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Physical Therapy Exercise Interventions in Tendinosis Injuries Brown, Paul; Lazjerowicz, Cleo; Martin, Aislin; Phillips, Margaret; Yeates, Michelle; Li, Linda 2007-07-30

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A Systematic Review By: Aislin Martin Cleo Lajzerowicz Michelle Yeates Maggie Phillips Paul Brown Supervisor: Dr. Linda Li Tendinopathy and the Effectiveness of Eccentric Exercise Overview ¾ Purpose ¾ Introduction ¾ Methods ¾ Results ¾ Discussion ¾ Clinical Relevance ¾ Future Research Purpose To systematically review the current evidence and determine the effectiveness of eccentric exercise in the treatment of chronic tendinosis Introduction Tendinosis: ¾ a non-inflammatory intratendinous collagen degeneration without clinical or histological signs of inflammation1,2 Common tendons affected: ¾ patellar, Achilles, tendons of the medial and lateral elbow, rotator cuff2 Introduction Prevalence ¾ Elite male volleyball players z 40% to 50% patellar tendinosis 3 ¾ General population z lateral epicondylitis annual incidence is between 1% -3%4,5 ¾ Competitive tennis players z incidence can be as high as 40% 4, 5 ¾ Elite and recreational runners z Achilles tendinopathies accounts for  9% of injuries 6 ™ Overuse injuries, including tendinopathies, account for nearly 7% of all injury related physician office visits in the United States 7 Introduction Common causes1: ¾ Aging ¾ Microtrauma ¾ Vascular compromise Common population3-7: ¾ Competitive and recreational athletes ¾ People in occupations consisting of repetitive tasks or manual labor Recovery times with treatment1: ¾ Early presentation: 6-10 weeks ¾ Chronic presentation: 3-6 months Introduction Histological Findings 1,2,4,8,9 ¾ ↑ cellularity - fibroblasts and myofibroblasts ¾ ↑ vascularity and ground substance ¾ Collagen disorientation, disorganization, focal necrosis or calcification, vascular spaces with or without neovascularization and fiber separation ¾ Absence of inflammatory cells Normal Introduction Conservative Treatments1-8 ¾ Ultrasound ¾ Laser ¾ Deep friction massage ¾ Orthotics and braces ¾ Corticosteroids ¾ Mobilizations and manipulations ¾ Thermotherapy ¾ Cryotherapy ¾ Rest ¾ Acupuncture ¾ Pulsed electromagnetic field therapy ¾ Eccentric exercise Introduction Eccentric Exercise ¾ The active lengthening of a muscle under force10 Introduction ¾ Eccentric training leads to increased net collagen synthesis in the tendon tissue through constant overload on the tendon11 ¾ 12 weeks of EE training normalized tendon structure and decreased tendon thickness in Achilles tendinosis12 RATIONALE ¾ The literature shows that eccentric exercise has promise for treatment of Achilles and patellar tendinopathies GOAL ¾ Review the literature to examine the effectiveness of eccentric exercise as a treatment for tendinosis Introduction Methods Methods: PICO P ¾Patients diagnosed with a tendinopathy (eg. clinical exam   / MRI / Ultrasound / Doctor) or chronic painful tendon greater than 3 months ¾Adults 16 years or older I ¾Eccentric exercise C ¾none O ¾Pain ¾ROM ¾Return to functional activities ¾Avoid surgical intervention ¾Strength ¾Tendon structure/healing Methods: Search Strategy Databases ¾ EMBASE ¾ CINAHL ¾ MEDLINE ¾ PEDro ¾ Cochrane library ¾ SPORTDISCUS Other Forms ¾ Hand searching Journals z Physiotherapy, Physical Therapy ¾ Reference lists ¾ Personal libraries ¾ Communicating with experts in the field z Doctoral candidate (Michael Ryan) Methods: Search Strategy ¾Main Terms z Tendinopathy, tendinosis, tendon disease, tendon injury z Achilles, swimmers shoulder, patellar tendon, golfer’s elbow, rotator cuff, jumper’s knee z Eccentric exercise 12 Golfer’s 13 Patella$ tend$.mp 14 Jumper’s 15 Achilles tend$.mp 16 17 or Exercise/ 18 Or/ 1-15 19 16 and 17 20 18 and 19 21 Limit 20 to (human and English language) Search Terms 1 2 3 4 Tend#n 5 Tend#n 6 Swimmer’s 7 Rotator cuff tend$.mp 8 Shoulder 9 Medial epicondyl$ 10 Tennis elbow/or medial epicondyle$ 11 Tennis elbow/or lateral epicondyle$ Table of Search Terms Methods: Study Selection Inclusion Criteria ¾ 16 years or older ¾ Clinical diagnosis of tendinopathy or: ¾ Tendon pain for > 3 months ¾ English studies ¾ Eccentric Exercise Exclusion Criteria ¾ Concurrent treatment ¾ Surgical intervention ¾ Tendinosis caused by injection Methods: Study Selection Study Selection ¾Screen of title and abstracts ¾Selection of articles based on inclusion criteria z 2 person independent review ¾Recovery and review of full articles z Random allocation to 2 persons for independent review Methods Study Selection ¾Pilot the data extraction form z Modified data extraction form provided by Dr. Linda Li z 10% of articles were tested using the form • 89.6% based on 115 variables z Changes were made to the form to increase accuracy and consistency Methods Data extraction ¾ Study description ¾ Participant description ¾ Study quality rating (van Tulder13) ¾ Baseline and post treatment outcome measurements ¾ Dropouts, adverse effects Methods: Quality of Studies ¾ Used Van Tulder13 Quality Assessment z 11 criteria rated: Yes, No, Unclear ¾ Methodological criteria were independently assessed by 2 reviewers 9 Consensus reached by discussion ¾ High Quality = Score of 6 of 11 or above ¾ Low Quality = Score 5 and below Methods: Quality of Studies ¾ Less than 1/3 of the studies fulfilled all of the following criteria: z adequate treatment allocation concealment, blinding of patients, and blinding of the care provider ¾ Less than 1/2 of the studies blinded the outcome assessor to the intervention or had acceptable compliance (> 70%) in all groups. Methods ¾ Standard mean differences: Hedge’s G z Studies with similar outcome measures ¾ Best evidence synthesis14 z Rates studies according to whether: Strong, moderate, limited, indicative, no evidence z Utilizes study design (RCT, CCT, other design), study quality (high/low), statistical findings Results Study Selection 201 citations 16 relevant articles Duplicate articlese xclude d: (n = 91) Articles e xclude d base d on title /abstract (n = 80) Articles retrie ve d for detailed eva luation (n = 30) Adde d studie s ba sed on personal libra rie s, c hecked re fe re nces a nd ha nd sea rching: (n = 15) Excluded articles: (n=29) -Not a n RCT or CCT (n=18) -Faile d e ligibility c riteria  (n=8) -No eccentric  e xe rcise inte rve ntion (n= 1) -La nguage (n=1) -Not fou nd (n=1) Final selection included in systematic review: (n= 16) RCT: (n = 12)   CCT: (n = 4) Search of databases: (n =201) EMBASE  [56] Sp ortdiscus [48] CINHAL  [47] MED LINE  [41] Coc hra ne  Libra ry RCT [13] PED ro [5] Results: Brief Summary of Included Studies ¾ Patellar tendon N = 6 z Age range: 22-31 years ¾ Achilles tendon N = 7 z Age range: 39-51 years ¾ Wrist extensors N = 3 z Age range: 38-47 years Results: Heterogeneity of studies ¾ Eccentric Exercise (EE): variety of exercises z some protocols have participants exercising through moderate amounts of pain ¾ Comparative Treatments (CT): z Concentric exercise, night splint, stretches, shock wave therapy, TENS, US, DTFM, control ¾ Duration of symptoms: 3-41 months ¾ Duration of Intervention: 4-24 weeks ¾ Number of participants: 15-124 persons ¾ Types of participants: z Recreational athletes (4 studies) z Competitive university volleyball players (5 studies) z General population Outcome Measurements ICF Classification Body function and structure: z Pain and strength Activity: z Functional 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: z Quality of life questionnaires and return to sport Included Studies 12 RCTs3,15-24 ¾ 7 studies rated as high quality (range 6-8) ¾ 5 studies rated as low quality (range 3-5) 4 CCTs25-28 ¾ 1study rated as high quality ( score 7) ¾ 3 studies rated as low quality (range 2-5) Results ¾Calculated 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 ¾Applied these findings to a best evidence synthesis model Results: SMD achilles Tendon Author Design PainSMD Strength SMD Functional Assessment SMD Health related QoL SMD Achilles Tendinosis Alfredson et al. (1998) CCT 1.77 iii) 0.65 Rompe et al. (2007) RCT ii) EE vs CT: 1.28 ii) 0.93 Roos et al. (2004) RCT i) EE vs EE + splint: 0.47 ii) EE vs splint: 0.69 Results: SMD patellar tendon Author Design PainSMD Strength SMD Functional Assessment SMD Health related QoL SMD Patellar Tendinosis Jonsson and Alfredson (2005) RCT 1.98 2.44 Purdam et al. (2004) CCT 1.79 Results: SMD wrist extensors Author Design PainSMD Strength SMD Functional Assessment SMD Health related QoL SMD Wrist Extensor tendinosis Croisier et al. (2001) CCT 2.39 ii) 1.02 iii) 2.14 1.04 Results: Best Evidence Synthesis Tool 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 ( RCTs or CCTs) Best Evidence Synthesis Limited Evidence ¾Statistically significant findings in outcome measures in at least one high quality RCT, OR ¾Consistent statistically significant findings in outcome measures in at least two high quality CCTs Indicative Findings ¾Statistically significant findings in outcome and/or process measures in at least one high quality CCT or low quality RCT No Evidence ¾Results of eligible studies do not meet the criteria for one of the above stated level of evidence, OR ¾In the case of conflicting results among RCTs and CCTs Table adapted from Steultjens et al. 2002 Achilles Limited evidence for the effectiveness of EE interventions on functional ability Limited evidence for the effectiveness of EE interventions on increasing health-related quality of life when compared to a “wait and see” control group No evidence to support the effectiveness of EE on decreasing pain or on increasing strength when compared to CT – due to conflicting findings Results: Best Evidence Synthesis Results: Best Evidence Synthesis Patella Indicative findings for the effectiveness of EE interventions on pain outcomes over other CTs. Indicative findings for the effectiveness of EE interventions on functional ability versus CTs. No evidence was found for the effectiveness of EE interventions on strength when compared to CTs. Results: Best Evidence Synthesis Wrist extensors Indicative findings that EE interventions are effective for improving the patient’s quality of life over other CTs. No evidence for the effectiveness of EE interventions on decreasing pain or increasing strength when compared against CTs (due to conflicting findings) Discussion General Limitations Study design z Intervening variables: • EE with concentric component (2 studies) • Treatment & control treatment groups share co-treatments (4 studies) z Poor control of intervention: • Monitoring adherence, controlling progression z Underpowered: • 12/16 studies with sample populations < 50 • Inability to conduct meta-analysis or sub group analysis due to heterogeneity z Lack 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. z Outcome measures • Non-validated and non-standardized preventing comparisons & weakening findings General Limitations ¾ Study Quality Shortcomings (van Tulder criteria13) z Description of randomization z Concealment of treatment allocation z Blinding outcome assessors z Intention to treat analysis ¾ Reporting z 7 out of 16 studies excluded from best evidence synthesis due to lack of data ¾ Generalizability z 8 out of 16 studies use young, elite athletes Eccentric Exercise: What is an optimal Protocol? ¾ Differences of opinion persist as to optimal exercise intervention ¾ 9 out of 16 studies use intervention based on Alfredson protocol (Alfredson 1998) 25 z 2 x/day z 7days/week z 3 x 15 reps z 12 week intervention z Exercise with pain (VAS score varies) z Progression with added weight Eccentric Protocol ¾ Alfredson model is based on clinical experience and lacks a scientific basis29 ¾ Croisier et al. (2007) found good results in a well controlled study training subjects 3 x/ week versus 7 x/week ¾ They argue that an optimal prescription involves periods of rest to allow for recovery from post exercise weakness Eccentric Protocol: How much pain? ¾ Alfredson et al. (1998) suggest that pain is an essential component of their successful intervention in AT ¾ Curwin and Stanish (1984) achieve good results with a painless protocol in PT and LET3,17,28 ¾ For LET, researchers argue against training into pain claiming that it may have a negative impact on patient compliance and provoke injury21,28 Clinical Relevance ¾ Overall, the studies demonstrate a positive trend in favour of EE ¾ Clinicians must consider whether the subjects studied are representative of their patient population and whether the EE intervention is realistic, particularly when considering prescribed loads, frequency and intensity of pain with exercise Future Research Design ¾Better research design ¾Consistent/validated Outcome Measures ¾ Larger samples z Allow subgroup analysis to uncover the impacts of factors such as age, sex, activity, biomechanical faults, and duration or severity of symptoms ¾Post treatment assessments z To determine long-term impact Future Research Topics ¾ Improve understanding of physiological effect of EE on the muscle tendon unit & whether this varies by tendon ¾ Optimal EE intervention ¾ Impact of intrinsic & extrinsic factors on occurrence of tendinosis z Intrinsic (e.g. age, gender, biomechanics, genetics) z Extrinsic factors (e.g. environment, physical load, training errors) ¾ Improved understanding of the pathophysiology of tendinosis across tendons Conclusion ¾ This review demonstrates a lack of well designed high quality studies providing limited evidence to support the clinical effectiveness of EE over other conservative treatments in the rehabilitation of tendinosis. Acknowledgements A great BIG Thanks to Dr. Linda Li and Charlotte Beck for their help with this project Questions? References 1. Khan K, Cook J., Bonar F, Harcourt P, Astrom M. Histopathology of common tendinopathies: update and implications for clinical management. Sports Med 1999;27:393-408. 2. Scott A, Ashe M. Common tendinopathies in the upper and lower extremities. Curr Sports 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 tendinopathy in volleyball players. Br Sports Med. 2005; 39: 102-105. 4. Sharma P, Maffulli N. Current concepts review, tendon injury and tendinopathy: healing and repair. J Bone Joint Surg Am 2005;87:187-202. 5. Smidt N, Assendelf J. Effectiveness of physiotherapy for later epicondylitis: a systematic review. Annals of Medicine. 2003; 35: 51-62. 6. Satyendra L, Byl N. Effectiveness of physical therapy for Achilles tendinopathy: An evidence based review of eccentric exercises. Isokinetics and 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. Puddu G, Ippolito E, Postacchini F. A classification of Achilles tendon disease. Am J Sports Med 1976;4:145-150. 10. Lieber R 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 peritendinous type I collagen synthesis in humans with Achilles tendinosis. Scand J Med Sci Sports 2007;17:61-66. 12. Öhberg 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. 13. van Tulder M, Furlan A, Bombardier C. Updated method guidelines for systematic reviews in the Cochrane collaboration back review group. Spine 2003;28:1290-1299. 14. Steultjens E, Dekker J, Bouter L, van Schaardenburg D, van Kuyk M, van den Ende C. Occupational therapy for rheumatoid arthritis: A systematic review. Arthritis Care Res 2002;47(6):672-685. 15. Norregaard J, Larsen C, Bieler T, Langberg H. Eccentric exercise in treatment of Achilles tendinopathy. Scand J Med Sci Sports 2007;17(2):133-138. 16. 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(5):286-295 17. Cannell L, Taunton J, Clement D, Smith C, Khan K. A randomised clinical 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. Silbernagel K, Thomee P, Karlsson J. Eccentric overload training for patients with chronic Achilles tendon pain--a randomised controlled study with reliability testing of the evaluation methods. Scand J Med Sci Sports 2001;11(4):197-206. 19. Visnes H, Hoksrud A, Cook J, Bahr R. No effect of eccentric training on jumper's knee in volleyball players during the competitive season: A randomized clinical trial. Clin J 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. Clin Rehabil 2004;18(4):347-352. 21. Martinez-Silvestrini J, Newcomer K, Gay R, Schaefer M, Kortebein P, Arendt K. Chronic lateral epicondylitis: comparative effectiveness of a home exercise program including stretching alone versus stretching supplemented with eccentric or concentric strengthening. J Hand Ther 2005;18(4):411. 22. Rompe J, Nafe B, Furia J, Maffulli N. Eccentric Loading, Shock-Wave Treatment, or a Wait- and-See Policy for Tendinopathy of the Main Body of Tendo Achillis: A Randomized Controlled Trial. Am J Sports Med 2007;35(3):374-383. 23. Bahr R, Fossan B, Loken S, Engebretsen L. Surgical treatment compared with eccentric training for patellar tendinopathy (jumper's knee): A randomized, controlled trial. J Bone Joint Surg Am Vol 2006;88(8):1689-1698. 24. 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(1):42- 47. 25. 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(3):360-366. 26. Purdam C, Johnsson P, Alfredson H, Loretnzon R, 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. Svernlov B, Adolfsson L. Non-operative treatment regime including eccentric training for lateral humeral epicondylalgia. Scand J Med Sci Sports 2001;11(6):328-334 28. Croisier J, Foidart-Dessalle M, Tinant F, Crielaard J, Forthomme B. An isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy. 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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