.41 - 5.62)	no
			13	30	+10 (167%)*	30	+11 (183%)*	RR = 1.16 (0.39 - 3.42)	no
		N asymptomatic step up	5	30	+12 (109%)*	30	+10 (125%)*	RR = 0.75 (0.26 - 2.20)	no
			13	30	+11 (100%)*	30	+14 (175%)*	RR = 1.51 (0.53 - 4.33)	no
		N asymptomatic step down	5	30	+11 (138%)*	30	+7 (140%)*	RR = 0.53 (0.17 - 1.66)	no
			13	30	+15 (188%)*	30	+15 (300%)*	RR = 1.00 (0.36 - 2.81)	no
Wijnen 1996	Pain	VAS (0-10) walking stairs	6	7	-1.2 (-23%)	8	-1.9 (-30%)	0.3 (-2.66 - 3.26)	no
		VAS (0-10) sitting with knees bent	6	7	-0.5 (-10%)	8	-2.7 (-59%)	-2.4 (-10.6 - 5.84)	no
		VAS (0-10) squatting	6	7	+0.4 (7%)	8	-2.6 (-34%)	-0.9 (-2.30 - 0.50)	no
	Function	KPFS	6	7	+9.5 (15%)	8	+25.7 (44%)	9.9 (-2.32 - 22.12)	no
		Ranawat scale	6	7	+6.3 (8%)	8	+20.6 (28%)	9.7 (-3.72 - 23.12)	no
	Satisfaction	VAS (0-10) with therapy	6	7	4.3	8	7.6	3.3 (0.32 - 6.28)	yes?
		VAS (0-10) with recovery	6	7	3.4	8	6.1	2.7 (0.24 - 5.46)	no
Stiene 1996	Function	Retro-step repetitions	8	12	+1.8 (72%)	11	+15.4 (481%)*	13.6	yes
			52	12	+4.2 (168%)	11	+24.1 (753%)*	19.9	yes
Gaffney 1992	Pain	VAS (0-10)	6	?	-3.17 (55%)*	?	-3.21 (53%)*	0.04	no
	Function	N improved	6	32	15 (47%)*	28	18 (64%)*	RR = 1.37 (0.87 - 2.17)	no
	Satisfaction	N treatment succes	6	32	24 (75%)*	28	25 (89%)*	RR = 1.19 (0.94 - 1.51)	no
Colòn 1988	Pain	N improved > 50%	6-8	11	9 (82%)*	14	13 (93%)*	RR = 1.13 (0.83 - 1.55)	no
* = significant change from baseline NS = not significant = significant difference between therapies		VAS=Visual Analog Scale KPFS=Kujala Patellofemoral Function Scale

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