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Pain-enduring Eccentric Exercise for the Treatment of Chronic Achilles Tendinopathy Dixon, Claire; Holloway, Laureen; Lee, Teresa; Lo, Nick; Meier, Janice; Reid, Darlene Oct 5, 2006

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Pain Enduring Eccentric Exercise for the Treatment of Chronic Achilles Tendinopathy Claire Dixon Laureen Holloway Janice Meier Nick Lo Teresa Lee Supervisors: W Darlene Reid Ph.D. & Sunita Mathur Ph.D.  Outline „ Introduction „ Methods „ Results „ Discussion „ Recent  Research  Why we chose this topic „ Increased  interest in pain enduring eccentric exercise as a focus of treatment for chronic Achilles tendinopathy „ Closer examination of the literature needed due to ethical concerns of pushing patients through pain „ Update on current body of knowledge and consensus on treatment  Introduction to the Topic Achilles Tendinopathy (Tendinosis, Partial Rupture, Tendinitis)  Background „ One  of the most common injuries in runners and other sports participants (Kvist, 1994); also seen in sedentary individuals (Afredson & Lorentzon, 2000)  „ Risk  factors, but no definitively known etiology  Predisposing factors „ Weak  plantar flexors, larger inversion angle on touchdown, over-pronation  (McCrory et al., 1999)  „ Decreased 1999)  „ Increase  dorsiflexion range (Kaufmann et al.,  in level of activity (Cook et al., 2002) „ Running- inconsistent stretching, many years of running (McCrory et al., 1999) „ Poor footwear (Hess et al., 1989)  Pathology „ Irregular  tendon structure with collagen degeneration and increased glycosaminoglycans (Alfredson & Lorentzon, 2003) „ Neovascularization in area, with increase in glutamate and lactate levels (Ohberg & Alfredson, 2004)  „ No  inflammatory cells (Ohberg & Alfredson, 2004)  Signs and Symptoms „ Mild  or severe pain „ Tenderness on palpation, nodule? „ Decreased strength „ Decreased range of movement „ Decreased function „ Pain may be gradual or more sudden; most often associated w/tendon loading  Conventional treatments „ „ „ „ „ „ „  Joint and soft tissue mobilizations Concentric exercises Stretching exercises Ultrasound Ice Iontophoresis Laser  „ „ „ „ „ „ „ „  Friction massage Splinting Orthotics NSAIDs Corticosteroids Activity modification Rest Surgery  Pivotal Article „ Increased  interest in 1998 with Alfredson et al’s study out of Sweden „ Initiated a series of studies  Methods  Chronic Achilles Tendinosis Operational definition „  Chronic- greater than 3 months  „  Degenerative changes 2-7cm above the calcaneal tendon  Literature Search „ Electronic  databases, reference lists, experts in the field, hand searches, gray literature searches „ Results: – 4 RCT’s – 4 Cohorts „ Not  a lot of information, relatively new topic  Article Selection 259 articles found initially X 154 not Achilles X 32 not primary research X 21 not eccentric intervention X 20 inappropriate outcome measures X 15 surgical patients X 3 did not push through pain X 2 subjects not human X 2 in a language other than English X 2 same study, different journal! 8 appropriate articles  Quality Assessment and Levels of Evidence „ Adapted  Megens and Harris Scale  – Scores of <5 were ‘Weak’ – Scores of 5, 6, 7 were ‘Moderate’ – Scores of 8, 9, 10 were ‘Strong’ „ Sackett’s  Levels of Evidence  – 1 to 5 scale  Results  Subjects „ „ „  Age: Range 19-77 yrs, average 47 yrs Sex: average ratio of M:F 21:10 Location: – mid-portion 7/8 papers – mixed mid and insertional 1/8 papers  „  Duration of Symptoms: – Average 16.4 months  „  Activity levels: – Wide variety but all appeared to be active prior to injury  Method of Diagnosis „  Clinical exam and ultrasonography – 5/8 studies  „  Clinical exam and MRI – 1/8 studies  „  Clinical exam alone – 2/8 studies  Intervention „  Alfredson et al 1998 eccentric protocol: – 3 sets of 15 reps eccentric heel drops 2x/day, 7days/week for 12 weeks – Work through nondisabling pain – Progressively add weight  Intervention „ 6/8  studies used the Alfredson eccentric protocol „ 1/8 used a variation of the Alfredson protocol – gradually increased reps to reduce soreness „ 1/8  used a 12 week series of primarily eccentric exercises  ‘Control’ Groups „  Conventional Treatments: – – – – –  „  Surgery Pain free concentric exercises Pain free stretching Night splint Night splint with eccentric exercises  Others: – Insertional tendinopathies – Contralateral tendon  „  No control!  Outcome Measures „  Pain outcome measures: – VAS – Questionnaires – Subjective expression of pain  „  Function outcome measures: – Ability to return to pre-injury activity – Jumping height – Plantar flexion ROM at the ankle – Calf muscle strength – Global assessment  Results: Pain „ At  12 weeks:  – In 5/8 studies pain was significantly improved by an average of 42% – In 2/8 studies a significant difference was not apparent at 12 weeks, but was apparent at 6 weeks, 6 months and 1 year – In 1/8 studies pain was only qualitatively recorded; after an average of 3.8 years it did not interfere with subjects’ pre-injury activities  Results: Pain „ In  5/8 studies improvements were seen in both the eccentric and control groups „ Results were on average 34% better in the eccentric groups „ 2/8 studies showed no difference between the groups; both of these studies involved stretching in the control group  Results: Function „ At  12 weeks function improved an average of 42% from baseline in the eccentric groups  „ The  control groups also improved an average of 33% from baseline  Quality Assessment & Levels of Evidence Alfredson et al 1998 Mafi et al 2001 Silbernagel et al 2001 Fahlstrom et al 2003 Ohberg et al 2004 Roos et al. 2004 Shalabi et al. 2004 Norregaard et al 2006  Quality 4/10 3.5/10 10/10 3.5/10 3.5/10 8.5/10 3.5/10 8/10  Levels of Evidence 4 2b 2b 4 4 2b 4 2b  Quality Assessment & Levels of Evidence „ Sackett’s  Levels of Evidence  – 4 low quality RCTs (Level 2b) – 4 prospective cohort studies (Level 4) – 100% interrater agreement „ Adapted  Megens and Harris Scale  – 3 studies considered strong – 5 studies considered weak – Average score of all 8 studies was 5.56/10 – 100% interrater agreement  Discussion  General Critique „ Most  studies NOT randomized, controlled or blinded - relatively low quality „ Many studies out of the same centers „ Varying methods of diagnosis „ Variety of ‘control’ groups „ Variety of outcome measures used  Discussion points „  Mid-portion vs. insertional tendinopathy – In 2/8 studies, eccentric exercise protocol LESS effective on insertional tendinopathy – Why? – More studies needed to confirm  Discussion points „ Disproportionately  higher number of men  to women „ Is conventional treatment significantly less effective? What about stretching? „ Ethical responsibility?  Conclusions „  „ „  Shift towards heavy-load eccentric exercise as a therapeutic intervention The evidence base on the whole is persuasive Suggesting that pain enduring eccentric exercise is superior to conventional treatments  Clinical Recommendations conservative, non-surgical treatment recommended „ As it stands evidence is not strong enough to ethically allow us, as practitioners, to encourage patients to push through pain „ Initial  Update „ Sayana  & Maffuli, 2006 „ Determine effectiveness of eccentric exercise protocol for non-athletic patients with achilles tendinosis „ Prospective study, 34 patients  Update „ Langberg  et al, 2006 „ Proposed mechanism for why heavy load eccentric exercise is effective „ Suggest link between collagen metabolism and recovery from tendon injury  New Research „ VISA-A  questionnaire as outcome measure (Victorian Institute of Sports Assessment – Achilles) „ Reliable and valid „ Available in Swedish and English „ Can be used in research, and clinically  References „ „ „ „ „ „ „ „ „  „ „  Kvist M. Achilles tendon injuries in athletes. Sports Med 1994;18:173-201. Cook JL, Khan KM, Purdam C. Achilles tendinopathy. Man Ther 2002;7:121-130. Alfredson H, Lorentzon R. Chronic achilles tendinosis: Recommendations for treatment and prevention. Sports Med 2000;29:135-146. Maffulli N, Kader D. Tendinopathy of tendo achillis. J Bone Joint Surg Br 2002;84:1-8. McCrory JL, Martin DF, Lowery RB. Etiologic factors associated with achilles tendinitis in runners. Med Sci Sports Exerc 1999;31:1374-1381. Kaufman KR, Brodine SK, Shaffer RA, et al. The effect of foot structure and range of motion on musculoskeletal overuse injuries. Am J Sports Med 1999;27:585-593. Brukner P, Khan K. Clinical Sports Medicine. 4th ed. Sydney, Australia: McGraw-Hill; 2001. Alfredson, H. Chronic midportion Achilles tendinopathy: an update on research and treatment. Clin Sports Med 2003;22:727-741. Alfredson H, Pietila T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic achilles tendinosis. Am J Sports Med 1998;26:360-366. Baechle TR, Earle RW. Essentials of Strength Training and Conditioning. 2nd ed. Champaign: Human Kinetics; 2000. Centre for Evidence-Based Medicine. Levels of Evidence and Grades of Recommendation. Available at: Accessed June 20, 2006.  References „  „  „  „  „  „  „  Medlicott MS, Harris SR. A systematic review of the effectiveness of exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of temporomandibular disorder. Phys Ther 2006; 86(7):955-973. Mafi N, Lorentzon R, Alfredson H. 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. Knee Surg Sports Traumatol Arthrosc 2001;9:42-47. Silbernagel KG, Thomee R, Thomee P, Karlsson J. Eccentric overload training for patients with chronic achilles tendon pain - a randomized controlled study with reliability testing of the evaluation methods. Scand J Med Sci Sports 2001;11:197-206. Fahlstrom M, Jonsson P, Lorentzon R, Alfredson H. Chronic achilles tendon pain treated with eccentric calf-muscle training. Knee Surg Sports Traumatol Arthrosc 2003;11:327-333. Ohberg L, Lorentzon R, Alfredson H. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. Br J Sports Med 2004;38:8-11. Roos E, Engstrom M, Lagerquist A, Soderberg B. 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 Sci Sports 2004;14:286-295. Shalabi A, Kristoffersen-Wilberg M, Svensson L. Eccentric training of the gastrocnemius-soleus complex in chronic achilles tendinopathy results in decreased tendon volume and intratendinous signal as evaluated by MRI. Am J Sports Med 2004;32:1286-1296.  References „  „ „  „  „  „  „ „  Norregaard J, Larsen CC, Bieler T, Langberg H. Eccentric exercise in treatment of Achilles tendinopathy [serial online] 2006;4:[17 screens]. Available from: Accessed May 14, 2006. Maffulli N, Kenward MG, Testa V, Capasso G, Regine R, King JB. Clinical diagnosis of Achilles tendinopathy with tendinosis. Clin J Sport Med 2003;13(1):11-15. Khan KM, Forster BB, Robinson J, Cheong Y, Louis L, Maclean L, Taunton JE. Are ultrasound and magnetic resonance imaging of value in assessment of Achilles tendon disorders? A two year prospective study. Br J Sports Med 2003;37:149-153. Åström M, Gentz CF, Nilsson P, Rausing A, Sjöberg S, Westlin N. Imaging in chronic achilles tendinopathy: a comparison of ultrasonography, magnetic resonance imaging and surgical findings in 27 histologically verified cases. Skeletal Radiol 1996;25:615–620. Silbernagel KG, Thomeé R, Karlsson J. Cross-cultural adaptation of the VISA-A questionnaire, an index of clinical severity for patients with Achilles tendinopathy, with reliability, validity and structure evaluations. BMC Musculoskelet Disord 2005;6:12. Robinson JM, Cook JL, Purdam C, Visentini PJ, Ross J, Maffulli N, Taunton JE, Khan KM. The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. Br J Sports Med 2001;35(5):335-341. Sayana MK, Maffulli N. Eccentric calf muscle in non-athletic patients with Achilles tendinopathy. J Sci Med Sport 2006. Langberg H, Ellingsgaard H, Madsen T, Jansson J, Magnusson SP, Aagaard P, Kjaer M. Eccentric rehabilitation exercise increases peritendinous type I collagen synthesis in humans with Achilles tendinosis. Scand J Med Sci Sports 2006.  Thank you  


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