A Thermographic Investigation of Patellofemoral Problems

1
A Thermographic Investigation of Patellofemoral
Problems

• Natalie Hardaker, BSc (Hons), Research Assistant,
  Department of Allied Health Professions,
  University of Central Lancashire,
• Dr James Selfe, PhD, Department of Allied Health
  Professions, University of Central Lancashire
• Sue Greenhalgh, Consultant Physiotherapist,
  Bolton Primary Care Trust, Lever Chambers, Bolton

2
Background

• Patellofemoral pain syndrome commonly treated
  with exercise based treatment program based on
  McConnell technique (McConnell 1986)
• Some patients fail to respond to this
  intervention
• Although biomechanically appealing, the
  malalignment theory has failed to explain the
  presence of anterior knee pain in many patients
  (Scott Dye 1999)
• Why??

3
Background

• There is some evidence of circulatory disruption
  in Patellofemoral Pain Syndrome (PFPS) (Arnoldi,
  1991 and Sanchis-Alfonso Rosello-Sastre 2000)
• The role of vascular damage or insufficiency in
  PFPS has not been studied extensively, (Harrison
  Magee 2001)
• PFPS symptoms may be attributable to vascular
  disturbance

4
Main components of the rete patellae
Supreme Genicular artery
Lateral Superior Genicular artery
Medial Superior Genicular artery
Lateral Inferior Genicular artery
Medial Inferior Genicular artery
Anterior Tibial Recurrent Artery
5
Clinical Data

• Sandow Goodfellow (1985)
• - study sample of 54 adolescent girls
• - 9/54 (16.7) had pain that was aggravated by
  cold weather
• Price et al (2000)
• - study sample of 46 chronic, traumatic AKP
  patients
• - 28/ 46 (61) had pain aggravated by cold
  weather

6
Selfe et al 2003

• Clinical study to identify PFPS patients with
  cold knees
• N77
• Do your legs feel cold even in warm
  surroundings?
• 14/77 (18) of patients were classed as cold
  sufferers
• Worse scores on 4 outcome measures
• At 3 month review following discharge, no
  significant improvement with exercise based
  physiotherapy intervention

7
Background

• Vascular disruption leads to local hypothermia
  (Ben-Eliyahu 1992)
• Few clinical studies have investigated this
  phenomenon.
• Cold group need to be accurately clinically
  identified in order that patients receive
  appropriate treatment
• This study seeks to identify and define cold
  sub-group
• Local hypothermia may be observed through
  infrared thermography (Ben-Eliyahu 1992)

8
Normal Thermography

• The lower limb shows substantial regional
  variation in temperature
• The coldest part is consistently the centre of
  the patella which may be up to 3 degrees cooler
  than the thigh

9
Methods

• N23, patients recruited from Bolton PCT and
  Bolton Hospitals NHS Trust orthopaedic
  outpatients
• Written informed consent was gained
• No prior consumption of metabolic stimulants,
  exercise or cigarettes
• 15 minute Acclimatisation period

10
Methods

• Anatomical Marker System (AMS) applied to skin
  surface for subsequent thermal data analysis

11
Thermal Washout Technique (Karki et al. 2004)

• Cryo/cuff (Aircast)
• 30mm/Hg at 40cm
• Cuff allowed to fill for 1min
• Left in place for a further 3 min

12
Methods

• Other measures taken
• - Modfied Functional Index Questionnaire
  (MFIQ)
• - Body Fat Percentage (BF)
• - Patella Skin fold

13
Results

• Room temperature was 23.41.5 ºC

14
Results
15
(No Transcript)
16
Discussion

• MFIQ 10 questions asked relating to how lower
  limb problem is impacting on daily life
• MFIQ Valid clinical outcome measure in PFPS
  (Selfe et al 2001)
• Change in score of 10 is clinically significant
  (Selfe et al 2001)

17
Discussion

• Previously, Selfe et al (2003) MFIQ scores
• -Normal mean score 33
• -Cold mean 40
• MFIQ scores
• -Difference statistically NS (pgt.05)
• -Difference clinically NS

18
Discussion

• Present study MFIQ scores
• -Normal 28
• -Cold 40
• MFIQ scores
• -NS difference pgt.05
• -Clinically significant
• MFIQ scores of 40 or more may be a useful
  clinical indicator when identifying cold patients

19
Discussion

• Interesting to find no significant difference
  between cold normal BF
• Yet, significant difference (p.029)between
  patella skinfold measurements
• Normal patients demonstrating significantly
  higher skinfold compared to cold

20
Discussion

• Adipose tissue acts an effective insulator (Kane
  Sternheim 1988)
• Thicker skinfold, greater insulation!
• Relatively low adiposity may contribute to
  symptoms experienced by the cold group
• Potentially serving as a useful clinical measure
  in identifying these patients

21
Discussion

• Baseline temperature statistically ns between
  cold normal groups
• T20 rewarming - normal group demonstrated
  significantly higher SST than the cold group
• Highlighting slower recovery to baseline in the
  cold group
• Indicates a decreased flow of heat into the local
  area

22
Discussion

• Baseline temperature differences ns (p 0.123)
• Cold group 28.11.0ºC
• Normal group 29.11.2ºC
• Difference of 1.0ºC
• Clinical relevance?

23
Discussion
24
Conclusion/Clinical Relevance

• Objective clinical indicators
• Patella Skinfold of 5mm
• MFIQ score 40
• Contralateral temperature differences of 0.5ºC
  in unilateral cases

25
Conclusion/Clinical Relevance

• Clinically indicative subjective questions
• Do your knees feel cold even in warm
  surroundings?
• Is your pain aggravated by cold weather?
• Do you use an electric blanket even in summer?

26
Conclusion/Clinical Relevance

• Collectively these measures contribute to
  clinical reasoning when classifying/identifying
  cold patients
• May also be useful to determine a local baseline
  temperature critical to the cold group
• Work is ongoing..

27
References

• Dye, S. F., Staubli, H. U., Biedert, R. M.,
  Vaupel, G. L. (1999) "The mosaic of
  pathophysiology causing patellofemoral pain
  Therapeutic implications", Operative Techniques
  in Sports Medicine, 7(2) 46-54.
• Harrison, E. Magee, D. 2001, "Patellofemoral
  pain syndrome The ongoing challenges in
  etiology, diagnosis and managment", Critical
  Reviews in Physical and Rehabilitation Medicine,
  13(23) 105-129.
• Karki, A., Karppi, P., Ekberg, J., Selfe, J.
  (2004) "A thermographic investigation of skin
  temperature changes in response to a thermal
  washout of the knee in healthy young adults",
  Thermology International, 14(4) 137-141.
• Price, AJ et al (2000) Chronic traumatic
  anterior knee pain Injury International Journal
  of the care of the injured 31 373-378
• McConnell, J (1986), The Management of
  Chondromalacia Patellae A Long Term Solution
  Australian Journal of Physiotherapy 32(14) 215 -
  223
• Sandow, M. J. Goodfellow, J. (1985) "The
  natural history of anterior knee pain in
  adolescents", J.Bone Joint Surg.Br., 67 36-38.
• Selfe, J, Harper, L, Pedersen, I, Breen-Turner, J
  Waring, J. (2001), Four outcome measures for
  patellofemoral joint problems part 1 development
  and validity Physiotherapy 87 (10) 507515.
• Selfe, J, Harper, L, Pedersen, I, Breen-Turner, J
  Waring, J. (2001), Four outcome measures for
  patellofemoral joint problems part 2 reliability
  and clinical sensitivity Physiotherapy 87 (10)
  516522
• Selfe, J, Harper, L, Pedersen, I, Breen-Turner, J
  Waring, J Stevens, D (2003) Cold legs a
  potential indicator of negative outcome in the
  rehabilitation of patients with patellofemoral
  pain syndrome The Knee 10 (2) 139-143
• Selfe, J., Karki, A., Stevens, D. A review of
  the role of circulatory deficit in the genesis of
  patellofmoral pain Physical Therapy Reviews 7,
  169-172. 2002.

28

• THANKYOU
• QUESTIONS?