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Eccentric Exercise in the Treatment of Midportion Achilles Tendinopathy; A Systematic Review Fashler, Danielle 2011

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Hayley Carter Nikki Christopher Danielle Fashler Ryan Hill Christine Reid Drew Teskey  Background Information and Research Questions  Chronic pain in the Achilles tendon  Aggravated with loading activities  Tenderness on palpation  Often “thickening” of the tendon  ↓ participation in sport, ADLs  Up to 18% of all injuries seen in runners  9% of elite runners are affected  Not JUST athletes...  31% of AT study participants are sedentary  INTRINSIC  Overpronation hindfoot  Varus forefoot  Quads and Gastroc weakness  Advanced age  Obesity EXTRINSIC  Training errors  Poor movement techniques  Poor footwear  Running on hard/uneven surfaces    Interaction between intrinsic & extrinsic factors: Failed healing response?  Neovasculature and nerve proliferation ↓ neovessels ↓ pain Scott, A., (2010) Ultrasound Shock-wave therapy Corticosteroid injections Surgery   NSAIDs  Eccentric Exercise Conservative approach Low-cost No equipment Self-management Effective Is eccentric exercise more effective than other physical therapy treatments at reducing pain in adults with chronic Achilles tendinopathy? Is eccentric exercise more effective than other physical therapy treatments at improving function and patient satisfaction in adults with chronic Achilles tendinopathy? Search Strategy, Selection Criteria and Quality Assessment   Example: EMBASE  1) Randomized control trial 2) Human participants, mean age 18-65, with chronic (≥ 3 months) mid-portion AT 3) Participants with no other past or present Achilles tendon pathology or other significant L/E pathology 4) Experimental group underwent eccentric heel drop exercise protocol lasting ≥ 6 weeks 5) Included outcome measures of pain, function (ROM, strength, or functional scales), patient satisfaction, or return to activity 1) Not available in full text 2) Not available in English 3) Retrospective or non-original studies 4) In-vitro studies 5) Animal subjects 6) Comparison group included an eccentric protocol   Sackett’s Level of Evidence & PEDro Scores: Study Sackett’ s Level of Evidenc e PEDro criteria* PEDr o score (/11) 1 2 3 4 5 6 7 8 9 10 11 Chester II (n=16) √ √ √ X X X √ X X √ √ 6 Herringto n II (n=25) √ √ X √ X X √ √ √ √ X 7 Mafi II (n=44) √ √ √ √ X X X √ X √ √ 7 Peterson I (n=72) √ √ √ √ X X X √ √ √ √ 8 Rompe I (n=75) √ √ √ √ X X √ √ √ √ √ 9 PEDro criteria: 1 – Eligibility criteria  2 – Random allocation  3 – Concealed allocation  4 – Baseline comparability  5 – Subject blinding 6 – Therapist blinding  7 – Assessor blinding  8 – > 85% follow-up for at least one outcome  9 – Intention-to-treat analysis 10 – Between-group comparisons  11 – Point measures and variability reported √ - Criterion met  X – Criterion not met or not specified Description of Review Findings  Insufficient homogeneity for meta- analysis 1. Different comparatorsStudy Comparison Group(s) Chester et al. (2007) Ultrasound Herrington & McCulloch (2007) Standard Care (ultrasound, deep friction massage and stretching) Mafi et al. (2000) Concentric Exercise Petersen et al. (2007) AirHeel Brace Rompe et al. (2007) 1) Wait-and-See 2) Shockwave Therapy Results 2. Different outcome measures ▪ (VAS, VISA-A, Load-induced pain, Pain threshold, TOP) ▪ (FILLA, AOFAS, VISA-A) ▪ (EuroQol, SF-36, Likert scale, “Yes/No”) Pain Functio n Patient Satisfaction *VAS scores at rest, during walking, and/or during sport. **Load-induced pain, pain threshold, and tenderness on palpation. ***Effects of AHB significantly greater than EE Comparison Outcome Measure Eccentrics better? EE vs. Ultrasound VAS* No      (all) EE vs. AirHeel Brace VAS Yes     (rest; P<0.001) No***  (walking) No      (sport) EE vs. Concentric Exercise VAS Yes     (walking;              P<0.001) EE vs. Shockwave Author designed** No EE vs. Wait and See Author designed Yes    (P<0.001) Comparison Outcome Measure Eccentrics Better? EE vs. Ultrasound FILLA No EE vs. AirHeel Brace AOFAS No EE vs. Shockwave Therapy VISA-A No EE vs. Standard Care VISA-A Yes (P = 0.014) EE vs. Wait-and- See VISA-A Yes (P < 0.001) Comparison Outcome Measure Eccentrics Better? EE vs. Ultrasound EuroQol No EE vs. AirHeel Brace SF-36 Return to Sport No No EE vs. Shockwave Therapy Likert Scale No EE vs. Concentric Exercise Return to Sport Yes (P = 0.002) EE vs. Wait-and-See Likert Scale Yes (P < 0.001) Comparison Outcome Measure Eccentrics better? EE vs. Ultrasound VAS* No   (all) EE vs. AirHeel Brace VAS Yes   (rest; P<0.001) No#  (walking) No    (sport) EE vs. Concentric Exercise VAS Yes   (walking; P<0.001) EE vs. Shockwave Author designed** No EE vs. Wait and See Author designed Yes    (P<0.001) Comparison Outcome Measure Eccentrics Better? EE vs. Ultrasound FILLA No EE vs. AirHeel Brace AOFAS No EE vs. Shockwave Therapy VISA-A No EE vs. Standard Care VISA-A Yes (P = 0.014) EE vs. Wait-and-See VISA-A Yes (P < 0.001) Comparison Outcome Measure Eccentrics Better? EE vs. Ultrasound EuroQol No EE vs. AirHeel Brace SF-36 Return to Sport No No EE vs. Shockwave Therapy Likert Scale No EE vs. Concentric Exercise Return to Sport Yes (P = 0.002) EE vs. Wait-and-See Likert Scale Yes (P < 0.001) PA IN SA TI SF AC TI O N FU NC TI O N Comparison Outcome Measure Eccentrics better? EE vs. Ultrasound VAS* No   (all) EE vs. AirHeel Brace VAS Yes   (rest; P<0.001) No#  (walking) No    (sport) EE vs. Concentric Exercise VAS Yes   (walking; P<0.001) EE vs. Shockwave Author designed** No EE vs. Wait and See Author designed Yes    (P<0.001) Comparison Outcome Measure Eccentrics Better? EE vs. Ultrasound FILLA No EE vs. AirHeel Brace AOFAS No EE vs. Shockwave Therapy VISA-A No EE vs. Standard Care VISA-A Yes (P = 0.014) EE vs. Wait-and-See VISA-A Yes (P < 0.001) Comparison Outcome Measure Eccentrics Better? EE vs. Ultrasound EuroQol No EE vs. AirHeel Brace SF-36 Return to Sport No No EE vs. Shockwave Therapy Likert Scale No EE vs. Concentric Exercise Return to Sport Yes (P = 0.002) EE vs. Wait-and-See Likert Scale Yes (P < 0.001) PA IN SA TI SF AC TI O N FU NC TI O N Comparison Outcome Measure Eccentrics better? EE vs. Ultrasound VAS* No   (all) EE vs. AirHeel Brace VAS Yes   (rest; P<0.001) No#  (walking) No    (sport) EE vs. Concentric Exercise VAS Yes   (walking; P<0.001) EE vs. Shockwave Author designed** No EE vs. Wait and See Author designed Yes    (P<0.001) Comparison Outcome Measure Eccentrics Better? EE vs. Ultrasound FILLA No EE vs. AirHeel Brace AOFAS No EE vs. Shockwave Therapy VISA-A No EE vs. Standard Care VISA-A Yes (P = 0.014) EE vs. Wait-and-See VISA-A Yes (P < 0.001) Comparison Outcome Measure Eccentrics Better? EE vs. Ultrasound EuroQol No EE vs. AirHeel Brace SF-36 Return to Sport No No EE vs. Shockwave Therapy Likert Scale No EE vs. Concentric Exercise Return to Sport Yes (P = 0.002) EE vs. Wait-and-See Likert Scale Yes (P < 0.001) PA IN SA TI SF AC TI O N FU NC TI O N Comparison Outcome Measure Eccentrics better? EE vs. Ultrasound VAS* No   (all) EE vs. AirHeel Brace VAS Yes   (rest; P<0.001) No#  (walking) No    (sport) EE vs. Concentric Exercise VAS Yes   (walking; P<0.001) EE vs. Shockwave Author designed** No EE vs. Wait and See Author designed Yes    (P<0.001) Comparison Outcome Measure Eccentrics Better? EE vs. Ultrasound FILLA No EE vs. AirHeel Brace AOFAS No EE vs. Shockwave Therapy VISA-A No EE vs. Standard Care VISA-A Yes (P = 0.014) EE vs. Wait-and-See VISA-A Yes (P < 0.001) Comparison Outcome Measure Eccentrics Better? EE vs. Ultrasound EuroQol No EE vs. AirHeel Brace SF-36 Return to Sport No No EE vs. Shockwave Therapy Likert Scale No EE vs. Concentric Exercise Return to Sport Yes (P = 0.002) EE vs. Wait-and-See Likert Scale Yes (P < 0.001) PA IN SA TI SF AC TI O N FU NC TI O N Explanation of the Results, Study Limitations and Implications for Research & Clinicians Variability of results makes it difficult to draw firm conclusions Contributing Factors: 1. Study quality 2. Study sample characteristics 3. Intervention parameters 4. Selection of outcome measures. PEDro Scores  Subject & therapist blinding  Assessor blinding Conflict of Interest? PEDro Scores: Study Sackett’ s Level of Evidenc e PEDro criteria* PEDr o score (/11) 1 2 3 4 5 6 7 8 9 10 11 Chester II (n=16) √ √ √ X X X √ X X √ √ 6 Herringto n II (n=25) √ √ X √ X X √ √ √ √ X 7 Mafi II (n=44) √ √ √ √ X X X √ X √ √ 7 Peterson I (n=72) √ √ √ √ X X X √ √ √ √ 8 Rompe I (n=75) √ √ √ √ X X √ √ √ √ √ 9 PEDro criteria: 1 – Eligibility criteria  2 – Random allocation  3 – Concealed allocation  4 – Baseline comparability  5 – Subject blinding 6 – Therapist blinding  7 – Assessor blinding  8 – > 85% follow-up for at least one outcome  9 – Intention-to-treat analysis 10 – Between-group comparisons  11 – Point measures and variability reported √ - Criterion met  X – Criterion not met or not specified  Chester et al (2007): PEDro score = 6/11  Pilot study  Difference at baseline. ▪ Average age ▪ Average duration of symptoms ▪ Male to female ratio ▪ Greater mean functional impairment ▪ Lower incidence of existing pathologies ▪ Lower mean resting pain VAS scores ▪ Higher pain reported after sport  Average age  No relationship  Previous fitness level of participants  Apparent positive correlation between the previous fitness level and effectiveness of EE  Early studies on recreational athletes.  EE protocols require patients to push through pain to complete multiple repetitions of exercises  Patients with previous experience with exercise may…  Be more likely to adhere to an exercise program  Have better body awareness  Have a more positive attitude toward exercise  Have superior exercise form and body mechanics  Have increased experience pushing through pain and fatigue  Previously sedentary participants with no history of physical activity may…  Have to make a substantial lifestyle adjustment  Have some difficulty with skill acquisition of the exercises  Have some difficulty with adherence to an exercise program Variability between EE protocols  90 repetitions/day (Chester et al., 2007)  180 reps/day (Herrington & McCulloch, 2007; Mafi et al., 2000; Rompe et al., 2007)  270 repetitions/day (Petersen et al., 2007) Comparability of EE and comparison interventions  Unable to compare most intensities (e.g. EE vs. US)  Mafi et al. (2000); EE vs. CE 4. Outcome Measures Lowest Quality Highest Quality Pain Function FILLA AOFAS VISA-A Patient Satisfaction “Yes/No” Questionnaires EuroQol SF-36 Specific Likert Scales VAS Load-induced pain Pain threshold Tenderness on palpation   Implications for Clinicians Not a stand-alone treatment! Remember… INTRINSIC  Overpronation hindfoot  Varus forefoot  Quads and Gastroc weakness  Advanced age  Obesity EXTRINSIC  Training errors  Poor movement techniques  Poor footwear  Running on hard/uneven surfaces Take home message EE is at least as effective as other treatments Eccentric Exercise is a safe and effective treatment option for adults with chronic Achilles tendinopathy. It should be used alongside other physiotherapy interventions to ensure a holistic approach to care. Special thank you to: Dr. Teresa Liu-Ambrose Other contributors: Dr. Alex Scott Dr. Elizabeth Dean Dr. Darlene Reid Charlotte Beck Dean Giustini Abbassian, A. and Khan, R., (2009). 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