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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 2006-10-05

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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 dorsiflexion range (Kaufmann et al., 1999) „ Increase 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 non- disabling 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 Quality     Levels of Evidence Alfredson et al 1998            4/10                4 Mafi et al 2001                  3.5/10              2b Silbernagel et al 2001         10/10              2b Fahlstrom et al 2003          3.5/10              4 Ohberg et al 2004             3.5/10              4 Roos et al. 2004                8.5/10              2b Shalabi et al. 2004            3.5/10               4 Norregaard et al 2006         8/10                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 „ Initial 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 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: http://www.cebm.net/levels_of_evidence.asp. 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: http://www.blackwell- synergy.com/doi/full/10.1111/j.1600-0838.2006.00545.x. 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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