The goal of this single-arm pilot study is to examine the feasibility, acceptability, and preliminary efficacy of a progressive outdoor mindful physical activity intervention delivered via the Headspace mobile application for individuals with patellofemoral pain.

AIM 1: Determine the feasibility and acceptability of the mindful activity intervention.

AIM 2: Determine the preliminary efficacy of the mindful running intervention to improve the primary outcome of (2a) anterior knee pain, and secondary outcomes of (2b) kinesiophobia and (2c) running cadence and vertical forces (gait kinematics) in individuals with PFP.

Our central hypothesis is that the intervention will be feasible and acceptable and will improve pain, kinesiophobia (injury-related fear), and running cadence (steps per minute) in individuals with patellofemoral pain.

Participants will complete a three-phase progressive mindful physical activity intervention that involves:

Phase 1: Introduction to mindfulness Phase 2: Guided mindful running Phase 3: Mindful running.

One in four Americans suffer from chronic knee pain, leading to inactivity, poor health outcomes, and psychological distress. Patellofemoral pain (PFP) is the leading cause of knee pain in the United States and is not a self-limiting condition, meaning intervention is necessary to resolve or improve symptoms. Even with interventions to target biomechanics and strength, most young adults (40-90%) report unfavorable persistent symptoms 1-20 years after PFP diagnosis, significantly impacting long-term quality of life.

Psychological distress is a central feature of PFP that may impact physical activity engagement, symptoms, and long-term health outcomes. Injury-related fear (i.e., fear of pain, painful movement, reinjury) is a common form of psychological distress in individuals with PFP and is associated with pain and disability. Higher levels of fear are also associated with reduced step rate (i.e., cadence), a key biomechanical variable linked to increased load and injury risk. Walking and running are primary modes of physical activity in both the general population and high performing athletes, often the first step in return to activity plans, and key behaviors in a healthy lifestyle.

Despite the known negative consequences of kinesiophobia, few studies have examined psychologically focused interventions for individuals with PFP. Mindfulness, the ability to stay fully present without judgement, has been used to address chronic pain and kinesiophobia in this population. However, no studies have examined how integrating mindfulness during physical activity, when patients are most likely to experience pain and fear, can improve outcomes.

This study will investigate the 1) feasibility and acceptability and 2) preliminary efficacy of a progressive and technology based mindful physical activity intervention to reduce knee pain/disability, reduce pain-related fear, and increase running cadence in adults with patellofemoral pain.

Patients will complete a three phase progressive mindful physical activity using the Headspace mobile application including 1) Introduction to mindfulness: listening to the Headspace Pain Management Course at home (ten 10 minute sessions), 2) Guided mindful running: three runs on separate days (12, 15, and 20 minutes respectively) listening to guided running audio scripts from Headspace, and 3) Mindful running: three runs on separate days (12, 15, and 20 minutes respectively) with no audio input, integrating learned mindfulness and pain management skills.

Inclusion Criteria:

• 18 years old or older
• Have access to an electronic mobile device that can be used to download the Headspace application
• Meet the established diagnostic criteria for patellofemoral pain: pain in/around the anterior knee, and reproduction of this pain with movements that load the patellofemoral joint (i.e., squatting, stair climbing or descent, running, or jumping) based on self-report

Exclusion Criteria:

• History of other musculoskeletal injuries in the past 6 months
• Previous lower extremity musculoskeletal surgery in the past 12 months
• Neuromuscular conditions that may affect movement,
• Currently pregnant
• Unable to attend in person study visits
• Unable or unwilling to run for up to 20 minutes

The proposed research will include data from all patients regardless of successful completion of the proposed experimental protocol. The final dataset will include demographic information, self-reported knee pain/function, pain-related fear, and mindfulness questionnaires, and raw biomechanics data. Accompanying the data, a documentation file will be provided containing the methodological procedures used during the collection of the data and providing a key for all variables included within the final dataset. Prior to sharing this data, all personal identifying information will be removed to protect the rights and privacy of the participants.

Deidentified individual data that supports the results will be shared beginning 9 and continuing for 36 months following publication.

IPD will only be shared provided the investigator who proposes to use the data has approval from an Institutional Review Board (IRB), Independent Ethics Committee (IEC), or Research Ethics Board (REB), as applicable, and executes a data use/sharing agreement with UNC.