Background
Patellofemoral Pain Syndrome (PFPS) is a well-recognised condition in athletes confounded by multifactorial causes. Literature highlighted that the overall evidence base was primarily centred on athletic/military patients with a lack of substantive guidelines. Furthermore, clinical physiotherapists reported problem areas in managing treatment options and accessing 'best practice', prompting the initiation of this study in 2009. This area has continued to be problematic for applied physiotherapy practice with initial developments only starting to emerge in 2012.
Aims
The thesis focused on the exploration of issues surrounding implementation of evidence in practice, critically appraising the utility of current approaches in assessment, management and treatment of PFPS by physiotherapy practitioners. As a consequence it sought to understand the complex area of applied physiotherapy practice in PFPS in order to identify areas for improvement and remedial strategies for implementing best practice.
Methods
The thesis adopted a mixed methods approach, including the framing of the thesis phases as a series of case studies that explored different dimensions of applied physiotherapy practice in PFPS. The 7 phases included a scoping review of reviews, reporting the current evidence base; an applied PFPS review, reporting the current physiotherapy clinical practice as well as a utility review of measures and metrics in practice, reporting the reliability and criterion validity of the physiotherapy tools in practice. Additional phases involved an evaluation of
tools and the usefulness of their outcome measures; practitioner context practitioner role reporting the effectiveness of the applied physiotherapy treatment and finally modelling across cases leading to the development of an explanatory theoretical framework.
Findings
A systematic review of reviews undertaken highlighted that most of the literature had used athletic/military populations whilst the most prevalent causes of PFPS were weakness and shortening of a variety of muscles. However, there was no evidence whether these findings were applicable to PFPS patients referred to district NHS physiotherapy departments. The overall thesis reported 'poor bridging' between evidence and clinical practice with a lack of evidence being applied in practice. In response, physiotherapists modified their approaches,
detaching themselves from evidence and 'surfacing' of knowledge about PFPS focused on athletic patient. The thesis identified the key contexts that influence applied physiotherapy practice and developed an explanatory PFPS model. It consisted of interrelated core elements focused on practitioner, patient, evidence and organisational contexts. Implementation required a context and facilitation orientated approach focused on adopting PARIHS as a framework.
Discussion
The original contribution of the thesis builds upon the empirical development of a PFPS model and highlights the key contexts that influence applied physiotherapy practice in the NHS. This thesis identified the complexity of implementation, requiring facilitation that involves 'bridging' between PFPS applied physiotherapy, the evidence base and guidelines. It is important that new evidence addresses the dissonance apparent in the key contexts that influence PFPS physiotherapy practice and focuses on implementation using frameworks that provide a synthesis between individual, organisational and wider context to support applied physiotherapy practice in PFPS.