GSS cIRcle Open Scholar Award (UBCV Non-Thesis Graduate Work)

Pain-enduring Eccentric Exercise for the Treatment of Chronic Achilles Tendinopathy Dixon, Claire; Holloway, Laureen; Lee, Teresa; Lo, Nick; Meier, Janice; Reid, Darlene 2006-10-05

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Pain Enduring Eccentric Exercise Pain Enduring Eccentric Exercise for the Treatment of Chronic for the Treatment of Chronic Achilles Achilles TendinopathyTendinopathyClaire DixonLaureenHollowayJanice MeierNick LoTeresa LeeSupervisors:   W Darlene Reid Ph.D. & SunitaMathurPh.D.OutlineOutline????IntroductionIntroduction????MethodsMethods????ResultsResults????DiscussionDiscussion????Recent ResearchRecent ResearchWhy we chose this topicWhy we chose this topic????Increased interest in pain enduring Increased interest in pain enduring eccentric exercise as a focus of treatment eccentric exercise as a focus of treatment for chronic Achilles for chronic Achilles tendinopathytendinopathy????Closer examination of the literature Closer examination of the literature needed due to ethical concerns of pushing needed due to ethical concerns of pushing patients through painpatients through pain????Update on current body of knowledge and Update on current body of knowledge and consensus on treatment  consensus on treatment  Introduction to the TopicIntroduction to the TopicAchilles Achilles TendinopathyTendinopathy((TendinosisTendinosis, Partial Rupture, , Partial Rupture, TendinitisTendinitis))BackgroundBackground????One of the most common injuries in One of the most common injuries in runners and other sports participants runners and other sports participants (Kvist, 1994); also seen in sedentary individuals ; also seen in sedentary individuals (Afredson& Lorentzon, 2000)????Risk factors, but no definitively known Risk factors, but no definitively known etiologyetiologyPredisposing factorsPredisposing factors????Weak plantar flexors, larger inversion Weak plantar flexors, larger inversion angle on touchdown, overangle on touchdown, over--pronationpronation(McCroryet al., 1999)????Decreased Decreased dorsiflexiondorsiflexionrange range (Kaufmann et al., (Kaufmann et al., 1999)1999)????Increase in level of activity Increase in level of activity (Cook et al., 2002)(Cook et al., 2002)????RunningRunning--inconsistent stretching, many inconsistent stretching, many years of running years of running (McCroryet al., 1999)????Poor footwear Poor footwear (Hess et al., 1989)(Hess et al., 1989)PathologyPathology????Irregular tendon structure with collagen Irregular tendon structure with collagen degeneration and increased degeneration and increased glycosaminoglycansglycosaminoglycans(Alfredson& Lorentzon, 2003)????NeovascularizationNeovascularizationin area, with increase in area, with increase in glutamate and lactate levels in glutamate and lactate levels (Ohberg& Alfredson, 2004)????No inflammatory cells No inflammatory cells (Ohberg& Alfredson, 2004)Signs and SymptomsSigns and Symptoms????Mild or severe painMild or severe pain????Tenderness on palpation, nodule?Tenderness on palpation, nodule?????Decreased strength Decreased strength ????Decreased range of movementDecreased range of movement????Decreased functionDecreased function????Pain may be gradual or more sudden; Pain may be gradual or more sudden; most often associated w/tendon loadingmost often associated w/tendon loadingConventional treatmentsConventional treatments????Joint and soft tissue Joint and soft tissue mobilizationsmobilizations????Concentric exercisesConcentric exercises????Stretching exercisesStretching exercises????UltrasoundUltrasound????Ice Ice ????IontophoresisIontophoresis????LaserLaser????Friction massageFriction massage????SplintingSplinting????OrthoticsOrthotics????NSAIDsNSAIDs????CorticosteroidsCorticosteroids????Activity modificationActivity modification????RestRest????Surgery Surgery Pivotal ArticlePivotal Article????Increased interest in 1998 with Increased interest in 1998 with AlfredsonAlfredsonet alet al??s study out of Swedens study out of Sweden????Initiated a series of studiesInitiated a series of studiesMethodsMethodsChronic Achilles Chronic Achilles TendinosisTendinosisOperational definitionOperational definition????ChronicChronic--greater greater than 3 monthsthan 3 months????Degenerative Degenerative changes 2changes 2--7cm 7cm above the above the calcanealcalcanealtendontendonLiterature SearchLiterature Search????Electronic databases, reference lists, Electronic databases, reference lists, experts in the field, hand searches, gray experts in the field, hand searches, gray literature searchesliterature searches????Results:Results:??4 4 RCTRCT??ss??4 Cohorts4 Cohorts????Not a lot of information, relatively new Not a lot of information, relatively new topictopicArticle SelectionArticle Selection259 articles found initially259 articles found initiallyXX154 not Achilles154 not AchillesXX32 not primary research32 not primary researchXX21 not eccentric intervention21 not eccentric interventionXX20 inappropriate outcome measures 20 inappropriate outcome measures XX15 surgical patients15 surgical patientsXX3 did not push through pain3 did not push through painXX2 subjects not human2 subjects not humanXX2 in a language other than English2 in a language other than EnglishXX2 same study, different journal!2 same study, different journal!8 appropriate articles8 appropriate articlesQuality Assessment and Quality Assessment and Levels of EvidenceLevels of Evidence????Adapted Adapted MegensMegensand Harris Scaleand Harris Scale??Scores of <5 were Scores of <5 were ??WeakWeak????Scores of 5, 6, 7 were Scores of 5, 6, 7 were ??ModerateModerate????Scores of 8, 9, 10 were Scores of 8, 9, 10 were ??StrongStrong??????SackettSackett??ssLevels of EvidenceLevels of Evidence??1 to 5 scale1 to 5 scaleResultsResultsSubjectsSubjects????Age: Range 19Age: Range 19--77 yrs, average 47 yrs77 yrs, average 47 yrs????Sex: average ratio of M:F  21:10Sex: average ratio of M:F  21:10????Location:Location:?mid-portion 7/8 papers?mixed mid and insertional1/8 papers????Duration of Symptoms:Duration of Symptoms:?Average 16.4 months????Activity levels:Activity levels:?Wide variety but all appeared to be active prior to  injuryMethod of DiagnosisMethod of Diagnosis????Clinical exam and Clinical exam and ultrasonographyultrasonography?5/8 studies????Clinical exam and MRIClinical exam and MRI?1/8 studies????Clinical exam aloneClinical exam alone?2/8 studiesInterventionIntervention????AlfredsonAlfredsonet al 1998 et al 1998 eccentric protocol:eccentric protocol:?3 sets of 15 reps  eccentric heel drops  2x/day, 7days/week  for 12 weeks?Work through non-disabling pain?Progressively add  weightInterventionIntervention????6/8 studies used the 6/8 studies used the AlfredsonAlfredsoneccentric eccentric protocolprotocol????1/8 used a variation of the 1/8 used a variation of the AlfredsonAlfredsonprotocolprotocol??gradually increased reps to reduce soreness gradually increased reps to reduce soreness ????1/8 used a 12 week series of primarily1/8 used a 12 week series of primarilyeccentriceccentricexercisesexercises??ControlControl??GroupsGroups????Conventional Treatments:Conventional Treatments:?Surgery?Pain free concentric exercises?Pain free stretching?Night splint?Night splint with eccentric exercises????Others:Others:?Insertionaltendinopathies?Contralateraltendon????No control!No control!Outcome MeasuresOutcome Measures????Pain outcome measures:Pain outcome measures:?VAS?Questionnaires?Subjective expression of pain????Function outcome measures:Function outcome measures:?Ability to return to pre-injury activity?Jumping height?Plantar flexion ROM at the ankle?Calf muscle strength?Global assessmentResults: PainResults: Pain????At 12 weeks:At 12 weeks:??In 5/8 studies pain was significantly improved In 5/8 studies pain was significantly improved by an average of 42% by an average of 42% ??In 2/8 studies a significant difference was not In 2/8 studies a significant difference was not apparent at 12 weeks, but was apparent at 6 apparent at 12 weeks, but was apparent at 6 weeks, 6 months and 1 yearweeks, 6 months and 1 year??In 1/8 studies pain was only qualitatively In 1/8 studies pain was only qualitatively recorded; after an average of 3.8 years it did recorded; after an average of 3.8 years it did not interfere with subjectsnot interfere with subjects??prepre--injury activities injury activities Results: PainResults: Pain????In 5/8 studies improvements were seen in In 5/8 studies improvements were seen in both the eccentric and control groupsboth the eccentric and control groups????Results were on average 34% better in Results were on average 34% better in the eccentric groupsthe eccentric groups????2/8 studies showed no difference between 2/8 studies showed no difference between the groups; both of these studies involved the groups; both of these studies involved stretching in the control groupstretching in the control groupResults: FunctionResults: Function????At 12 weeks function improved an average At 12 weeks function improved an average of 42% from baseline in the eccentric of 42% from baseline in the eccentric groupsgroups????The control groups also improved an The control groups also improved an average of 33% from baselineaverage of 33% from baselineQuality Assessment & Levels of Quality Assessment & Levels of EvidenceEvidenceQuality     Levels of EvidenceAlfredsonet al 1998            4/10                4Mafiet al 2001                  3.5/10              2bSilbernagelet al 2001         10/10              2bFahlstromet al 2003          3.5/10              4Ohberget al 2004             3.5/10              4Rooset al. 2004                8.5/10              2b Shalabiet al. 2004            3.5/10               4Norregaardet al 2006         8/10                2bQuality Assessment & Levels of Quality Assessment & Levels of EvidenceEvidence????SackettSackett??ssLevels of EvidenceLevels of Evidence??4 low quality 4 low quality RCTsRCTs(Level 2b)(Level 2b)??4 prospective cohort studies (Level 4)4 prospective cohort studies (Level 4)??100% 100% interraterinterrateragreementagreement????Adapted Adapted MegensMegensand Harris Scaleand Harris Scale??3 studies considered strong3 studies considered strong??5 studies considered weak5 studies considered weak??Average score of all 8 studies was 5.56/10Average score of all 8 studies was 5.56/10??100% 100% interraterinterrateragreement agreement DiscussionDiscussionGeneral Critique General Critique ????Most studies NOT randomized, controlled Most studies NOT randomized, controlled or blinded or blinded --relatively low quality relatively low quality ????Many studies out of the same centersMany studies out of the same centers????Varying methods of diagnosisVarying methods of diagnosis????Variety of Variety of ??controlcontrol??groupsgroups????Variety of outcome measures usedVariety of outcome measures usedDiscussion pointsDiscussion points????MidMid--portion vs. insertional portion vs. insertional tendinopathytendinopathy?In 2/8 studies, eccentric exercise  protocol LESS effective on insertional  tendinopathy?Why? ?More studies needed to confirmDiscussion pointsDiscussion points????Disproportionately higher number of men Disproportionately higher number of men to womento women????Is conventional treatment significantly less Is conventional treatment significantly less effective? What about stretching?effective? What about stretching?????Ethical responsibility?Ethical responsibility?ConclusionsConclusions????Shift towards heavyShift towards heavy--load load eccentric exercise as a eccentric exercise as a therapeutic interventiontherapeutic intervention????The evidence base on the whole The evidence base on the whole is persuasiveis persuasive????Suggesting that pain enduring Suggesting that pain enduring eccentric exercise is superior to eccentric exercise is superior to conventional treatmentsconventional treatmentsClinical RecommendationsClinical Recommendations????Initial conservative, nonInitial conservative, non--surgical surgical treatment recommendedtreatment recommended????As it stands evidence is not strong enough As it stands evidence is not strong enough to ethically allow us, as practitioners, to to ethically allow us, as practitioners, to encourage patients to push through painencourage patients to push through painUpdateUpdate????SayanaSayana& & MaffuliMaffuli, 2006, 2006????Determine effectiveness of eccentric Determine effectiveness of eccentric exercise protocol for nonexercise protocol for non--athletic patients athletic patients with with achillesachillestendinosistendinosis????Prospective study, 34 patientsProspective study, 34 patientsUpdateUpdate????LangbergLangberget al, 2006et al, 2006????Proposed mechanism for why heavy load Proposed mechanism for why heavy load eccentric exercise is effectiveeccentric exercise is effective????Suggest link between collagen metabolism Suggest link between collagen metabolism and recovery from tendon injuryand recovery from tendon injuryNew ResearchNew Research????VISAVISA--A questionnaire as outcome measure A questionnaire as outcome measure (Victorian Institute of Sports Assessment (Victorian Institute of Sports Assessment ??Achilles)Achilles)????Reliable and validReliable and valid????Available in Swedish and EnglishAvailable in Swedish and English????Can be used in research, and clinicallyCan be used in research, and clinicallyReferencesReferences????KvistKvistM. Achilles tendon injuries in athletes. Sports Med 1994;18:173M. Achilles tendon injuries in athletes. Sports Med 1994;18:173--201. ????Cook JL, Khan KM, Cook JL, Khan KM, PurdamPurdamC. Achilles C. Achilles tendinopathytendinopathy. Man Ther2002;7:121-130.????AlfredsonAlfredsonH, H, LorentzonLorentzonR. Chronic R. Chronic achillesachillestendinosistendinosis: Recommendations for : Recommendations for treatment and prevention. Sports Med 2000;29:135treatment and prevention. Sports Med 2000;29:135--146.????MaffulliMaffulliN, N, KaderKaderD. D. TendinopathyTendinopathyof of tendotendoachillisachillis. J Bone Joint . J Bone Joint SurgSurgBr 2002;84:1Br 2002;84:1--8. ????McCroryMcCroryJL, Martin DF, Lowery RB. Etiologic factors associated with JL, Martin DF, Lowery RB. Etiologic factors associated with achillesachillestendinitistendinitisin runners. Med in runners. Med SciSciSports Exerc1999;31:1374-1381.????Kaufman KR, Kaufman KR, BrodineBrodineSK, Shaffer RA, et al. 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