Online-delivered education, exercise and anti-inflammatory eating program to people with patellofemoral pain: A single-arm feasibility trial

The intervention will be delivered online through 1:1 consultation led by a licensed Physiotherapist and a licensed Dietitian. After the individual consultations, participants will gain access to online platforms to support their education, exercise and dietary plan. Education and exercise therapy Participants will attend a 60-minute online consultation (Zoom®) with a Physiotherapist. This 1:1 consultation will include a patient-centred history and information focused on the benign nature of patellofemoral pain, including the explanation of the lack of relationship between knee structural features in imaging exams or knee crepitus with clinical symptoms. Patellofemoral pain will not be referred to as an injury. The importance of actively engaging in an evidence-based exercise program and load management will be emphasised. Participants will be advised to gradually increase physical activity participation to avoid exacerbation of knee pain following the envelope of function model. Strategies to improve self-management will be discussed, and the Physiotherapist will guide the participants on how to best use the ‘My Knee Cap’ online platform for 12 weeks, including prescribing an exercise program customisable through the online platform . Physical Exercise Goals: During the 1:1 online consultation with the physiotherapist, the exercise goal will be explored, and it will be tailored accordingly to each participant’s previous exercise and sports experience personal goals. The website “My Knee Cap” has a progression of six different levels for each exercise group (CORE exercises, bridge exercises, hip exercises, quadriceps exercises). Participants will be instructed to progress according to their symptoms. The physiotherapist will provide five tips for them to self-assess their pain and progress to the next level: 1. Ideally keep pain <2/10 during your activities if possible 2. Do not exceed 5/10 pain during exercise 3. Pain should return to normal levels 60 minutes post-exercise 4. Pain should not be increased the following morning post-exercise 5. Do your physical activities based on your pain response. Participants will be instructed to perform the exercises 2-3x week, and at each day they will follow those tips to progress or regress the level of their exercise. Strategy to self-managed: Participants will be advised about load management during their exercises and during daily activities; the five tips described above also fit in the strategy to self-manage their symptoms. Exercise program prescribed: The “My Knee Cap” website will provide four groups of exercises: CORE, bridge, hip and quadriceps exercises. Participants will be instructed to progress in levels according to their symptoms. We will provide five tips for them to self-assess their pain and progress to the next level: 1. Ideally keep pain <2/10 during your activities if possible 2. Do not exceed 5/10 pain during exercise 3. Pain should return to normal levels 60 minutes post-exercise 4. Pain should not be increased the following morning post-exercise 5. Do your physical activities based on your pain response. CORE: Level 1 - Bench plank - 3 x 60 seconds - resting 60 seconds between sets Level 2 - Bench plank inclined decreased - 3 x 60 seconds - resting 60 seconds between sets Level 3 - Elbow plank - 3 x 60 seconds - resting 60 seconds between sets Level 4 - Hands plank - 3 x 60 seconds - resting 60 seconds between sets Level 5 - One-legged plank - 3 x 60 seconds - resting 60 seconds between sets Level 6 - Side plank - 3 x 60 seconds - resting 60 seconds between sets Bridge exercises: Level 1 - Two-legged bridging - 3 x 12 repetitions - resting 60 seconds between sets Level 2 - Two-legged bridging (increased speed) - 3 x 12 repetitions - resting 60 seconds between sets Level 3 - Weighted two-legged bridging - 3 x 12 repetitions - resting 60 seconds between sets Level 4 - One-legged bridging - 3 x 12 repetitions - resting 60 seconds between sets Level 5 - One-legged bridging (increased speed) - 3 x 12 repetitions - resting 60 seconds between sets Level 6 - Weighted one-legged bridging - 3 x 12 repetitions - resting 60 seconds between sets Hip exercises: Level 1 - Side leg lifts - 3 x 12 repetitions - resting 60 seconds between sets Level 2 - Side leg lifts (resisted) - 3 x 12 repetitions - resting 60 seconds between sets Level 3 - Standing leg lifts - 3 x 12 repetitions - resting 60 seconds between sets Level 4 - Standing leg lifts (hands off support) - 3 x 12 repetitions - resting 60 seconds between sets Level 5 - Standing leg lifts (gym-based machine) - 3 x 12 repetitions - resting 60 seconds between sets Level 6 - Powerful standing leg lifts - 3 x 12 repetitions - resting 60 seconds between sets Quadriceps exercises: Level 1 - Wall-sit - 3 x 60 seconds - resting 60 seconds between sets Level 2 - Wall-sit (increased depth) - 3 x 60 seconds - resting 60 seconds between sets Level 3 - Two-legged squats - 3 x 12 repetitions - resting 60 seconds between sets Level 4 - Weighted two-legged squats - 3 x 12 repetitions - resting 60 seconds between sets Level 5 - One-legged squats - 3 x 12 repetitions - resting 60 seconds between sets Level 6 - Weighted one-legged squats - 3 x 12 repetitions - resting 60 seconds between sets Monitoring the adherence will be done with weekly emails asking, “How many days did you complete your exercises last week?” ‘My Knee Cap’ has been co-designed with patients and health professionals, and tested by our research team, and provides education to people with patellofemoral pain through four main sections (i) understanding your pain, (ii) treatment options, (iii) exercise program, and (iv) patient stories. All information on the platform is provided in plain language, with multimedia resources such as infographics, animated videos, and podcasts, to facilitate engagement and understanding. Participants will be advised to complete the exercise program from the website 2-3x a week. They can access the website at any time they desire for information about the exercises program, prognosis, other types of treatments Anti-inflammatory diet Participants will attend a 60-minute online appointment (Zoom®) with an Accredited Practicing Dietitian. On this 1:1 appointment, using a shared decision-making model the Dietitian will prescrib a tailored anti-inflammatory food program considering the participants’ socioeconomic condition and personal preferences. The Dietitian will also provid a comprehensive explanation of the anti-inflammatory eating pattern and its benefits and addressed questions and/or concerns. In general, participants will be advised to follow a food program containing minimally processed foods, higher amounts of whole foods and “good” fats. Examples of whole foods (moderate amounts): lean meats, eggs, and dairy; (higher amounts): fish, fruit, vegetables, nuts, and seeds. “Good fats” will include monounsaturated fats with a favourable omega-6:omega-3 ratio, such as fish, seeds, and olive oil. Participants will be advised to limit highly-processed and refined foods, such as refined carbohydrates (pasta, bread, rice), confectionary, and processed meats. Participants will not be encouraged to follow an energy-restricted diet and were advised to eat to satiety. This food program is based on the recommendations of Cooper et al. (An anti-inflammatory diet intervention for knee osteoarthritis: a feasibility study. BMC Musculoskelet Disord 23, 47 (2022)). This appointment will be supported by a 12-week subscription to the Total Wellbeing Diet (CSIRO) online platform. In this platform, participants will be able to self-customise their anti-inflammatory food program every week and register whether they had compliance with their plan. The Dietitian will provide initial guidance on how to use the platform and assist with realistic and beneficial goal setting, including shopping and meal planning, navigating social events and eating out, and cooking tips (cooking in a budget and time constraints). Tailored food program and how the food program will be tailored: Participants will fill out a 3-day food diary prior to dietitian consultation. The dietitian will analyse the document and discuss with the participants the potential inflammatory food they may take and modify it when possible based on participant's personal preferences, food restrictions and routine.