Eccentric Exercise in the Treatment of Mid-portion Achilles Tendinopathy: A Systematic Review

1. Hayley Carter Nikki Christopher Danielle Fashler Ryan Hill Christine Reid Drew Teskey Eccentric Exercise in the Treatment of Mid-portion Achilles Tendinopathy: A Systematic Review

2. Overview

3. Introduction Background Information and Research Questions

4. Achilles Tendinopathy (AT) • Chronic pain in the Achilles tendon • Aggravated with loading activities • Tenderness on palpation • Often “thickening” of the tendon • ↓ participation in sport, ADLs

5. Epidemiology • 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?”

6. Etiology Interaction between intrinsic & extrinsic factors: INTRINSIC EXTRINSIC Training errors Poor movement techniques Poor footwear Running on hard/uneven surfaces • Overpronation hindfoot • Varus forefoot • Quads and Gastroc weakness • Advanced age • Obesity

7. Origin of Pain • Failed healing response? • Neovasculature and nerve proliferation ↓ pain ↓ neovessels Scott, A., (2010)

8. Current Treatment Options • Ultrasound • Shock-wave therapy • Corticosteroid injections • Surgery • NSAIDs • Eccentric Exercise

9. Eccentric Exercise • Conservative approach • Low-cost • No equipment • Self-management • Effective

10. Research Questions 1 Is eccentric exercise more effective than other physical therapy treatments at reducing pain in adults with chronic Achilles tendinopathy? 2 Is eccentric exercise more effective than other physical therapy treatments at improving function and patient satisfaction in adults with chronic Achilles tendinopathy?

11. Methods Search Strategy, Selection Criteria and Quality Assessment

12. PICO

13. Databases Searched

14. Search Strategy Example: EMBASE

15. Search Strategy Results

16. Inclusion Criteria • Randomized control trial • Human participants, mean age 18-65, with chronic (≥ 3 months) mid-portion AT • Participants with no other past or present Achilles tendon pathology or other significant L/E pathology • Experimental group underwent eccentric heel drop exercise protocol lasting ≥ 6 weeks • Included outcome measures of pain, function (ROM, strength, or functional scales), patient satisfaction, or return to activity

17. Exclusion Criteria • Not available in full text • Not available in English • Retrospective or non-original studies • In-vitro studies • Animal subjects • Comparison group included an eccentric protocol

18. Study Selection

19. Quality Assessment • Sackett’s Level of Evidence & PEDro Scores: PEDro criteria: 1 – Eligibility criteria 2 – Random allocation 3 – Concealed allocation 4 – Baseline comparability 5 – Subject blinding 6 – 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 reported  - Criterion met X – Criterion not met or not specified

20. Results Description of Review Findings

21. Results • Insufficient homogeneity for meta-analysis • Different comparators

22. Results 2.Different outcome measures • (VAS, VISA-A, Load-induced pain, Pain threshold, TOP) • (FILLA, AOFAS, VISA-A) • (EuroQol, SF-36, Likert scale, “Yes/No”) Pain Function Patient Satisfaction

23. Pain *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 EE

24. Function

25. Patient Satisfaction

26. PAIN FUNCTION SATISFACTION

27. PAIN FUNCTION SATISFACTION

28. PAIN FUNCTION SATISFACTION

29. PAIN FUNCTION SATISFACTION

30. Discussion Explanation of the Results, Study Limitations and Implications for Research & Clinicians

31. Discussion • Variability of results makes it difficult to draw firm conclusions • Contributing Factors: • Study quality • Study sample characteristics • Intervention parameters • Selection of outcome measures.

32. 1. Study Quality • PEDro Scores • Subject & therapist blinding • Assessor blinding • Conflict of Interest?

33. Quality Assessment PEDro Scores: PEDro criteria: 1 – Eligibility criteria 2 – Random allocation 3 – Concealed allocation 4 – Baseline comparability 5 – Subject blinding 6 – 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 reported  - Criterion met X – Criterion not met or not specified

34. 1. Study Quality • 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

35. 2. Study Sample Characteristics • 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

36. 2. Study Sample Characteristics • Patients with previous experience with exercise may… • 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

37. 3. Intervention Parameters • 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. CE

38. 4. Outcome Measures VAS Load-induced pain Pain threshold Tenderness on palpation

39. Review Limitations/Implications for Research

40. Implications for the Clinician

41. Implications for Clinicians • Not a stand-alone treatment! • Remember… INTRINSIC EXTRINSIC • Overpronation hindfoot • Varus forefoot • Quads and Gastroc weakness • Advanced age • Obesity • Training errors • Poor movement techniques • Poor footwear • Running on hard/uneven surfaces

42. Conclusion Take home message

43. Conclusions EE is at least as effective as other treatments

44. Overall Recommendation Eccentric 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.

45. Special thank you to: Dr. Teresa Liu-AmbroseOther contributors: Dr. Alex Scott Dr. Elizabeth Dean Dr. Darlene Reid Charlotte Beck Dean Giustini

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49. Questions?