Hayley CarterNikki ChristopherDanielle FashlerRyan HillChristine ReidDrew Teskey

Background 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, ADLs

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

INTRINSIC

Overpronation hindfoot Varus forefoot Quads and Gastroc

weakness Advanced age Obesity

EXTRINSIC

Training errors Poor movement

techniques Poor footwear Running on hard/uneven

surfaces

Interaction between intrinsic & extrinsic factors:

Failed healing response? Neovasculature and nerve proliferation

↓ neovessels ↓ pain

Scott, A., (2010)

Ultrasound Shock-wave therapy Corticosteroid injections Surgery NSAIDs

Eccentric Exercise

Conservative approach Low-cost No equipment Self-management Effective

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 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?

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

Example: EMBASE

1) 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 weeks

5) 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

protocol

Sackett’s Level of Evidence & PEDro Scores:

StudySackett’s Level of

Evidence

PEDro criteria* PEDro score (/11)1 2 3 4 5 6 7 8 9 10 11

Chester II (n=16) X X X X X 6

Herrington II (n=25) X X X X 7

Mafi II (n=44) X X X X 7

Peterson I (n=72) X X X 8

Rompe I (n=75) X X 9

PEDro 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 reported - Criterion met X – Criterion not met or not specified

Description of Review Findings

Insufficient homogeneity for meta-analysis1. Different comparators

Study Comparison Group(s)

Chester et al. (2007) Ultrasound

Herrington & McCulloch (2007) Standard Care (ultrasound, deep friction massage and stretching)

Mafi et al. (2000) Concentric Exercise

Petersen et al. (2007) AirHeel Brace

Rompe et al. (2007) 1) Wait-and-See2) Shockwave Therapy

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

*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

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** No

EE vs. Wait and See Author designed Yes (P<0.001)

Comparison Outcome Measure Eccentrics Better?

EE vs. Ultrasound FILLA No

EE vs. AirHeel Brace AOFAS No

EE vs. Shockwave Therapy

VISA-A No

EE 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 No

EE vs. AirHeel Brace SF-36Return to Sport

NoNo

EE vs. Shockwave Therapy

Likert Scale No

EE 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** No

EE vs. Wait and See Author designed Yes (P<0.001)

Comparison Outcome Measure Eccentrics Better?

EE vs. Ultrasound FILLA No

EE vs. AirHeel Brace AOFAS No

EE vs. Shockwave Therapy VISA-A No

EE 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 No

EE vs. AirHeel Brace SF-36Return to Sport

NoNo

EE vs. Shockwave Therapy Likert Scale No

EE vs. Concentric Exercise Return to Sport Yes (P = 0.002)

EE vs. Wait-and-See Likert Scale Yes (P < 0.001)

PAIN

SAT

ISFA

CTIO

NFU

NCT

ION

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** No

EE vs. Wait and See Author designed Yes (P<0.001)

Comparison Outcome Measure Eccentrics Better?

EE vs. Ultrasound FILLA No

EE vs. AirHeel Brace AOFAS No

EE vs. Shockwave Therapy VISA-A No

EE 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 No

EE vs. AirHeel Brace SF-36Return to Sport

NoNo

EE vs. Shockwave Therapy Likert Scale No

EE vs. Concentric Exercise Return to Sport Yes (P = 0.002)

EE vs. Wait-and-See Likert Scale Yes (P < 0.001)

PAIN

SAT

ISFA

CTIO

NFU

NCT

ION

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** No

EE vs. Wait and See Author designed Yes (P<0.001)

Comparison Outcome Measure Eccentrics Better?

EE vs. Ultrasound FILLA No

EE vs. AirHeel Brace AOFAS No

EE vs. Shockwave Therapy VISA-A No

EE 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 No

EE vs. AirHeel Brace SF-36Return to Sport

NoNo

EE vs. Shockwave Therapy Likert Scale No

EE vs. Concentric Exercise Return to Sport Yes (P = 0.002)

EE vs. Wait-and-See Likert Scale Yes (P < 0.001)

PAIN

SAT

ISFA

CTIO

NFU

NCT

ION

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** No

EE vs. Wait and See Author designed Yes (P<0.001)

Comparison Outcome Measure Eccentrics Better?

EE vs. Ultrasound FILLA No

EE vs. AirHeel Brace AOFAS No

EE vs. Shockwave Therapy VISA-A No

EE 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 No

EE vs. AirHeel Brace SF-36Return to Sport

NoNo

EE vs. Shockwave Therapy Likert Scale No

EE vs. Concentric Exercise Return to Sport Yes (P = 0.002)

EE vs. Wait-and-See Likert Scale Yes (P < 0.001)

PAIN

SAT

ISFA

CTIO

NFU

NCT

ION

Explanation 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 parameters

4. Selection of outcome measures.

PEDro Scores Subject & therapist blinding Assessor blinding

Conflict of Interest?

PEDro Scores:

StudySackett’s Level of

Evidence

PEDro criteria* PEDro score (/11)1 2 3 4 5 6 7 8 9 10 11

Chester II (n=16) X X X X X 6

Herrington II (n=25) X X X X 7

Mafi II (n=44) X X X X 7

Peterson I (n=72) X X X 8

Rompe I (n=75) X X 9

PEDro 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 reported - 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 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

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

4. Outcome Measures

Lowest Quality Highest Quality

Pain

Function FILLA AOFAS VISA-A

Patient Satisfaction

“Yes/No” Questionnaires

EuroQol SF-36 Specific Likert Scales

VASLoad-induced pain

Pain thresholdTenderness on palpation

Implications for Clinicians

Not a stand-alone treatment! Remember…

INTRINSIC

Overpronation hindfoot Varus forefoot Quads and Gastroc

weakness Advanced age Obesity

EXTRINSIC

Training errors Poor movement

techniques Poor footwear Running on hard/uneven

surfaces

Take home message

EE is at least as effective as other treatments

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.

Special thank you to:Dr. Teresa Liu-Ambrose

Other contributors:Dr. Alex ScottDr. Elizabeth DeanDr. Darlene ReidCharlotte BeckDean Giustini

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Questions?