"Medicine, Faculty of"@en . "Physical Therapy, Department of"@en . "DSpace"@en . "Brown, Paul"@en . "Lazjerowicz, Cleo"@en . "Martin, Aislin"@en . "Phillips, Margaret"@en . "Yeates, Michelle"@en . "Li, Linda C."@en . "2007-07-30T20:58:59Z"@en . "2007-07-30"@en . "MPT Systematic Reviews and Research Projects."@en . "https://circle.library.ubc.ca/rest/handle/2429/129?expand=metadata"@en . "44136712 bytes"@en . "1341049 bytes"@en . "application/octet-stream"@en . "application/pdf"@en . "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 \u00C2\u00BE Purpose \u00C2\u00BE Introduction \u00C2\u00BE Methods \u00C2\u00BE Results \u00C2\u00BE Discussion \u00C2\u00BE Clinical Relevance \u00C2\u00BE Future Research Purpose To systematically review the current evidence and determine the effectiveness of eccentric exercise in the treatment of chronic tendinosis Introduction Tendinosis: \u00C2\u00BE a non-inflammatory intratendinous collagen degeneration without clinical or histological signs of inflammation1,2 Common tendons affected: \u00C2\u00BE patellar, Achilles, tendons of the medial and lateral elbow, rotator cuff2 Introduction Prevalence \u00C2\u00BE Elite male volleyball players z 40% to 50% patellar tendinosis 3 \u00C2\u00BE General population z lateral epicondylitis annual incidence is between 1% -3%4,5 \u00C2\u00BE Competitive tennis players z incidence can be as high as 40% 4, 5 \u00C2\u00BE Elite and recreational runners z Achilles tendinopathies accounts for 9% of injuries 6 \u00C2\u0099 Overuse injuries, including tendinopathies, account for nearly 7% of all injury related physician office visits in the United States 7 Introduction Common causes1: \u00C2\u00BE Aging \u00C2\u00BE Microtrauma \u00C2\u00BE Vascular compromise Common population3-7: \u00C2\u00BE Competitive and recreational athletes \u00C2\u00BE People in occupations consisting of repetitive tasks or manual labor Recovery times with treatment1: \u00C2\u00BE Early presentation: 6-10 weeks \u00C2\u00BE Chronic presentation: 3-6 months Introduction Histological Findings 1,2,4,8,9 \u00C2\u00BE \u00E2\u0086\u0091 cellularity - fibroblasts and myofibroblasts \u00C2\u00BE \u00E2\u0086\u0091 vascularity and ground substance \u00C2\u00BE Collagen disorientation, disorganization, focal necrosis or calcification, vascular spaces with or without neovascularization and fiber separation \u00C2\u00BE Absence of inflammatory cells Normal Introduction Conservative Treatments1-8 \u00C2\u00BE Ultrasound \u00C2\u00BE Laser \u00C2\u00BE Deep friction massage \u00C2\u00BE Orthotics and braces \u00C2\u00BE Corticosteroids \u00C2\u00BE Mobilizations and manipulations \u00C2\u00BE Thermotherapy \u00C2\u00BE Cryotherapy \u00C2\u00BE Rest \u00C2\u00BE Acupuncture \u00C2\u00BE Pulsed electromagnetic field therapy \u00C2\u00BE Eccentric exercise Introduction Eccentric Exercise \u00C2\u00BE The active lengthening of a muscle under force10 Introduction \u00C2\u00BE Eccentric training leads to increased net collagen synthesis in the tendon tissue through constant overload on the tendon11 \u00C2\u00BE 12 weeks of EE training normalized tendon structure and decreased tendon thickness in Achilles tendinosis12 RATIONALE \u00C2\u00BE The literature shows that eccentric exercise has promise for treatment of Achilles and patellar tendinopathies GOAL \u00C2\u00BE Review the literature to examine the effectiveness of eccentric exercise as a treatment for tendinosis Introduction Methods Methods: PICO P \u00C2\u00BEPatients diagnosed with a tendinopathy (eg. clinical exam / MRI / Ultrasound / Doctor) or chronic painful tendon greater than 3 months \u00C2\u00BEAdults 16 years or older I \u00C2\u00BEEccentric exercise C \u00C2\u00BEnone O \u00C2\u00BEPain \u00C2\u00BEROM \u00C2\u00BEReturn to functional activities \u00C2\u00BEAvoid surgical intervention \u00C2\u00BEStrength \u00C2\u00BETendon structure/healing Methods: Search Strategy Databases \u00C2\u00BE EMBASE \u00C2\u00BE CINAHL \u00C2\u00BE MEDLINE \u00C2\u00BE PEDro \u00C2\u00BE Cochrane library \u00C2\u00BE SPORTDISCUS Other Forms \u00C2\u00BE Hand searching Journals z Physiotherapy, Physical Therapy \u00C2\u00BE Reference lists \u00C2\u00BE Personal libraries \u00C2\u00BE Communicating with experts in the field z Doctoral candidate (Michael Ryan) Methods: Search Strategy \u00C2\u00BEMain Terms z Tendinopathy, tendinosis, tendon disease, tendon injury z Achilles, swimmers shoulder, patellar tendon, golfer\u00E2\u0080\u0099s elbow, rotator cuff, jumper\u00E2\u0080\u0099s knee z Eccentric exercise 12 Golfer\u00E2\u0080\u0099s elbow.mp 13 Patella$ tend$.mp 14 Jumper\u00E2\u0080\u0099s knee.mp 15 Achilles tend$.mp 16 Eccentric.mp 17 Exercise.mp 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 Tend#nopathy.mp 2 Tend#nosis.mp 3 Tend#nitis.mp 4 Tend#n disease.mp 5 Tend#n injury.mp 6 Swimmer\u00E2\u0080\u0099s shoulder.mp 7 Rotator cuff tend$.mp 8 Shoulder injury.mp 9 Medial epicondyl$ injury.mp 10 Tennis elbow/or medial epicondyle$ injury.mp 11 Tennis elbow/or lateral epicondyle$ injury.mp Table of Search Terms Methods: Study Selection Inclusion Criteria \u00C2\u00BE 16 years or older \u00C2\u00BE Clinical diagnosis of tendinopathy or: \u00C2\u00BE Tendon pain for > 3 months \u00C2\u00BE English studies \u00C2\u00BE Eccentric Exercise Exclusion Criteria \u00C2\u00BE Concurrent treatment \u00C2\u00BE Surgical intervention \u00C2\u00BE Tendinosis caused by injection Methods: Study Selection Study Selection \u00C2\u00BEScreen of title and abstracts \u00C2\u00BESelection of articles based on inclusion criteria z 2 person independent review \u00C2\u00BERecovery and review of full articles z Random allocation to 2 persons for independent review Methods Study Selection \u00C2\u00BEPilot the data extraction form z Modified data extraction form provided by Dr. Linda Li z 10% of articles were tested using the form \u00E2\u0080\u00A2 89.6% based on 115 variables z Changes were made to the form to increase accuracy and consistency Methods Data extraction \u00C2\u00BE Study description \u00C2\u00BE Participant description \u00C2\u00BE Study quality rating (van Tulder13) \u00C2\u00BE Baseline and post treatment outcome measurements \u00C2\u00BE Dropouts, adverse effects Methods: Quality of Studies \u00C2\u00BE Used Van Tulder13 Quality Assessment z 11 criteria rated: Yes, No, Unclear \u00C2\u00BE Methodological criteria were independently assessed by 2 reviewers 9 Consensus reached by discussion \u00C2\u00BE High Quality = Score of 6 of 11 or above \u00C2\u00BE Low Quality = Score 5 and below Methods: Quality of Studies \u00C2\u00BE 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 \u00C2\u00BE Less than 1/2 of the studies blinded the outcome assessor to the intervention or had acceptable compliance (> 70%) in all groups. Methods \u00C2\u00BE Standard mean differences: Hedge\u00E2\u0080\u0099s G z Studies with similar outcome measures \u00C2\u00BE 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 \u00C2\u00BE Patellar tendon N = 6 z Age range: 22-31 years \u00C2\u00BE Achilles tendon N = 7 z Age range: 39-51 years \u00C2\u00BE Wrist extensors N = 3 z Age range: 38-47 years Results: Heterogeneity of studies \u00C2\u00BE Eccentric Exercise (EE): variety of exercises z some protocols have participants exercising through moderate amounts of pain \u00C2\u00BE Comparative Treatments (CT): z Concentric exercise, night splint, stretches, shock wave therapy, TENS, US, DTFM, control \u00C2\u00BE Duration of symptoms: 3-41 months \u00C2\u00BE Duration of Intervention: 4-24 weeks \u00C2\u00BE Number of participants: 15-124 persons \u00C2\u00BE 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: \u00E2\u0080\u00A2 Victorian Institute of Sport Assessment (VISA) \u00E2\u0080\u00A2 Foot and Ankle Outcome Score (FAOS) \u00E2\u0080\u00A2 Pain free grip (PFG) \u00E2\u0080\u00A2 The Disabilities of the Arm, Shoulder and Hand (DASH) \u00E2\u0080\u00A2 Grip strength, global assessments, performance measurements Participation: z Quality of life questionnaires and return to sport Included Studies 12 RCTs3,15-24 \u00C2\u00BE 7 studies rated as high quality (range 6-8) \u00C2\u00BE 5 studies rated as low quality (range 3-5) 4 CCTs25-28 \u00C2\u00BE 1study rated as high quality ( score 7) \u00C2\u00BE 3 studies rated as low quality (range 2-5) Results \u00C2\u00BECalculated 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 \u00C2\u00BEApplied 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 \u00C2\u00BEStatistically significant findings in outcome measures in at least one high quality RCT, OR \u00C2\u00BEConsistent statistically significant findings in outcome measures in at least two high quality CCTs Indicative Findings \u00C2\u00BEStatistically significant findings in outcome and/or process measures in at least one high quality CCT or low quality RCT No Evidence \u00C2\u00BEResults of eligible studies do not meet the criteria for one of the above stated level of evidence, OR \u00C2\u00BEIn 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 \u00E2\u0080\u009Cwait and see\u00E2\u0080\u009D control group No evidence to support the effectiveness of EE on decreasing pain or on increasing strength when compared to CT \u00E2\u0080\u0093 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\u00E2\u0080\u0099s 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: \u00E2\u0080\u00A2 EE with concentric component (2 studies) \u00E2\u0080\u00A2 Treatment & control treatment groups share co-treatments (4 studies) z Poor control of intervention: \u00E2\u0080\u00A2 Monitoring adherence, controlling progression z Underpowered: \u00E2\u0080\u00A2 12/16 studies with sample populations < 50 \u00E2\u0080\u00A2 Inability to conduct meta-analysis or sub group analysis due to heterogeneity z Lack of true controls \u00E2\u0080\u00A2 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 \u00E2\u0080\u00A2 Non-validated and non-standardized preventing comparisons & weakening findings General Limitations \u00C2\u00BE Study Quality Shortcomings (van Tulder criteria13) z Description of randomization z Concealment of treatment allocation z Blinding outcome assessors z Intention to treat analysis \u00C2\u00BE Reporting z 7 out of 16 studies excluded from best evidence synthesis due to lack of data \u00C2\u00BE Generalizability z 8 out of 16 studies use young, elite athletes Eccentric Exercise: What is an optimal Protocol? \u00C2\u00BE Differences of opinion persist as to optimal exercise intervention \u00C2\u00BE 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 \u00C2\u00BE Alfredson model is based on clinical experience and lacks a scientific basis29 \u00C2\u00BE Croisier et al. (2007) found good results in a well controlled study training subjects 3 x/ week versus 7 x/week \u00C2\u00BE They argue that an optimal prescription involves periods of rest to allow for recovery from post exercise weakness Eccentric Protocol: How much pain? \u00C2\u00BE Alfredson et al. (1998) suggest that pain is an essential component of their successful intervention in AT \u00C2\u00BE Curwin and Stanish (1984) achieve good results with a painless protocol in PT and LET3,17,28 \u00C2\u00BE 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 \u00C2\u00BE Overall, the studies demonstrate a positive trend in favour of EE \u00C2\u00BE 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 \u00C2\u00BEBetter research design \u00C2\u00BEConsistent/validated Outcome Measures \u00C2\u00BE 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 \u00C2\u00BEPost treatment assessments z To determine long-term impact Future Research Topics \u00C2\u00BE Improve understanding of physiological effect of EE on the muscle tendon unit & whether this varies by tendon \u00C2\u00BE Optimal EE intervention \u00C2\u00BE 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) \u00C2\u00BE Improved understanding of the pathophysiology of tendinosis across tendons Conclusion \u00C2\u00BE 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. 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Scand J Med Sci Sports 2007;17:61-66. 12. \u00C3\u0096hberg 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. 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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."@en . "Presentation"@en . "10.14288/1.0081225"@en . "eng"@en . "Unreviewed"@en . "Vancouver : University of British Columbia Library"@en . "Attribution-NonCommercial-NoDerivatives 4.0 International"@en . "http://creativecommons.org/licenses/by-nc-nd/4.0/"@en . "Graduate"@en . "University of British Columbia. RSPT 572"@en . "Physical therapy"@en . "Physiotherapy"@en . "Systematic reviews"@en . "Exercise"@en . "Exercise therapy"@en . "Tendinopathy"@en . "Physical Therapy Exercise Interventions in Tendinosis Injuries"@en . "Text"@en . "Sound"@en . "http://hdl.handle.net/2429/129"@en .