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Eccentric Exercise in the Treatment of Midportion Achilles Tendinopathy; A Systematic Review Fashler, Danielle; Christopher, Nikki; Ried, Christine; Carter, Hayley; Teskey, Drew; Hill, Ryan 2010

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Hayley CarterNikki ChristopherDanielle FashlerRyan HillChristine ReidDrew TeskeyBackground Information and Research QuestionsChronic pain in the Achilles tendonAggravated with loading activities Tenderness on palpationOften “thickening” of the tendon↓ participation in sport, ADLsUp to 18% of all injuries seen in runners9% of elite runners are affectedNot JUST athletes...31% of AT study participants are sedentary INTRINSICOverpronation hindfootVarus forefootQuads and Gastroc weaknessAdvanced ageObesityEXTRINSICTraining errorsPoor movement techniquesPoor footwearRunning on hard/uneven surfaces   Interaction between intrinsic & extrinsic factors:Failed healing response?Neovasculature and nerve proliferation↓ neovessels↓ painScott, A., (2010)UltrasoundShock-wave therapyCorticosteroid injectionsSurgery NSAIDs Eccentric ExerciseConservative approachLow-costNo equipmentSelf-managementEffectiveIs 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: EMBASERandomized control trialHuman participants, mean age 18-65, with chronic (≥ 3 months) mid-portion ATParticipants with no other past or present Achilles tendon pathology or other significant L/E pathology Experimental group underwent eccentric heel drop exercise protocol lasting ≥ 6 weeksIncluded outcome measures of pain, function (ROM, strength, or functional scales), patient satisfaction, or return to activity Not available in full textNot available in EnglishRetrospective or non-original studiesIn-vitro studiesAnimal subjectsComparison group included an eccentric protocolSackett’s Level of Evidence & PEDro Scores:StudySackett’s Level of EvidencePEDro criteria*PEDro score (/11)1234567891011ChesterII (n=16)XXXXX6HerringtonII (n=25)XXXX7MafiII (n=44)XXXX7PetersonI (n=72)XXX8RompeI (n=75)XX9PEDro 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 specifiedDescription of Review FindingsInsufficient homogeneity for meta-analysisDifferent comparatorsStudyComparison Group(s)Chester et al. (2007)UltrasoundHerrington & McCulloch (2007)Standard Care (ultrasound, deep friction massage and stretching)Mafi et al. (2000)Concentric ExercisePetersen et al. (2007)AirHeel Brace Rompe et al. (2007)1) Wait-and-See2) Shockwave TherapyResults	2. Different outcome measures			(VAS, VISA-A, Load-induced pain, Pain threshold, TOP)(FILLA, AOFAS, VISA-A)	(EuroQol, SF-36, Likert scale, “Yes/No”)PainFunctionPatient 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 EEComparisonOutcome MeasureEccentrics better?EE vs. UltrasoundVAS*No      (all)EE vs. AirHeel BraceVASYes     (rest; P<0.001)No***  (walking)No      (sport)EE vs. Concentric ExerciseVASYes     (walking;                      P<0.001)EE vs. Shockwave Author designed**NoEE vs. Wait and SeeAuthor designedYes    (P<0.001)ComparisonOutcome MeasureEccentrics Better?EE vs. UltrasoundFILLANoEE vs. AirHeel BraceAOFASNoEE vs. Shockwave TherapyVISA-ANoEE vs. Standard CareVISA-AYes (P = 0.014)EE vs. Wait-and-SeeVISA-AYes (P < 0.001)ComparisonOutcome MeasureEccentrics Better?EE vs. UltrasoundEuroQolNoEE vs. AirHeel BraceSF-36Return to SportNoNoEE vs. Shockwave TherapyLikert ScaleNoEE vs. Concentric ExerciseReturn to SportYes (P = 0.002)EE vs. Wait-and-SeeLikert ScaleYes (P < 0.001)ComparisonOutcome MeasureEccentrics better?EE vs. UltrasoundVAS*No   (all)EE vs. AirHeel BraceVASYes   (rest; P<0.001)No#  (walking)No    (sport)EE vs. Concentric ExerciseVASYes   (walking; P<0.001)EE vs. Shockwave Author designed**NoEE vs. Wait and SeeAuthor designedYes    (P<0.001)ComparisonOutcome MeasureEccentrics Better?EE vs. UltrasoundFILLANoEE vs. AirHeel BraceAOFASNoEE vs. Shockwave TherapyVISA-ANoEE vs. Standard CareVISA-AYes (P = 0.014)EE vs. Wait-and-SeeVISA-AYes (P < 0.001)ComparisonOutcome MeasureEccentrics Better?EE vs. UltrasoundEuroQolNoEE vs. AirHeel BraceSF-36Return to SportNoNoEE vs. Shockwave TherapyLikert ScaleNoEE vs. Concentric ExerciseReturn to SportYes (P = 0.002)EE vs. Wait-and-SeeLikert ScaleYes (P < 0.001)PAINSATISFACTIONFUNCTIONComparisonOutcome MeasureEccentrics better?EE vs. UltrasoundVAS*No   (all)EE vs. AirHeel BraceVASYes   (rest; P<0.001)No#  (walking)No    (sport)EE vs. Concentric ExerciseVASYes   (walking; P<0.001)EE vs. Shockwave Author designed**NoEE vs. Wait and SeeAuthor designedYes    (P<0.001)ComparisonOutcome MeasureEccentrics Better?EE vs. UltrasoundFILLANoEE vs. AirHeel BraceAOFASNoEE vs. Shockwave TherapyVISA-ANoEE vs. Standard CareVISA-AYes (P = 0.014)EE vs. Wait-and-SeeVISA-AYes (P < 0.001)ComparisonOutcome MeasureEccentrics Better?EE vs. UltrasoundEuroQolNoEE vs. AirHeel BraceSF-36Return to SportNoNoEE vs. Shockwave TherapyLikert ScaleNoEE vs. Concentric ExerciseReturn to SportYes (P = 0.002)EE vs. Wait-and-SeeLikert ScaleYes (P < 0.001)PAINSATISFACTIONFUNCTIONComparisonOutcome MeasureEccentrics better?EE vs. UltrasoundVAS*No   (all)EE vs. AirHeel BraceVASYes   (rest; P<0.001)No#  (walking)No    (sport)EE vs. Concentric ExerciseVASYes   (walking; P<0.001)EE vs. Shockwave Author designed**NoEE vs. Wait and SeeAuthor designedYes    (P<0.001)ComparisonOutcome MeasureEccentrics Better?EE vs. UltrasoundFILLANoEE vs. AirHeel BraceAOFASNoEE vs. Shockwave TherapyVISA-ANoEE vs. Standard CareVISA-AYes (P = 0.014)EE vs. Wait-and-SeeVISA-AYes (P < 0.001)ComparisonOutcome MeasureEccentrics Better?EE vs. UltrasoundEuroQolNoEE vs. AirHeel BraceSF-36Return to SportNoNoEE vs. Shockwave TherapyLikert ScaleNoEE vs. Concentric ExerciseReturn to SportYes (P = 0.002)EE vs. Wait-and-SeeLikert ScaleYes (P < 0.001)PAINSATISFACTIONFUNCTIONComparisonOutcome MeasureEccentrics better?EE vs. UltrasoundVAS*No   (all)EE vs. AirHeel BraceVASYes   (rest; P<0.001)No#  (walking)No    (sport)EE vs. Concentric ExerciseVASYes   (walking; P<0.001)EE vs. Shockwave Author designed**NoEE vs. Wait and SeeAuthor designedYes    (P<0.001)ComparisonOutcome MeasureEccentrics Better?EE vs. UltrasoundFILLANoEE vs. AirHeel BraceAOFASNoEE vs. Shockwave TherapyVISA-ANoEE vs. Standard CareVISA-AYes (P = 0.014)EE vs. Wait-and-SeeVISA-AYes (P < 0.001)ComparisonOutcome MeasureEccentrics Better?EE vs. UltrasoundEuroQolNoEE vs. AirHeel BraceSF-36Return to SportNoNoEE vs. Shockwave TherapyLikert ScaleNoEE vs. Concentric ExerciseReturn to SportYes (P = 0.002)EE vs. Wait-and-SeeLikert ScaleYes (P < 0.001)PAINSATISFACTIONFUNCTIONExplanation of the Results, Study Limitations and Implications for Research & CliniciansVariability of results makes it difficult to draw firm conclusionsContributing Factors:Study quality Study sample characteristics Intervention parametersSelection of outcome measures. PEDro ScoresSubject & therapist blindingAssessor blindingConflict of Interest?PEDro Scores:StudySackett’s Level of EvidencePEDro criteria*PEDro score (/11)1234567891011ChesterII (n=16)XXXXX6HerringtonII (n=25)XXXX7MafiII (n=44)XXXX7PetersonI (n=72)XXX8RompeI (n=75)XX9PEDro 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 specifiedChester et al (2007): PEDro score = 6/11 Pilot studyDifference at baseline.Average ageAverage duration of symptomsMale to female ratioGreater mean functional impairmentLower incidence of existing pathologiesLower mean resting pain VAS scoresHigher pain reported after sportAverage ageNo relationshipPrevious fitness level of participantsApparent positive correlation between the previous fitness level and effectiveness of EEEarly studies on recreational athletes. EE protocols require patients to push through pain to complete multiple repetitions of exercisesPatients with previous experience with exercise may…Be more likely to adhere to an exercise programHave better body awarenessHave a more positive attitude toward exerciseHave superior exercise form and body mechanicsHave increased experience pushing through pain and fatiguePreviously sedentary participants with no history of physical activity may…Have to make a substantial lifestyle adjustmentHave some difficulty with skill acquisition of the exercisesHave some difficulty with adherence to an exercise programVariability between EE protocols90 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 interventionsUnable to compare most intensities (e.g. EE vs. US)Mafi et al. (2000); EE vs. CE4. Outcome MeasuresLowest QualityHighest QualityPainFunctionFILLAAOFASVISA-APatient Satisfaction“Yes/No” QuestionnairesEuroQolSF-36Specific Likert ScalesVASLoad-induced painPain thresholdTenderness on palpationImplications for CliniciansNot a stand-alone treatment!Remember…INTRINSICOverpronation hindfootVarus forefootQuads and Gastroc weaknessAdvanced ageObesityEXTRINSICTraining errorsPoor movement techniquesPoor footwearRunning on hard/uneven surfacesTake home messageEE is at least as effective as other treatmentsEccentric 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-AmbroseOther contributors:	Dr. Alex Scott	Dr. Elizabeth Dean	Dr. Darlene Reid	Charlotte Beck	Dean Giustini					Abbassian, A. and Khan, R., (2009). Achilles tendinopathy: pathology and management strategies. Br J Hosp Med, 70(9), 519-523. Alfredson, H., Pietilä, T., Jonsson, P., & Lorentzon, R. (1998). Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med, 26, 360 Alfredson, H. (2005). The chronic painful Achilles and patellar tendon: Research on basic biology and treatment. Scand J Med Sci Sports, 15, 252–259. Brazier, J. E., Jones, N. M., Kind, P. (1993). Testing the validity of the EuroQol and comparing it with the SF-36 health survey questionnaire. Quality of Life Research, 2(3), 169-180. Brooks, R. (1996). EuroQol: the current state of play. Health Policy, 37, 53–72. Chester, R., Costa, M.L., Cooper, A. & Donell, S.T. (2007). Eccentric calf muscle training compared with therapeutic ultrasound for chronic Achilles tendon pain – A pilot study. Manual Therapy. 13, 484-91. Herrington, L. & McCulloch, R. (2007). The role of eccentric training in the management of Achilles tendinopathy: A pilot study. Physical Therapy in Sport. 8, 191-6. Langberg, H., Ellingsgaard, H., Madsen, T. Jansson, J., Magnusson, S.P., Aagaard, P., & Kjær, M. (2007). Eccentric rehabilitation exercise increases peritendinous type I collagen synthesis in humans with Achilles tendinosis. Sacd J Med Sci Sports, 17, 61-6.    Mafi, N., Lorentzon, R. & Alfredson, H. (2001). Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Journal of Knee Surgery, Sports Traumatology and Arthroscopy. 9, 42-7.  Magnussen, R. A., Dunn, W. R., & Thompson, B. (2009). Nonoperative treatment of midportion Achilles tendinopathy: A systematic review. Clin J Sport Med, 19(1), 54-64.Nørregaard, J., Larsen,  C. C., Bieler, T., & Langberg, H. (2007). Eccentric exercise in treatment of Achilles tendinopathy. Scand J Med Sci Sports, 17, 133-8. Paavola, M., Orava, S., Leppilahti, J., Kannus, P., & Järvinen, M., (2000). Chronic Achilles tendon overuse injury: Complications after surgical treatment. An analysis of 432 consecutive patients. Am J Sports Med, 28, 77–82. Petersen, W., Welp, R. & Rosenbaum, D. (2007). Chronic Achilles tendinopathy: A prospective randomized control study comparing the therapeutic benefit of eccentric training, the AirHeel Brace, and a combination of both. The American Journal of Sports Medicine. 35(10), 1659-66. Rees, J., Wilson, A., & Wolman, R. (2006).  Current concepts in the management of tendon disorders. Oxford University Press, 45, 508-521.  Rees, J. D., Lichtwark, G. A., Wolman, R. L., & Wilson, A. M. (2008). The mechanism for efficacy of eccentric loading in Achilles tendon injury; an in vivo study in humans. Rheumatology, 47, 1493-7. Robinson, J. M., Cook, J. L., Purdam, C., Visentini, P. J., Ross,  J., Maffulli, et al. et al. (2001). The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. British Journal of Sports Medicine, 35, 335-341. Rompe, J.D., Nafe, B., Furia, J.P. & Maffulli, N. (2007). Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of Tendo Achillis: A randomized control trial. The American Journal of Sports Medicine.35(3), 374-83. Rompe, J. D., Furia, J. P., & Maffulli, N. (2008). Mid-portion achilles tendinopathy - current options for treatment. Disability & Rehabilitation, 30(20), 1666-76.Scott, A. (2010). Tendinopathies: Beyond the Achilles [PowerPoint slides]. Retrieved from http://www.bcphysio.org/app/index.cfm?fuseaction=membercourse.download Silbernagel, K. G., Thomee, R., Thomee, P., & Karlsson, J. (2001). Eccentric overload training for patients with chronic Achilles tendon pain – a randomized controlled study with reliability testing of the evaluation methods. Scan J Med Sci Sports, 11, 197-206. Süleyman, H., Demircan, B., & Karagöz, Y. (2007). Anti-inflammatory and side effects of cyclooxygenase inhibitors. Pharmacological Reports, 59, 247-258. Tan, S. C., & Chan, O. (2008). Achilles and patellar tendinopathy: Current understanding of pathophysiology and management. Disability & Rehabilitation, 30(20), 1608-15. Tsai, W., Hsu, C., Chou, S., Chung, C., & Chen, J. (2007). Effects of celecoxib on migration, proliferation and collagen expression of tendon cells. Connect Tissue Res, 48(1), 46-51. Verhagen, A., de Vet, H., de Bie, R., Kessels, A., Boers, M., Bouter L., & Knipschild, P. (1998). The delphi list: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by delphi consensus. Journal of Clinical Epidemiology, 51, 1235–1241. Woodley, B.L., Newsham-West, R.J., & Baxter, G.D. (2007). Chronic tendinopathy: Effectiveness of eccentric exercise. Br J Sports Med, 41, 188-199.Questions? ***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 promoting return to sport in adults with chronic Achilles tendinopathy?*Have each row come up individually????**Change to green*Mention how we’ll just look at the study that had the lowest PEDro score to explain some of the inconsistencies. *Of course Chester wasn’t the only study that had quality issues that put some of their resuts into question… but in the interest of time we’ve just discussed the most extreme example from our review.*Small sample size:	Minimum 80% power for clinically significant results	 sample size = more generalizable results2) Lack of follow up	Only 2 studies followed patients post-intervention	Would provide strong evidence for use of EE over other Rx options3) No comparable outcome measures:4) Unclear exercise parameters:	each used slightly diff parameters	this must be clarified in research*Verbalize: These are all factors that contribute to the development of the conditions and all of them need to be considered! EE does not address all of the above; especially not the extrinsic factors. The clinician should take a holistic approach to treatment, and should include education about lifestyle modifications that apply to the individual, including but not limited to footwear, training tips and weight management.*Research still needed:-Optimal exercise dose and prescription-Optimal patient populations-Impact of patient compliance and long-term outcomes-High quality studies with comparable outcome measures and data*“Despite the inconsistencies seen in the studies reviewed, it is the opinion of the authors that eccentric exercise provides an important treatment option for those with chronic, mid-portion achilles tendinopathy.   The exercise program provides a low-cost, low risk option for patient self-management of this chronic disorder”* Hayley CarterNikki ChristopherDanielle FashlerRyan HillChristine ReidDrew TeskeyBackground Information and Research QuestionsChronic pain in the Achilles tendonAggravated with loading activities Tenderness on palpationOften “thickening” of the tendon↓ participation in sport, ADLsUp to 18% of all injuries seen in runners9% of elite runners are affectedNot JUST athletes...31% of AT study participants are sedentary INTRINSICOverpronation hindfootVarus forefootQuads and Gastroc weaknessAdvanced ageObesityEXTRINSICTraining errorsPoor movement techniquesPoor footwearRunning on hard/uneven surfaces   Interaction between intrinsic & extrinsic factors:Failed healing response?Neovasculature and nerve proliferation↓ neovessels↓ painScott, A., (2010)UltrasoundShock-wave therapyCorticosteroid injectionsSurgery NSAIDs Eccentric ExerciseConservative approachLow-costNo equipmentSelf-managementEffectiveIs 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: EMBASERandomized control trialHuman participants, mean age 18-65, with chronic (≥ 3 months) mid-portion ATParticipants with no other past or present Achilles tendon pathology or other significant L/E pathology Experimental group underwent eccentric heel drop exercise protocol lasting ≥ 6 weeksIncluded outcome measures of pain, function (ROM, strength, or functional scales), patient satisfaction, or return to activity Not available in full textNot available in EnglishRetrospective or non-original studiesIn-vitro studiesAnimal subjectsComparison group included an eccentric protocolSackett’s Level of Evidence & PEDro Scores:StudySackett’s Level of EvidencePEDro criteria*PEDro score (/11)1234567891011ChesterII (n=16)XXXXX6HerringtonII (n=25)XXXX7MafiII (n=44)XXXX7PetersonI (n=72)XXX8RompeI (n=75)XX9PEDro 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 specifiedDescription of Review FindingsInsufficient homogeneity for meta-analysisDifferent comparatorsStudyComparison Group(s)Chester et al. (2007)UltrasoundHerrington & McCulloch (2007)Standard Care (ultrasound, deep friction massage and stretching)Mafi et al. (2000)Concentric ExercisePetersen et al. (2007)AirHeel Brace Rompe et al. (2007)1) Wait-and-See2) Shockwave TherapyResults	2. Different outcome measures			(VAS, VISA-A, Load-induced pain, Pain threshold, TOP)(FILLA, AOFAS, VISA-A)	(EuroQol, SF-36, Likert scale, “Yes/No”)PainFunctionPatient 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 EEComparisonOutcome MeasureEccentrics better?EE vs. UltrasoundVAS*No      (all)EE vs. AirHeel BraceVASYes     (rest; P<0.001)No***  (walking)No      (sport)EE vs. Concentric ExerciseVASYes     (walking;                      P<0.001)EE vs. Shockwave Author designed**NoEE vs. Wait and SeeAuthor designedYes    (P<0.001)ComparisonOutcome MeasureEccentrics Better?EE vs. UltrasoundFILLANoEE vs. AirHeel BraceAOFASNoEE vs. Shockwave TherapyVISA-ANoEE vs. Standard CareVISA-AYes (P = 0.014)EE vs. Wait-and-SeeVISA-AYes (P < 0.001)ComparisonOutcome MeasureEccentrics Better?EE vs. UltrasoundEuroQolNoEE vs. AirHeel BraceSF-36Return to SportNoNoEE vs. Shockwave TherapyLikert ScaleNoEE vs. Concentric ExerciseReturn to SportYes (P = 0.002)EE vs. Wait-and-SeeLikert ScaleYes (P < 0.001)ComparisonOutcome MeasureEccentrics better?EE vs. UltrasoundVAS*No   (all)EE vs. AirHeel BraceVASYes   (rest; P<0.001)No#  (walking)No    (sport)EE vs. Concentric ExerciseVASYes   (walking; P<0.001)EE vs. Shockwave Author designed**NoEE vs. Wait and SeeAuthor designedYes    (P<0.001)ComparisonOutcome MeasureEccentrics Better?EE vs. UltrasoundFILLANoEE vs. AirHeel BraceAOFASNoEE vs. Shockwave TherapyVISA-ANoEE vs. Standard CareVISA-AYes (P = 0.014)EE vs. Wait-and-SeeVISA-AYes (P < 0.001)ComparisonOutcome MeasureEccentrics Better?EE vs. UltrasoundEuroQolNoEE vs. AirHeel BraceSF-36Return to SportNoNoEE vs. Shockwave TherapyLikert ScaleNoEE vs. Concentric ExerciseReturn to SportYes (P = 0.002)EE vs. Wait-and-SeeLikert ScaleYes (P < 0.001)PAINSATISFACTIONFUNCTIONComparisonOutcome MeasureEccentrics better?EE vs. UltrasoundVAS*No   (all)EE vs. AirHeel BraceVASYes   (rest; P<0.001)No#  (walking)No    (sport)EE vs. Concentric ExerciseVASYes   (walking; P<0.001)EE vs. Shockwave Author designed**NoEE vs. Wait and SeeAuthor designedYes    (P<0.001)ComparisonOutcome MeasureEccentrics Better?EE vs. UltrasoundFILLANoEE vs. AirHeel BraceAOFASNoEE vs. Shockwave TherapyVISA-ANoEE vs. Standard CareVISA-AYes (P = 0.014)EE vs. Wait-and-SeeVISA-AYes (P < 0.001)ComparisonOutcome MeasureEccentrics Better?EE vs. UltrasoundEuroQolNoEE vs. AirHeel BraceSF-36Return to SportNoNoEE vs. Shockwave TherapyLikert ScaleNoEE vs. Concentric ExerciseReturn to SportYes (P = 0.002)EE vs. Wait-and-SeeLikert ScaleYes (P < 0.001)PAINSATISFACTIONFUNCTIONComparisonOutcome MeasureEccentrics better?EE vs. UltrasoundVAS*No   (all)EE vs. AirHeel BraceVASYes   (rest; P<0.001)No#  (walking)No    (sport)EE vs. Concentric ExerciseVASYes   (walking; P<0.001)EE vs. Shockwave Author designed**NoEE vs. Wait and SeeAuthor designedYes    (P<0.001)ComparisonOutcome MeasureEccentrics Better?EE vs. UltrasoundFILLANoEE vs. AirHeel BraceAOFASNoEE vs. Shockwave TherapyVISA-ANoEE vs. Standard CareVISA-AYes (P = 0.014)EE vs. Wait-and-SeeVISA-AYes (P < 0.001)ComparisonOutcome MeasureEccentrics Better?EE vs. UltrasoundEuroQolNoEE vs. AirHeel BraceSF-36Return to SportNoNoEE vs. Shockwave TherapyLikert ScaleNoEE vs. Concentric ExerciseReturn to SportYes (P = 0.002)EE vs. Wait-and-SeeLikert ScaleYes (P < 0.001)PAINSATISFACTIONFUNCTIONComparisonOutcome MeasureEccentrics better?EE vs. UltrasoundVAS*No   (all)EE vs. AirHeel BraceVASYes   (rest; P<0.001)No#  (walking)No    (sport)EE vs. Concentric ExerciseVASYes   (walking; P<0.001)EE vs. Shockwave Author designed**NoEE vs. Wait and SeeAuthor designedYes    (P<0.001)ComparisonOutcome MeasureEccentrics Better?EE vs. UltrasoundFILLANoEE vs. AirHeel BraceAOFASNoEE vs. Shockwave TherapyVISA-ANoEE vs. Standard CareVISA-AYes (P = 0.014)EE vs. Wait-and-SeeVISA-AYes (P < 0.001)ComparisonOutcome MeasureEccentrics Better?EE vs. UltrasoundEuroQolNoEE vs. AirHeel BraceSF-36Return to SportNoNoEE vs. Shockwave TherapyLikert ScaleNoEE vs. Concentric ExerciseReturn to SportYes (P = 0.002)EE vs. Wait-and-SeeLikert ScaleYes (P < 0.001)PAINSATISFACTIONFUNCTIONExplanation of the Results, Study Limitations and Implications for Research & CliniciansVariability of results makes it difficult to draw firm conclusionsContributing Factors:Study quality Study sample characteristics Intervention parametersSelection of outcome measures. PEDro ScoresSubject & therapist blindingAssessor blindingConflict of Interest?PEDro Scores:StudySackett’s Level of EvidencePEDro criteria*PEDro score (/11)1234567891011ChesterII (n=16)XXXXX6HerringtonII (n=25)XXXX7MafiII (n=44)XXXX7PetersonI (n=72)XXX8RompeI (n=75)XX9PEDro 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 specifiedChester et al (2007): PEDro score = 6/11 Pilot studyDifference at baseline.Average ageAverage duration of symptomsMale to female ratioGreater mean functional impairmentLower incidence of existing pathologiesLower mean resting pain VAS scoresHigher pain reported after sportAverage ageNo relationshipPrevious fitness level of participantsApparent positive correlation between the previous fitness level and effectiveness of EEEarly studies on recreational athletes. EE protocols require patients to push through pain to complete multiple repetitions of exercisesPatients with previous experience with exercise may…Be more likely to adhere to an exercise programHave better body awarenessHave a more positive attitude toward exerciseHave superior exercise form and body mechanicsHave increased experience pushing through pain and fatiguePreviously sedentary participants with no history of physical activity may…Have to make a substantial lifestyle adjustmentHave some difficulty with skill acquisition of the exercisesHave some difficulty with adherence to an exercise programVariability between EE protocols90 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 interventionsUnable to compare most intensities (e.g. EE vs. US)Mafi et al. (2000); EE vs. CE4. Outcome MeasuresLowest QualityHighest QualityPainFunctionFILLAAOFASVISA-APatient Satisfaction“Yes/No” QuestionnairesEuroQolSF-36Specific Likert ScalesVASLoad-induced painPain thresholdTenderness on palpationImplications for CliniciansNot a stand-alone treatment!Remember…INTRINSICOverpronation hindfootVarus forefootQuads and Gastroc weaknessAdvanced ageObesityEXTRINSICTraining errorsPoor movement techniquesPoor footwearRunning on hard/uneven surfacesTake home messageEE is at least as effective as other treatmentsEccentric 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-AmbroseOther contributors:	Dr. Alex Scott	Dr. Elizabeth Dean	Dr. Darlene Reid	Charlotte Beck	Dean Giustini					Abbassian, A. and Khan, R., (2009). Achilles tendinopathy: pathology and management strategies. Br J Hosp Med, 70(9), 519-523. Alfredson, H., Pietilä, T., Jonsson, P., & Lorentzon, R. (1998). Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med, 26, 360 Alfredson, H. (2005). The chronic painful Achilles and patellar tendon: Research on basic biology and treatment. Scand J Med Sci Sports, 15, 252–259. Brazier, J. E., Jones, N. M., Kind, P. (1993). Testing the validity of the EuroQol and comparing it with the SF-36 health survey questionnaire. Quality of Life Research, 2(3), 169-180. Brooks, R. (1996). EuroQol: the current state of play. Health Policy, 37, 53–72. Chester, R., Costa, M.L., Cooper, A. & Donell, S.T. (2007). Eccentric calf muscle training compared with therapeutic ultrasound for chronic Achilles tendon pain – A pilot study. Manual Therapy. 13, 484-91. Herrington, L. & McCulloch, R. (2007). The role of eccentric training in the management of Achilles tendinopathy: A pilot study. Physical Therapy in Sport. 8, 191-6. Langberg, H., Ellingsgaard, H., Madsen, T. Jansson, J., Magnusson, S.P., Aagaard, P., & Kjær, M. (2007). Eccentric rehabilitation exercise increases peritendinous type I collagen synthesis in humans with Achilles tendinosis. Sacd J Med Sci Sports, 17, 61-6.    Mafi, N., Lorentzon, R. & Alfredson, H. (2001). Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Journal of Knee Surgery, Sports Traumatology and Arthroscopy. 9, 42-7.  Magnussen, R. A., Dunn, W. R., & Thompson, B. (2009). Nonoperative treatment of midportion Achilles tendinopathy: A systematic review. Clin J Sport Med, 19(1), 54-64.Nørregaard, J., Larsen,  C. C., Bieler, T., & Langberg, H. (2007). Eccentric exercise in treatment of Achilles tendinopathy. Scand J Med Sci Sports, 17, 133-8. Paavola, M., Orava, S., Leppilahti, J., Kannus, P., & Järvinen, M., (2000). Chronic Achilles tendon overuse injury: Complications after surgical treatment. An analysis of 432 consecutive patients. Am J Sports Med, 28, 77–82. Petersen, W., Welp, R. & Rosenbaum, D. (2007). Chronic Achilles tendinopathy: A prospective randomized control study comparing the therapeutic benefit of eccentric training, the AirHeel Brace, and a combination of both. The American Journal of Sports Medicine. 35(10), 1659-66. Rees, J., Wilson, A., & Wolman, R. (2006).  Current concepts in the management of tendon disorders. Oxford University Press, 45, 508-521.  Rees, J. D., Lichtwark, G. A., Wolman, R. L., & Wilson, A. M. (2008). The mechanism for efficacy of eccentric loading in Achilles tendon injury; an in vivo study in humans. Rheumatology, 47, 1493-7. Robinson, J. M., Cook, J. L., Purdam, C., Visentini, P. J., Ross,  J., Maffulli, et al. et al. (2001). The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. British Journal of Sports Medicine, 35, 335-341. Rompe, J.D., Nafe, B., Furia, J.P. & Maffulli, N. (2007). Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of Tendo Achillis: A randomized control trial. The American Journal of Sports Medicine.35(3), 374-83. Rompe, J. D., Furia, J. P., & Maffulli, N. (2008). Mid-portion achilles tendinopathy - current options for treatment. Disability & Rehabilitation, 30(20), 1666-76.Scott, A. (2010). Tendinopathies: Beyond the Achilles [PowerPoint slides]. Retrieved from http://www.bcphysio.org/app/index.cfm?fuseaction=membercourse.download Silbernagel, K. G., Thomee, R., Thomee, P., & Karlsson, J. (2001). Eccentric overload training for patients with chronic Achilles tendon pain – a randomized controlled study with reliability testing of the evaluation methods. Scan J Med Sci Sports, 11, 197-206. Süleyman, H., Demircan, B., & Karagöz, Y. (2007). Anti-inflammatory and side effects of cyclooxygenase inhibitors. Pharmacological Reports, 59, 247-258. Tan, S. C., & Chan, O. (2008). Achilles and patellar tendinopathy: Current understanding of pathophysiology and management. Disability & Rehabilitation, 30(20), 1608-15. Tsai, W., Hsu, C., Chou, S., Chung, C., & Chen, J. (2007). Effects of celecoxib on migration, proliferation and collagen expression of tendon cells. Connect Tissue Res, 48(1), 46-51. Verhagen, A., de Vet, H., de Bie, R., Kessels, A., Boers, M., Bouter L., & Knipschild, P. (1998). The delphi list: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by delphi consensus. Journal of Clinical Epidemiology, 51, 1235–1241. Woodley, B.L., Newsham-West, R.J., & Baxter, G.D. (2007). Chronic tendinopathy: Effectiveness of eccentric exercise. Br J Sports Med, 41, 188-199.Questions? ***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 promoting return to sport in adults with chronic Achilles tendinopathy?*Have each row come up individually????**Change to green*Mention how we’ll just look at the study that had the lowest PEDro score to explain some of the inconsistencies. *Of course Chester wasn’t the only study that had quality issues that put some of their resuts into question… but in the interest of time we’ve just discussed the most extreme example from our review.*Small sample size:	Minimum 80% power for clinically significant results	 sample size = more generalizable results2) Lack of follow up	Only 2 studies followed patients post-intervention	Would provide strong evidence for use of EE over other Rx options3) No comparable outcome measures:4) Unclear exercise parameters:	each used slightly diff parameters	this must be clarified in research*Verbalize: These are all factors that contribute to the development of the conditions and all of them need to be considered! EE does not address all of the above; especially not the extrinsic factors. The clinician should take a holistic approach to treatment, and should include education about lifestyle modifications that apply to the individual, including but not limited to footwear, training tips and weight management.*Research still needed:-Optimal exercise dose and prescription-Optimal patient populations-Impact of patient compliance and long-term outcomes-High quality studies with comparable outcome measures and data*“Despite the inconsistencies seen in the studies reviewed, it is the opinion of the authors that eccentric exercise provides an important treatment option for those with chronic, mid-portion achilles tendinopathy.   The exercise program provides a low-cost, low risk option for patient self-management of this chronic disorder”*  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  Interaction between intrinsic & extrinsic factors: 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   Failed  healing response?   Neovasculature and nerve proliferation  ↓ pain  ↓ neovessels  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) 2)  3)  4)  5)  Randomized control trial Human participants, mean age 18-65, with chronic (≥ 3 months) mid-portion AT Participants with no other past or present Achilles tendon pathology or other significant L/E pathology Experimental group underwent eccentric heel drop exercise protocol lasting ≥ 6 weeks Included outcome measures of pain, function (ROM, strength, or functional  1) 2) 3) 4) 5) 6)  Not available in full text Not available in English Retrospective or non-original studies In-vitro studies Animal subjects Comparison group included an eccentric protocol    Sackett’s Level of Evidence & PEDro Scores:  Study  Sackett’ s Level of Evidenc e  PEDro criteria* 1  2  3  4  5  6  7  8  9  10  11  PEDr o score (/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 comparators Comparison Group(s)  Study  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 Pain ▪ (VAS, VISA-A, Load-induced pain, Pain threshold, TOP)  Functio n  ▪ (FILLA, AOFAS, VISA-A) Patient Satisfaction  Comparison  Outcome Measure  Eccentrics better?  EE vs. Ultrasound  VAS*  No  EE vs. AirHeel Brace  VAS  Yes (rest; P<0.001) No*** (walking) No (sport)  EE vs. Concentric Exercise  VAS  Yes  (all)  (walking; P<0.001)  EE vs. Shockwave  Author designed**  EE vs. Wait and See Author designed  No Yes  (P<0.001)  *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  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-andSee  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)  PAIN FUNCTION SATISFACTION  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  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)  (P<0.001)  PAIN FUNCTION SATISFACTION  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  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)  (P<0.001)  PAIN FUNCTION SATISFACTION  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  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)  (P<0.001)  PAIN FUNCTION SATISFACTION  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  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)  (P<0.001)  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* 1  2  3  4  5  6  7  8  9  10  11  PEDr o score (/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   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   Comparability  interventions  (Petersen et al., 2007)  of EE and comparison   Unable to compare most intensities (e.g. EE vs. US)  Mafi et al. (2000); EE vs. CE  4. Outcome Measures Lowest Quality  Highest Quality VAS Load-induced pain Pain threshold Tenderness on palpation  Pain  Function  FILLA  Patient Satisfaction  “Yes/No” Questionnaires  AOFAS  EuroQol  VISA-A  SF-36  Specific Likert Scales  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). Achilles tendinopathy: pathology and management strategies. Br J Hosp Med, 70(9), 519-523. Alfredson, H., Pietilä, T., Jonsson, P., & Lorentzon, R. (1998). Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med, 26, 360   Alfredson, H. (2005). The chronic painful Achilles and patellar tendon: Research on basic biology and treatment. Scand J Med Sci Sports, 15, 252–259. Brazier, J. E., Jones, N. M., Kind, P. (1993). Testing the validity of the EuroQol and comparing it with the SF-36 health survey questionnaire. Quality of Life Research, 2(3), 169-180.   Brooks, R. (1996). EuroQol: the current state of play. Health Policy, 37, 53–72.   Chester, R., Costa, M.L., Cooper, A. & Donell, S.T. (2007). Eccentric calf muscle training compared with therapeutic ultrasound for chronic Achilles tendon pain – A pilot study. Manual Therapy. 13, 484-91.   Herrington, L. & McCulloch, R. (2007). The role of eccentric training in the management of Achilles tendinopathy: A pilot study. Physical Therapy in Sport. 8, 191-6.   Langberg, H., Ellingsgaard, H., Madsen, T. Jansson, J., Magnusson, S.P., Aagaard, P., & Kjær, M. (2007). Eccentric rehabilitation exercise increases peritendinous type I collagen synthesis in humans with Achilles tendinosis. Sacd J Med Sci Sports, 17, 61-6.   Mafi, N., Lorentzon, R. & Alfredson, H. (2001). Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Journal of Knee Surgery, Sports Traumatology and Arthroscopy. 9, 42-7.    Magnussen, R. A., Dunn, W. R., & Thompson, B. (2009). Nonoperative treatment of midportion Achilles tendinopathy: A systematic review. Clin J Sport Med, 19(1), 54-64. Nørregaard, J., Larsen, C. C., Bieler, T., & Langberg, H. (2007). Eccentric exercise in treatment of Achilles tendinopathy. Scand J Med Sci Sports, 17, 133-8.   Paavola, M., Orava, S., Leppilahti, J., Kannus, P., & Järvinen, M., (2000). Chronic Achilles tendon overuse injury: Complications after surgical treatment. An analysis of 432 consecutive patients. Am J Sports Med, 28, 77–82.   Petersen, W., Welp, R. & Rosenbaum, D. (2007). Chronic Achilles tendinopathy: A prospective randomized control study comparing the therapeutic benefit of eccentric training, the AirHeel Brace, and a combination of both. The American Journal of Sports Medicine. 35(10), 1659-66.   Rees, J., Wilson, A., & Wolman, R. (2006). Current concepts in the management of tendon disorders. Oxford University Press, 45, 508-521.   Rees, J. D., Lichtwark, G. A., Wolman, R. L., & Wilson, A. M. (2008). The mechanism for efficacy of eccentric loading in Achilles tendon injury; an in vivo study in humans. Rheumatology, 47, 1493-7.   Robinson, J. M., Cook, J. L., Purdam, C., Visentini, P. J., Ross, J., Maffulli, et al. et al. (2001). The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. British Journal of Sports Medicine, 35, 335-341.   Rompe, J.D., Nafe, B., Furia, J.P. & Maffulli, N. (2007). Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of Tendo Achillis: A randomized control trial. The American Journal of Sports Medicine.35(3), 374-83.    Rompe, J. D., Furia, J. P., & Maffulli, N. (2008). Mid-portion achilles tendinopathy - current options for treatment. Disability & Rehabilitation, 30(20), 1666-76. Scott, A. (2010). Tendinopathies: Beyond the Achilles [PowerPoint slides]. Retrieved from http://www.bcphysio.org/app/index.cfm?fuseaction=membercourse.download   Silbernagel, K. G., Thomee, R., Thomee, P., & Karlsson, J. (2001). Eccentric overload training for patients with chronic Achilles tendon pain – a randomized controlled study with reliability testing of the evaluation methods. Scan J Med Sci Sports, 11, 197-206.   Süleyman, H., Demircan, B., & Karagöz, Y. (2007). Anti-inflammatory and side effects of cyclooxygenase inhibitors. Pharmacological Reports, 59, 247-258.   Tan, S. C., & Chan, O. (2008). Achilles and patellar tendinopathy: Current understanding of pathophysiology and management. Disability & Rehabilitation, 30(20), 1608-15.   Tsai, W., Hsu, C., Chou, S., Chung, C., & Chen, J. (2007). Effects of celecoxib on migration, proliferation and collagen expression of tendon cells. Connect Tissue Res, 48(1), 46-51.   Verhagen, A., de Vet, H., de Bie, R., Kessels, A., Boers, M., Bouter L., & Knipschild, P. (1998). The delphi list: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by delphi consensus. Journal of Clinical Epidemiology, 51, 1235–1241.   Woodley, B.L., Newsham-West, R.J., & Baxter, G.D. (2007). Chronic tendinopathy: Effectiveness of eccentric exercise. Br J Sports Med, 41, 188-199.  Questions?  

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