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Physical Therapy Exercise Interventions in Tendinosis Injuries Brown, Paul; Lazjerowicz, Cleo; Martin, Aislin; Phillips, Margaret; Yeates, Michelle; Li, Linda 2007

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A Systematic ReviewA Systematic ReviewBy:AislinMartinCleo LajzerowiczMichelle YeatesMaggie PhillipsPaul BrownSupervisor: Dr. Linda LiTendinopathyTendinopathyand the Effectiveness of and the Effectiveness of Eccentric ExerciseEccentric ExerciseOverviewOverview??Purpose??Introduction??Methods??Results??Discussion??Clinical Relevance??Future ResearchPurposePurposeTo systematically review the current evidence and determine the effectiveness of eccentric exercise in the treatment of chronic tendinosisIntroductionIntroductionTendinosis:??a non-inflammatory intratendinouscollagen degeneration without clinical or histological signs of inflammation1,2Common tendons affected: ??patellar, Achilles, tendons of the medial and lateral elbow, rotator cuff2IntroductionIntroductionPrevalence ??Elite male volleyball playerszz40% to 50% patellar tendinosis3??General population zzlateral epicondylitisannual incidence is between 1% -3%4,5??Competitive tennis playerszzincidence can be as high as 40%4, 5??Elite and recreational runnerszzAchilles tendinopathiesaccounts for  9% of injuries 6??Overuse injuries, including tendinopathies, account for nearly 7%of all injury related physician office visits in the United States 7IntroductionIntroductionCommon causes1:??Aging??Microtrauma??Vascular compromise Common population3-7: ??Competitive and recreational athletes ??People in occupations consisting of repetitive tasks or manual laborRecovery times with treatment1:??Early presentation: 6-10 weeks??Chronic presentation: 3-6 monthsIntroductionIntroductionHistological Findings 1,2,4,8,9???cellularity-fibroblasts and myofibroblasts???vascularityand ground substance??Collagen disorientation, disorganization, focal necrosis or calcification, vascular spaces with or without neovascularizationand fiber separation??Absence of inflammatory cellsNormalIntroductionIntroductionConservative Treatments1-8??Ultrasound??Laser??Deep friction massage??Orthoticsand braces??Corticosteroids ??Mobilizations and manipulations??Thermotherapy ??Cryotherapy??Rest ??Acupuncture ??Pulsed electromagnetic field therapy??Eccentric exerciseIntroductionIntroductionEccentric Exercise ??The active lengthening of a muscle under force10IntroductionIntroduction??Eccentric training leads to increasednet collagen synthesis in the tendon tissue through constant overload on the tendon11??12 weeks of EE training normalized tendon structure and decreased tendon thickness in Achilles tendinosis12RATIONALE ??The literature shows that eccentric exercise has promise for treatment of Achilles and patellar tendinopathiesGOAL??Review the literature to examine the effectiveness of eccentric exercise as a treatment for tendinosisIntroductionIntroductionMethodsMethodsMethods: PICOMethods: PICOPP??Patients diagnosed with a tendinopathy(eg. clinical exam   / MRI / Ultrasound / Doctor) or chronic painful tendon greater than 3 months??Adults 16 years or olderII??Eccentric exerciseCC??noneOO??Pain??ROM??Return to functional activities??Avoid surgical intervention??Strength??Tendon structure/healingMethods: Search StrategyMethods: Search StrategyDatabases ??EMBASE??CINAHL??MEDLINE??PEDro??Cochrane library??SPORTDISCUSOther Forms ??Hand searching JournalszzPhysiotherapy, Physical Therapy??Reference lists??Personal libraries??Communicating with experts in the fieldzzDoctoral candidate (Michael Ryan)Methods: Search StrategyMethods: Search Strategy??Main TermszzTendinopathy, tendinosis, tendon disease, tendon injuryzzAchilles, swimmers shoulder, patellar tendon, golfer?s elbow, rotator cuff, jumper?s kneezzEccentric exercise12Golfer??s s elbow.mp13Patella$ tend$.mp14Jumper??s s knee.mp15Achilles tend$.mp16Eccentric.mp17Exercise.mpor Exercise/18Or/ 1-151916 and 172018 and 1921Limit 20 to (human and English  language)Search TermsSearch Terms11Tend#nopathy.mpTend#nopathy.mp22Tend#nosis.mpTend#nosis.mp33Tend#nitis.mpTend#nitis.mp44Tend#nTend#ndisease.mpdisease.mp55Tend#nTend#ninjury.mpinjury.mp66SwimmerSwimmer??s s shoulder.mpshoulder.mp77Rotator cuff Rotator cuff tend$.mptend$.mp88Shoulder Shoulder injury.mpinjury.mp99Medial Medial epicondylepicondyl$ $ injury.mpinjury.mp1010Tennis elbow/or medial Tennis elbow/or medial epicondyleepicondyle$ $ injury.mpinjury.mp1111Tennis elbow/or lateral Tennis elbow/or lateral epicondyleepicondyle$ $ injury.mpinjury.mpTable of Search TermsTable of Search TermsMethods: Study SelectionMethods: Study SelectionInclusion Criteria ??16 years or older??Clinical diagnosis of tendinopathyor:??Tendon pain for > 3 months??English studies??Eccentric ExerciseExclusion Criteria ??Concurrent treatment??Surgical intervention??Tendinosiscaused by injectionMethods: Study SelectionMethods: Study SelectionStudy Selection ??Screen of title and abstracts??Selection of articles based on inclusion criteriazz2 person independent review??Recovery and review of full articleszzRandom allocation to 2 persons for independent reviewMethodsMethodsStudy Selection ??Pilot the data extraction formzzModified data extraction form provided by Dr. Linda Lizz10% of articles were tested using the form?89.6% based on 115 variableszzChanges were made to the form to increase accuracy and consistencyMethodsMethodsData extraction ??Study description??Participant description??Study quality rating (van Tulder13)??Baseline and post treatment outcome measurements??Dropouts, adverse effectsMethods: Quality of StudiesMethods: Quality of Studies??Used Van Tulder13 Quality Assessmentzz11 criteria rated: Yes, No, Unclear??Methodological criteria were independently assessed by 2 reviewers99Consensus reached by discussion??High Quality = Score of 6 of 11 or above??Low Quality = Score 5 and belowMethods: Quality of StudiesMethods: Quality of Studies??Less than 1/3 of the studies fulfilled all of the following criteria: zzadequate treatment allocation concealment, blinding of patients, and blinding of the care provider??Less than 1/2 of the studies blinded the outcome assessor to the intervention or had acceptable compliance (> 70%) in all groups.MethodsMethods??Standard mean differences: Hedge?s GzzStudies with similar outcome measures??Best evidence synthesis14zzRates studies according to whether: Strong, moderate, limited, indicative, no evidencezzUtilizes study design (RCT, CCT, other design), study quality (high/low), statistical findingsResultsResultsStudy SelectionStudy Selection201 citations16 relevant articlesDuplicatearticlesexcluded: (n = 91)Articles excluded based on title/abstract (n = 80)Articles retrieved for detailed evaluation (n = 30)Added studies based on personal libraries, checked references and hand searching:(n = 15)Excluded articles: (n=29)-Not an RCT or CCT (n=18)-Failed eligibility criteria (n=8)-No eccentric exercise intervention (n= 1)-Language (n=1)-Not found (n=1)Final selection included in systematic review: (n= 16)RCT: (n = 12)   CCT: (n = 4)Search of databases: (n =201)EMBASE  [56]Sportdiscus[48]CINHAL  [47]MEDLINE  [41]Cochrane Library RCT [13]PEDro[5]Results: Brief Summary of Included Results: Brief Summary of Included StudiesStudies??Patellar tendon N = 6zzAge range: 22-31 years??Achilles tendon N = 7zzAge range: 39-51 years??Wrist extensors N = 3zzAge range: 38-47 yearsResults: Heterogeneity of studiesResults: Heterogeneity of studies??Eccentric Exercise (EE): variety of exerciseszzsome protocols have participants exercising through moderate amounts of pain??Comparative Treatments (CT):zzConcentric exercise, night splint, stretches, shock wave therapy, TENS, US, DTFM, control??Duration of symptoms: 3-41 months??Duration of Intervention: 4-24 weeks??Number of participants: 15-124 persons ??Types of participants:zzRecreational athletes (4 studies)zzCompetitive university volleyball players (5 studies)zzGeneral populationOutcome MeasurementsOutcome MeasurementsICF ClassificationBody function and structure: zzPain and strengthActivity:zzFunctional assessments and questionnaires such as: ?Victorian Institute of Sport Assessment (VISA) ?Foot and Ankle Outcome Score (FAOS)  ?Pain free grip (PFG) ?The Disabilities of the Arm, Shoulder and Hand (DASH)  ?Grip strength,global assessments, performance measurements  Participation:zzQuality of life questionnaires and return to sport Included StudiesIncluded Studies12 RCTs3,15-24??7 studies rated as high quality (range 6-8)??5 studies rated as low quality (range 3-5)4 CCTs25-28??1study rated as high quality ( score 7)??3 studies rated as low quality (range 2-5)ResultsResults??Calculated the Standard Mean Difference (SMD) between the EE intervention and the CT* could only calculate SMD on 9 of 16 studies due to lack of data??Applied these findings to a best evidence synthesis model Results: SMD Results: SMD achillesachillesTendonTendonAuthorDesignPainSMDStrengthSMD Functional AssessmentSMD Health related QoLSMD Achilles Tendinosis Alfredsonet al. (1998)CCT1.77 iii) 0.65 Rompeet al. (2007)RCTii) EE vsCT:1.28 ii) 0.93 Rooset al. (2004)RCTi) EE vsEE + splint:    0.47 ii) EE vssplint: 0.69 Results: SMD patellar tendonResults: SMD patellar tendonAuthorDesignPainSMDStrengthSMD FunctionalAssessmentSMD Healthrelated QoLSMD Patellar Tendinosis JonssonandAlfredson(2005)RCT1.98 2.44 Purdamet al. (2004)CCT1.79 Results: SMD wrist extensorsResults: SMD wrist extensorsAuthorDesignPainSMDStrengthSMD FunctionalAssessmentSMD Healthrelated QoLSMD Wrist Extensor tendinosis Croisieret  al. (2001)                 CCT2.39ii) 1.02 iii) 2.141.04Results: Best Evidence SynthesisResults: Best Evidence SynthesisTool used to comment on the strength of the results based on:1.Statistically significant findings from the calculation of the SMD 2.The study design ( RCTsor CCTs) Best Evidence SynthesisBest Evidence SynthesisLimited Evidence ??Statistically significant findings in outcome measures in at least one high quality RCT, OR ??Consistent statistically significant findings in outcome measures in at least two high quality CCTsIndicative Findings ??Statistically significant findings in outcome and/or process measures in at least one high quality CCT or low quality RCTNo Evidence ??Results of eligible studies do not meet the criteria for one of the above stated level of evidence, OR??In the case of conflicting results among RCTsand CCTsTable adapted from Steultjenset al. 2002 Achilles Limited evidencefor the effectiveness of EE interventions on functional ability Limited evidencefor the effectiveness of EE interventions on increasing health-related quality of life when compared to a ?wait and see?control groupNo evidenceto support the effectiveness of EE on decreasing pain or on increasing strength when compared to CT ?due to conflicting findingsResults: Best Evidence SynthesisResults: Best Evidence SynthesisResults: Best Evidence SynthesisResults: Best Evidence SynthesisPatella Indicative findingsfor the effectiveness of EE interventions on pain outcomes over other CTs. Indicative findingsfor the effectiveness of EE interventions on functional ability versus CTs. No evidencewas found for the effectiveness of EE interventions on strength when compared to CTs.Results: Best Evidence SynthesisResults: Best Evidence SynthesisWrist extensors Indicative findingsthat EE interventions are effective for improving the patient?s quality of life over other CTs. No evidencefor the effectiveness of EE interventions on decreasing pain or increasing strength when compared against CTs(due to conflicting findings)DiscussionDiscussionGeneral LimitationsStudy designzzIntervening variables:?EE with concentric component(2 studies) ?Treatment & control treatment groups share co-treatments(4 studies)zzPoor control of intervention:?Monitoring adherence, controlling progressionzzUnderpowered:?12/16 studieswith sample populations < 50 ?Inability to conduct meta-analysis or sub group analysis due to heterogeneityzzLack of true controls?Use control treatments for comparison so does not examine absolute effectiveness of EE. Limits findings to effectiveness of EE versus alternative treatment.zzOutcome measures?Non-validated and non-standardized preventing comparisons & weakening findingsGeneral Limitations??Study Quality Shortcomings(van Tuldercriteria13)zzDescription of randomizationzzConcealment of treatment allocationzzBlinding outcome assessorszzIntention to treat analysis??Reportingzz7 out of 16 studies excluded from best evidence synthesis due to lack of data??Generalizabilityzz8 out of 16 studies use young, elite athletesEccentric Exercise: What is an optimal Protocol???Differences of opinion persist as to optimal exercise intervention??9 out of 16 studies use intervention based on Alfredsonprotocol (Alfredson1998) 2525zz2 x/day zz7days/week zz3 x 15 reps zz12 week interventionzzExercise with pain (VAS score varies)zzProgression with added weightEccentric Protocol??Alfredsonmodel is based on clinical experience and lacks a scientific basis29??Croisieret al. (2007) found good results in a well controlled study training subjects 3 x/ weekversus 7 x/week??They argue that an optimal prescriptioninvolves periods of rest to allow for recovery from post   exercise weaknessEccentric Protocol: How much pain???Alfredsonet al. (1998) suggest that pain is an essential componentof their successful intervention in AT??Curwinand Stanish(1984) achieve good results with a painless protocolin PT and LET3,17,28??For LET, researchers argue against training into pain claiming that it may have a negative impacton patient complianceand provoke injury21,28Clinical Relevance??Overall, the studies demonstrate a positive trend in favourof EE??Clinicians must consider whether the subjects studied are representative of their patient population andwhether the EE intervention is realistic, particularly when considering prescribedloads, frequencyand intensityof painwith exerciseFuture Research Design??Better research design??Consistent/validatedOutcome Measures??LargersampleszzAllow subgroup analysis to uncover the impacts of factors such as age, sex, activity, biomechanical faults, and duration or severity of symptoms??Post treatmentassessmentszzTo determine long-term impactFuture Research Topics??Improve understanding of physiological effect of EE on the muscle tendon unit& whether this varies by tendon??Optimal EE intervention??Impact of intrinsic & extrinsic factorson occurrence of tendinosiszzIntrinsic (e.g. age, gender, biomechanics, genetics) zzExtrinsic factors (e.g. environment, physical load, training errors)??Improved understanding of thepathophysiologyof tendinosisacross tendonsConclusion??This review demonstrates a lack of well designed high quality studiesproviding limited evidenceto support the clinical effectiveness of EE over other conservative treatments in the rehabilitation of tendinosis.AcknowledgementsAcknowledgementsA great BIGThanks to Dr. Linda Li and Charlotte Beck for their helpwith this projectQuestions?Questions?ReferencesReferences1.Khan K, Cook J., Bonar F, Harcourt P, AstromM. Histopathology of common tendinopathies: update and implications for clinical management. Sports Med 1999;27:393-408.2.Scott A, Ashe M. Common tendinopathiesin the upper and lower extremities. CurrSports Med Rep 2006;5(5):233-241.3.Young M, Cook J. Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathyin volleyball players. Br Sports Med. 2005; 39: 102-105.4.Sharma P, MaffulliN. Current concepts review, tendon injury and tendinopathy: healing and repair. J Bone Joint SurgAm 2005;87:187-202.5.SmidtN, AssendelfJ. Effectiveness of physiotherapy for later epicondylitis: a systematic review. Annals of Medicine. 2003; 35: 51-62.6.SatyendraL, BylN. Effectiveness of physical therapy for Achilles tendinopathy: An evidence based review of eccentric exercises. Isokineticsand Exercise Science. 2006; 14: 71-80. 7.Wilson J, Best T. Common overuse tendon Problems: A review and recommendations for treatment. American Family Physician. 2005;72, no 5. 8.Rees J, Wilson A, Wolman R. Current concepts in the management of tendon disorders. Rheumatology 2006;45(5):508-521.9.PudduG, IppolitoE, PostacchiniF. A classification of Achilles tendon disease. Am J Sports Med1976;4:145-150.10.LieberR editor. Skeletal muscle structure, function, and plasticity: the physiological basis of rehabilitation. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2002.11.Langberg H, Ellingsgaard H, Madsen T, Jansson J, Magnusson S, Aagaard P, et al. Eccentric rehabilitation exercise increases peritendinoustype I collagen synthesis in humans with Achilles tendinosis. Scand J Med SciSports 2007;17:61-66. 12.?hbergL, LorentzonR, AlfredsonH. Eccentric training in patients with chronic Achilles tendinosis: normalisedtendon structure and decreased thickness at follow up. Br J Sports Med 2004;38:8-11.13.van TulderM, FurlanA, Bombardier C. Updated method guidelines for systematic reviews in the Cochrane collaboration back review group. Spine 2003;28:1290-1299.14.SteultjensE, Dekker J, BouterL, van SchaardenburgD, van KuykM, van den EndeC. Occupational therapy for rheumatoid arthritis: A systematic review. Arthritis Care Res 2002;47(6):672-685. 15.NorregaardJ, Larsen C, BielerT, LangbergH. Eccentric exercise in treatment of Achilles les tendinopathy. Scand J Med SciSports 2007;17(2):133-138.16.RoosE, EngstromM, LagerquistA, SoderbergB. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy-a randomized trial with 1-year follow-up. Scand J Med SciSports 2004;14(5):286-29517.CannellL, Taunton J, Clement D, Smith C, Khan K. A randomisedclinical trial of the efficacy of drop squats or leg extension/leg curl exercises to treat clinically diagnosed jumper's knee in athletes: pilot study. Br J Sports Med 2001;35(1):60-64.18.SilbernagelK, ThomeeP, KarlssonJ. Eccentric overload training for patients with chronic Achilles tendon pain--a randomisedcontrolled study with reliability testing of the evaluation methods. Scand J Med SciSports 2001;11(4):197-206.19.VisnesH, HoksrudA, Cook J, Bahr R. No effect of eccentric training on jumper's knee in volleyball players during the competitive season: A randomized clinical trial. ical trial. ClinJ Sport Med 2005;15(4):225-232.20.Stasinopoulos D, Stasinopoulos I. Comparison of effects of exercise programme, pulsed ultrasound and transverse friction in the treatment of chronic patellar tendinopathy. ClinRehabil2004;18(4):347-352.21.Martinez-SilvestriniJ, Newcomer K, Gay R, Schaefer M, KortebeinP, Arendt K. Chronic lateral epicondylitis: comparative effectiveness of a home exercise program includingstretching alone versus stretching supplemented with eccentric or concentric strengthening. J Hand Ther2005;18(4):411.22.RompeJ, NafeB, FuriaJ, MaffulliN. Eccentric Loading, Shock-Wave Treatment, or a Wait-and-See Policy for Tendinopathyof the Main Body of in Body of TendoAchillis: A Randomized Controlled Trial. Am J Sports Med 2007;35(3):374-383.23.Bahr R, FossanB, LokenS, EngebretsenL. Surgical treatment compared with eccentric training for patellar tendinopathy(jumper's knee): A randomized, controlled trial. J Bone Joint SurgAm Vol2006;88(8):1689-1698.24.MafiN, LorentzonR, AlfredsonH. Superior short-term results with eccentric calf muscle term results with eccentric calf muscle training compared to concentric training in a randomized prospectraining compared to concentric training in a randomized prospective multicenterstudy on patients with chronic Achilles tendinosis. Knee SurgSports TraumatolArthrosc2001;9(1):42-47.25.AlfredsonH, PietilaT, JonssonP, LorentzonR. Heavy-load eccentric calf muscle training for load eccentric calf muscle training for the treatment of chronic achillestendinosis. Am J Sports Med 1998;26(3):360-366.26.PurdamC, JohnssonP, AlfredsonH, LoretnzonR, Cook J, Khan K. A pilot study of the eccentric decline squat in the management of painful chronic patellar tendinopathy. Br J Sports Med 2004;38(4):395-397.27.SvernlovB, AdolfssonL. Non-operative treatment regime including eccentric training for lateral humeral epicondylalgia. Scand J Med SciSports 2001;11(6):328-33428.CroisierJ, Foidart-DessalleM, TinantF, CrielaardJ, ForthommeB. An isokineticeccentric programmefor the management of chronic lateral epicondylartendinopathy. Br J Sports Med 2007 April 1;41(4):269-275.29.Woodley B, Newsham-West R, Baxter G. Chronic Tendinopathy: Effectiveness of Eccentric Exercise. Br J Sports Med 2006;4(41):188-198.

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