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Eccentric Exercise in the Treatment of Midportion Achilles Tendinopathy; A Systematic Review Carter, Hayley; Christopher, Nikki; Fashler, Danielle; Hill, Ryan; Ried, Christine; Teskey, Drew 2010-07

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Hayley	CarterNikki	ChristopherDanielle	FashlerRyan	HillChristine	ReidDrew	TeskeyIntroductionMethodsResultsDiscussionConclusionBackground	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,	ADLsAchilles	Tendonitis• Inflammation	of	the	Achilles	tendon	(misnomer)Achilles	Tendinosis• Damage	at	the	cellular	level	(histological	term)¡ 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“Sports	injury?”INTRINSIC¡ Overpronation	hindfoot¡ Varus	forefoot¡ Quads	and	Gastroc	weakness¡ Advanced	age¡ ObesityEXTRINSIC¡ Training	errors¡ Poor	movement	techniques¡ Poor	footwear¡ Running	on	hard/uneven	surfacesInteraction	between	intrinsic	&	extrinsic	factors:¡ Failed	healing	response?§ Neovasculature	and	nerve	proliferation↓	neovessels ↓	painScott, A., (2010)¡ Ultrasound¡ Shock-wave	therapy¡ Corticosteroid	injections¡ Surgery§ NSAIDs§ Eccentric	Exercise¡ Conservative	approach¡ Low-cost¡ No	equipment¡ Self-management¡ Effective• Mechanical	sclerosing• Collagen	remodellingMechanism?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	Population • Adults	(18-65)	with	chronic	(≥	3months)	mid-portion	Achilles	TendinopathyIntervention • Eccentric	heel	drop	protocol	≥	6wk	durationComparison • Other	treatment	(including	no	treatment)Outcome • Pain	(Primary)• Function	and	Patient	Satisfaction	(Secondary)MEDLINE	(1950	– Present)EMBASE	(1980	– Present)CINAHL	(1982	– Present)PubMed (1949	– Present)PEDro (1929	– Present)Wed	of	ScienceGrey	Literature	(eg.	TRIP,	SUMSearch,	Toby)ANDAchillesORAchilles	Tendon	(Thesaurus)Tend*ORTendinitis	– focus(Thesaurus)EccentricOREccentric	Muscle	Contraction	– explode(Thesaurus)RCT	filter	=	(random*	AND	control*	AND	trial*)	OR	(RCT*)Example: EMBASE284	(with	duplicates)EMBASE	16 CINAHL	17Other155PEDro15PubMed24Medline25Web	of	Science321) Randomized	control	trial2) Human	participants,	mean	age	18-65,	with	chronic	(≥	3	months)	mid-portion	AT3) Participants	with	no	other	past	or	present	Achilles	tendon	pathology	or	other	significant	L/E	pathology	4) Experimental	group	underwent	eccentric	heel	drop	exercise	protocol	lasting	≥	6	weeks5) Included	outcome	measures	of	pain,	function	(ROM,	strength,	or	functional	scales),	patient	satisfaction,	or	return	to	activity	1) Not	available	in	full	text2) Not	available	in	English3) Retrospective	or	non-original	studies4) In-vitro	studies5) Animal	subjects6) Comparison	group	included	an	eccentric	protocolStudy SelectionINCLUDED	IN	REVIEWThird	level	screen• Full	textSecond	level	screen• AbstractFirst	level	screen• TitleTOTAL	HITS 28421	remain11	remain5	total¡ Sackett’s	Level	of	Evidence	&	PEDro	Scores:StudySackett’s Level of EvidencePEDro criteria* PEDro score (/11)1 2 3 4 5 6 7 8 9 10 11Chester II (n=16) Ö Ö Ö X X X Ö X X Ö Ö 6Herrington II (n=25) Ö Ö X Ö X X Ö Ö Ö Ö X 7Mafi II (n=44) Ö Ö Ö Ö X X X Ö X Ö Ö 7Peterson I (n=72) Ö Ö Ö Ö X X X Ö Ö Ö Ö 8Rompe I (n=75) Ö Ö Ö Ö X X Ö Ö Ö Ö Ö 9PEDro criteria: 1 – Eligibility criteria  2 – Random allocation  3 – Concealed allocation  4 – Baseline comparability  5 – Subject blinding6 – 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 reportedÖ - Criterion met X – Criterion not met or not specifiedDescription	of	Review	Findings¡ Insufficient	homogeneity	for	meta-analysis1. Different	comparatorsStudy Comparison	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	TherapyResults2. 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	EEComparison 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** NoEE	vs.	Wait	and	See Author	designed Yes				(P<0.001)Comparison Outcome	Measure Eccentrics	Better?EE	vs.	Ultrasound FILLA NoEE	vs.	AirHeel	Brace AOFAS NoEE	vs.	Shockwave	Therapy VISA-A NoEE	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 NoEE	vs.	AirHeel	Brace SF-36Return	to	Sport NoNoEE	vs.	Shockwave	Therapy Likert	Scale NoEE	vs.	Concentric	Exercise Return	to	Sport Yes	(P	=	0.002)EE	vs.	Wait-and-See Likert	Scale Yes	(P	<	0.001)Comparison Outcome	Measure Eccentrics	better?EE	vs.	Ultrasound VAS* No			(all)EE	vs.	AirHeel	Brace VAS Yes			(rest;	P<0.001)No# (walking)No				(sport)EE	vs.	Concentric	Exercise VAS Yes			(walking;	P<0.001)EE	vs.	Shockwave	 Author	designed** NoEE	vs.	Wait	and	See Author	designed Yes				(P<0.001)Comparison Outcome	Measure Eccentrics	Better?EE	vs.	Ultrasound FILLA NoEE	vs.	AirHeel	Brace AOFAS NoEE	vs.	Shockwave	Therapy VISA-A NoEE	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 NoEE	vs.	AirHeel	Brace SF-36Return	to	Sport NoNoEE	vs.	Shockwave	Therapy Likert	Scale NoEE	vs.	Concentric	Exercise Return	to	Sport Yes	(P	=	0.002)EE	vs.	Wait-and-See Likert	Scale Yes	(P	<	0.001)PAINSATISFACTIONFUNCTIONComparison 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** NoEE	vs.	Wait	and	See Author	designed Yes				(P<0.001)Comparison Outcome	Measure Eccentrics	Better?EE	vs.	Ultrasound FILLA NoEE	vs.	AirHeel	Brace AOFAS NoEE	vs.	Shockwave	Therapy VISA-A NoEE	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 NoEE	vs.	AirHeel	Brace SF-36Return	to	Sport NoNoEE	vs.	Shockwave	Therapy Likert	Scale NoEE	vs.	Concentric	Exercise Return	to	Sport Yes	(P	=	0.002)EE	vs.	Wait-and-See Likert	Scale Yes	(P	<	0.001)PAINSATISFACTIONFUNCTIONComparison 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** NoEE	vs.	Wait	and	See Author	designed Yes				(P<0.001)Comparison Outcome	Measure Eccentrics	Better?EE	vs.	Ultrasound FILLA NoEE	vs.	AirHeel	Brace AOFAS NoEE	vs.	Shockwave	Therapy VISA-A NoEE	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 NoEE	vs.	AirHeel	Brace SF-36Return	to	Sport NoNoEE	vs.	Shockwave	Therapy Likert	Scale NoEE	vs.	Concentric	Exercise Return	to	Sport Yes	(P	=	0.002)EE	vs.	Wait-and-See Likert	Scale Yes	(P	<	0.001)PAINSATISFACTIONFUNCTIONComparison 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** NoEE	vs.	Wait	and	See Author	designed Yes				(P<0.001)Comparison Outcome	Measure Eccentrics	Better?EE	vs.	Ultrasound FILLA NoEE	vs.	AirHeel	Brace AOFAS NoEE	vs.	Shockwave	Therapy VISA-A NoEE	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 NoEE	vs.	AirHeel	Brace SF-36Return	to	Sport NoNoEE	vs.	Shockwave	Therapy Likert	Scale NoEE	vs.	Concentric	Exercise Return	to	Sport Yes	(P	=	0.002)EE	vs.	Wait-and-See Likert	Scale Yes	(P	<	0.001)PAINSATISFACTIONFUNCTIONExplanation	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	parameters4. Selection	of	outcome	measures.	¡ PEDro	Scores§ Subject	&	therapist	blinding§ Assessor	blinding¡ Conflict	of	Interest?PEDro	Scores:StudySackett’s Level of EvidencePEDro criteria* PEDro score (/11)1 2 3 4 5 6 7 8 9 10 11Chester II (n=16) Ö Ö Ö X X X Ö X X Ö Ö 6Herrington II (n=25) Ö Ö X Ö X X Ö Ö Ö Ö X 7Mafi II (n=44) Ö Ö Ö Ö X X X Ö X Ö Ö 7Peterson I (n=72) Ö Ö Ö Ö X X X Ö Ö Ö Ö 8Rompe I (n=75) Ö Ö Ö Ö X X Ö Ö Ö Ö Ö 9PEDro criteria: 1 – Eligibility criteria  2 – Random allocation  3 – Concealed allocation  4 – Baseline comparability  5 – Subject blinding6 – 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 reportedÖ - 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	exercisemay…§ Be	more	likely	to	adhere	to	an	exercise	program§ Have	better	body	awareness§ Have	a	more	positive	attitude	toward	exercise§ Have	superior	exercise	form	and	body	mechanics§ Have	increased	experience	pushing	through	pain	and	fatigue¡ Previously	sedentary participants	with	no	history	of	physical	activity	may…§ Have	to	make	a	substantial	lifestyle	adjustment§ Have	some	difficulty	with	skill	acquisition	of	the	exercises§ Have	some	difficulty	with	adherence	to	an	exercise	program¡ Variability	between	EE	protocols§ 90	repetitions/day	(Chester	et	al.,	2007)§ 180	reps/day	(Herrington	&	McCulloch,	2007;	Mafi	et	al.,	2000;	Rompe	et	al.,	2007)§ 270	repetitions/day	(Petersen	et	al.,	2007)¡ Comparability	of	EE	and	comparison	interventions§ Unable	to	compare	most	intensities	(e.g.	EE	vs.	US)§ Mafi	et	al.	(2000);	EE	vs.	CE4. Outcome MeasuresLowest	Quality Highest	QualityPainFunction FILLA AOFAS VISA-APatient	Satisfaction“Yes/No”	Questionnaires EuroQol SF-36 Specific	Likert	ScalesVASLoad-induced	painPain	thresholdTenderness	on	palpation• Larger	sample	size• Blinding	of	assessorsLack	of	high	quality	studies• Include	3,	6,	12	month	follow-ups	of	participantsLack	of	follow-up• Use	standardized	outcome	measures,	with	high	sensitivity	and	specificity	(Eg.	VISA-A,	Likert)• Include	measure	of	participant	complianceLack	of	comparable	outcome	measures• Identify	optimal	dosage	(set,	reps,	intensity,	pain)• Identify	optimal	duration	of	trainingUnclear	exercise	parametersLack	comparable,	Level	I	data:• Lack	reproducible	results• Lack	quality,	generalizability• Lack	specific	exercise	parameters• Unclear	patient	demographicsSupport	for	eccentric	exercise:• At	least	as	effective	as	other	Rx• Safe,	low-cost,	non-invasive	option• Some	patients	may	respond	more	favourably• May	be	minimal	dose	below	which	there	may	be	limited	to	no	effectImplications for Clinicians¡ Not	a	stand-alone	treatment!¡ Remember…INTRINSIC¡ Overpronation	hindfoot¡ Varus	forefoot¡ Quads	and	Gastroc	weakness¡ Advanced	age¡ ObesityEXTRINSIC¡ Training	errors¡ Poor	movement	techniques¡ Poor	footwear¡ Running	on	hard/uneven	surfacesTake	home	messageTrends:• Patient	population:Athletic	>>	sedentary• Exercise	intensity:	higher	>>	lowerEE	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 ScottDr. Elizabeth DeanDr. Darlene ReidCharlotte BeckDean GiustiniAbbassian,	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,	360Alfredson,	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	surveyquestionnaire.	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.	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