Hayley Carter
Nikki Christopher
Danielle Fashler
Ryan Hill
Christine Reid
Drew Teskey
Introduction
Methods
Results
Discussion
Conclusion
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
Achilles 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
“Sports injury?”
sedentary
Interaction between intrinsic & extrinsic factors:
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

Failed healing response?
 Neovasculature and nerve proliferation
↓ pain
↓ neovessels
Scott, A., (2010)





Ultrasound
Shock-wave therapy
Corticosteroid injections
Surgery
NSAIDs
 Eccentric Exercise





Conservative approach
Low-cost
No equipment
Self-management
Effective
Mechanism?
• Mechanical sclerosing
• Collagen remodelling
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
Intervention
Comparison
Outcome
• Adults (18-65) with chronic (≥ 3months) midportion Achilles Tendinopathy
• Eccentric heel drop protocol ≥ 6wk duration
• Other treatment (including no treatment)
• Pain (Primary)
• Function and Patient Satisfaction (Secondary)
MEDLINE (1950 – Present)
EMBASE (1980 – Present)
CINAHL (1982 – Present)
PubMed (1949 – Present)
PEDro (1929 – Present)
Wed of Science
Grey Literature (eg. TRIP, SUMSearch, Toby)
Tend*
OR
Tendinitis – focus
(Thesaurus)
Achilles
OR
Achilles Tendon
(Thesaurus)
AND
Eccentric
OR
Eccentric Muscle
Contraction – explode
(Thesaurus)
RCT filter = (random*
AND control* AND
trial*) OR (RCT*)
Example: EMBASE
Web of
Science
32
EMBASE
16
CINAHL
17
284
Medline
25
(with
duplicates)
PubMed
24
PEDro
15
Other
155
1)
2)
3)
4)
5)
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
1)
2)
3)
4)
5)
6)
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
Study Selection
TOTAL HITS
284
First level screen
• Title
21
remain
Second level screen
• Abstract
Third level screen
11
remain
• Full text
INCLUDED IN REVIEW
5 total

Sackett’s Level of Evidence & PEDro Scores:
Study
Sackett’s
Level of
Evidence
PEDro criteria*
1
2
3
4
5
6
7
8
9
10
11
PEDro
score
(/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 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
Description of Review Findings

Insufficient homogeneity for meta-analysis
1. 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-See
2) Shockwave Therapy
Results
2. Different outcome measures
Pain
▪ (VAS, VISA-A, Load-induced pain, Pain threshold, TOP)
Function
▪ (FILLA, AOFAS, VISA-A)
Patient Satisfaction
▪ (EuroQol, SF-36, Likert scale, “Yes/No”)
Comparison
Outcome Measure
Eccentrics better?
EE vs. Ultrasound
VAS*
No
EE vs. AirHeel Brace
VAS
Yes (rest; P<0.001)
No*** (walking)
No (sport)
EE vs. Concentric
Exercise
VAS
Yes
EE vs. Shockwave
Author designed**
No
EE vs. Wait and See
Author designed
Yes (P<0.001)
(all)
(walking;
P<0.001)
*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
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-36
Return to Sport
No
No
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
FUNCTION
SATISFACTION
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-36
Return to Sport
No
No
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
FUNCTION
SATISFACTION
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-36
Return to Sport
No
No
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
FUNCTION
SATISFACTION
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-36
Return to Sport
No
No
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
FUNCTION
SATISFACTION
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-36
Return to Sport
No
No
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)
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:
Study
Sackett’s
Level of
Evidence
PEDro criteria*
1
2
3
4
5
6
7
8
9
10
11
PEDro
score
(/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 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

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
VAS
Load-induced pain
Pain threshold
Tenderness on palpation
Pain
Function
FILLA
Patient
Satisfaction
“Yes/No”
Questionnaires
AOFAS
EuroQol
VISA-A
SF-36
Specific Likert
Scales
Lack of high
quality studies
• Larger sample size
• Blinding of assessors
• Include 3, 6, 12 month follow-ups of participants
Lack of follow-up
• Use standardized outcome measures, with high
Lack of
sensitivity and specificity (Eg. VISA-A, Likert)
comparable
outcome measures • Include measure of participant compliance
Unclear exercise
parameters
• Identify optimal dosage (set, reps, intensity, pain)
• Identify optimal duration of training
Lack comparable, Level I data:
•
•
•
•
Lack reproducible results
Lack quality, generalizability
Lack specific exercise parameters
Unclear patient demographics
Support 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 effect
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
Trends:
• Patient population:
Athletic >> sedentary
• Exercise intensity:
higher >> lower
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 Scott
Dr. Elizabeth Dean
Dr. Darlene Reid
Charlotte Beck
Dean Giustini
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Questions?