1
|
Pavlova AV, Shim JSC, Moss R, Maclean C, Brandie D, Mitchell L, Greig L, Parkinson E, Alexander L, Tzortziou Brown V, Morrissey D, Cooper K, Swinton PA. Effect of resistance exercise dose components for tendinopathy management: a systematic review with meta-analysis. Br J Sports Med 2023; 57:1327-1334. [PMID: 37169370 PMCID: PMC10579176 DOI: 10.1136/bjsports-2022-105754] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVE To investigate potential moderating effects of resistance exercise dose components including intensity, volume and frequency, for the management of common tendinopathies. DESIGN Systematic review with meta-analysis and meta-regressions. DATA SOURCES Including but not limited to: MEDLINE, CINAHL, SPORTDiscus, ClinicalTrials.gov and ISRCTN Registry. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised and non-randomised controlled trials investigating resistance exercise as the dominant treatment class, reporting sufficient information regarding ≥2 components of exercise dose. RESULTS A total of 110 studies were included in meta-analyses (148 treatment arms (TAs), 3953 participants), reporting on five tendinopathy locations (rotator cuff: 48 TAs; Achilles: 43 TAs; lateral elbow: 29 TAs; patellar: 24 TAs; gluteal: 4 TAs). Meta-regressions provided consistent evidence of greater pooled mean effect sizes for higher intensity therapies comprising additional external resistance compared with body mass only (large effect size domains: β BodyMass: External = 0.50 (95% credible interval (CrI): 0.15 to 0.84; p=0.998); small effect size domains (β BodyMass: External = 0.04 (95% CrI: -0.21 to 0.31; p=0.619)) when combined across tendinopathy locations or analysed separately. Greater pooled mean effect sizes were also identified for the lowest frequency (less than daily) compared with mid (daily) and high frequencies (more than once per day) for both effect size domains when combined or analysed separately (p≥0.976). Evidence for associations between training volume and pooled mean effect sizes was minimal and inconsistent. SUMMARY/CONCLUSION Resistance exercise dose is poorly reported within tendinopathy management literature. However, this large meta-analysis identified some consistent patterns indicating greater efficacy on average with therapies prescribing higher intensities (through inclusion of additional loads) and lower frequencies, potentially creating stronger stimuli and facilitating adequate recovery.
Collapse
Affiliation(s)
| | - Joanna S C Shim
- School of Health Sciences, Robert Gordon University, Aberdeen, UK
| | - Rachel Moss
- School of Health Sciences, Robert Gordon University, Aberdeen, UK
| | - Colin Maclean
- Library Services, Robert Gordon University, Aberdeen, UK
| | - David Brandie
- Physiotherapy, Sportscotland Institute of Sport, Stirling, UK
| | | | - Leon Greig
- School of Health Sciences, Robert Gordon University, Aberdeen, UK
| | - Eva Parkinson
- School of Health Sciences, Robert Gordon University, Aberdeen, UK
| | | | | | - Dylan Morrissey
- Sports and Exercise Medicine, Queen Mary University of London, London, UK
- Physiotherapy Department, Barts Health NHS Trust, London, UK
| | - Kay Cooper
- School of Health Sciences, Robert Gordon University, Aberdeen, UK
| | - Paul A Swinton
- School of Health Sciences, Robert Gordon University, Aberdeen, UK
| |
Collapse
|
2
|
Schaefer L, Bittmann F. Mechanotendography in Achillodynia shows reduced oscillation variability of pre-loaded Achilles tendon: a pilot study. Eur J Transl Myol 2020. [DOI: 10.4081/ejtm.2020.8983] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The present study focuses on an innovative approach in measuring the mechanical oscillations of pre-loaded Achilles tendon by using Mechanotendography (MTG) during application of a short yet powerful mechanical pressure impact. This was applied on the forefoot from the plantar side in direction of dorsiflexion, while the subject stood on the ball of the forefoot on one leg. Participants with Achilles tendinopathy (AT; n = 10) were compared to healthy controls (Con; n = 10). Five trials were performed on each side of the body. For evaluation, two intervals after the impulse began (0-100ms; 30-100ms) were cut from the MTG and pressure raw signals. The intrapersonal variability between the five trials in both intervals were evaluated using the arithmetic mean and coefficient of variation of the mean correlation (Spearman rank correlation) and the normalized averaged mean distances, respectively. The AT-group showed a significantly reduced variability in MTG compared to the Con-group (from p = 0.006 to p = 0.028 for different parameters). The 95% confidence intervals (CI) of MTG results were disjoint, whereas the 95% CIs of the pressure signals were similar (p = 0.192 to p = 0.601). We suggest from this work that the variability of mechanical tendon oscillations could be an indicative parameter of an altered Achilles tendon functionality.
Collapse
|
3
|
Schaefer L, Bittmann F. Mechanotendography in Achillodynia shows reduced oscillation variability of pre-loaded Achilles tendon: a pilot study. Eur J Transl Myol 2020; 30:8983. [PMID: 32782763 PMCID: PMC7385694 DOI: 10.4081/ejtm.2019.8983] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 04/09/2020] [Indexed: 12/23/2022] Open
Abstract
The present study focuses on an innovative approach in measuring the mechanical oscillations of pre-loaded Achilles tendon by using Mechanotendography (MTG) during application of a short yet powerful mechanical pressure impact. This was applied on the forefoot from the plantar side in direction of dorsiflexion, while the subject stood on the ball of the forefoot on one leg. Participants with Achilles tendinopathy (AT; n = 10) were compared to healthy controls (Con; n = 10). Five trials were performed on each side of the body. For evaluation, two intervals after the impulse began (0-100ms; 30-100ms) were cut from the MTG and pressure raw signals. The intrapersonal variability between the five trials in both intervals were evaluated using the arithmetic mean and coefficient of variation of the mean correlation (Spearman rank correlation) and the normalized averaged mean distances, respectively. The AT-group showed a significantly reduced variability in MTG compared to the Con-group (from p = 0.006 to p = 0.028 for different parameters). The 95% confidence intervals (CI) of MTG results were disjoint, whereas the 95% CIs of the pressure signals were similar (p = 0.192 to p = 0.601). We suggest from this work that the variability of mechanical tendon oscillations could be an indicative parameter of an altered Achilles tendon functionality.
Collapse
Affiliation(s)
- Laura Schaefer
- Regulative Physiology and Prevention, Department of Sport and Health Sciences, University of Potsdam, Germany
| | - Frank Bittmann
- Regulative Physiology and Prevention, Department of Sport and Health Sciences, University of Potsdam, Germany
| |
Collapse
|
4
|
O'Neill S, Radia J, Bird K, Rathleff MS, Bandholm T, Jorgensen M, Thorborg K. Acute sensory and motor response to 45-s heavy isometric holds for the plantar flexors in patients with Achilles tendinopathy. Knee Surg Sports Traumatol Arthrosc 2019; 27:2765-2773. [PMID: 29974171 PMCID: PMC6706360 DOI: 10.1007/s00167-018-5050-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 06/28/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE The purpose of this study was to explore the immediate effects of heavy isometric plantar flexor exercise on sensory output (pain during a functional task and mechanical pain sensitivity) and motor output (plantar flexor torque) in individuals with Achilles tendinopathy. METHODS Sixteen subjects with Achilles tendinopathy participated in the study, mean (SD) age 48.6 (8.9) years and Victorian institute assessment-Achilles (VISA-A) score 61.3 (23.0). Sensory testing assessing pain during a functional task, mechanical pain sensitivity and motor output, and plantar flexor peak torque was completed prior to the intervention. All subjects completed a 45-s heavy isometric plantar flexor contraction and were then re-tested using the same sensory and motor tests. Motor output was assessed using isokinetic dynamometry at speeds previously identified as of interest in subjects with Achilles tendinopathy. RESULTS Only 9 of the 16 subjects experienced pain during a functional task, self-reported pain was 4.2 (1.9) numerical rating scale (NRS) pre-intervention and 4.9 (3.2) NRS postintervention (n.s.). Mechanical pressure sensitivity was 446.5 (± 248.5) g/mm2 pre-intervention and 411.8 (± 211.8) g/mm2 post-intervention (n.s.). Mean concentric plantar flexor torque at 90 and 225°/s was 47.1 (14.5) and 33.6 (11.6) Nm, respectively, pre-intervention and 53.0 (18.5) and 33.4 (6.6) Nm post-intervention (p = 0.039 and n.s.). Eccentric torque at 90°/s was 98.5 (34.2) Nm preintervention versus 106.0 (41.4) Nm post-intervention (n.s.). CONCLUSION In this exploratory study, patients with Achilles tendinopathy had a varied sensory and motor output response to heavy isometric contractions. Using the recommended approach of heavy 45-s isometric contractions did not offer a meaningful acute benefit for sensory or motor output for subjects with Achilles tendinopathy. Based on this study, heavy 45-s isometric contractions cannot be recommended for immediate pain relief or improved motor output for patients with Achilles tendinopathy. LEVEL OF EVIDENCE IV, prospective cohort study.
Collapse
Affiliation(s)
- S O'Neill
- School of Allied Health, University of Leicester, Leicester, UK.
| | - J Radia
- School of Allied Health, University of Leicester, Leicester, UK
| | - K Bird
- School of Allied Health, University of Leicester, Leicester, UK
| | - M S Rathleff
- Research Unit for General Practice in Aalborg, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Occupational Therapy and Physiotherapy, Aalborg University Hospital, Aalborg University, Aalborg, Denmark
| | - T Bandholm
- Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Department of Physical and Occupational Therapy, Clinical Research Center, Amager-Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
- Department of Orthopedic Surgery, Clinical Research Center, Amager-Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - M Jorgensen
- Department of Geriatrics, Aalborg University Hospital, Aalborg, Denmark
| | - K Thorborg
- Sport Orthopedic Research Center-Copenhagen (SORC-C), Amager-Hvidovre University Hospital, Copenhagen, Denmark
| |
Collapse
|
5
|
Udeze CP, Jones ER, Riley GP, Morrissey D, Screen HRC. An in vitro investigation into the effects of 10 Hz cyclic loading on tenocyte metabolism. Scand J Med Sci Sports 2019; 29:1511-1520. [PMID: 31102473 DOI: 10.1111/sms.13465] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 03/25/2019] [Accepted: 04/30/2019] [Indexed: 12/25/2022]
Abstract
Tendinopathy is a prevalent, highly debilitating condition, with poorly defined etiology. A wide range of clinical treatments has been proposed, with systematic reviews largely supporting shock wave therapy or eccentric exercise. Characterizing these treatments have demonstrated both generate perturbations within tendon at a frequency of approximately 8-12 Hz. Consequently, it is hypothesized that loading in this frequency range initiates increased anabolic tenocyte behavior, promoting tendon repair. The primary aim of this study was to investigate the effects of 10 Hz perturbations on tenocyte metabolism, comparing gene expression in response to a 10 Hz and 1 Hz loading profile. Tenocytes from healthy and tendinopathic human tendons were seeded into 3D collagen gels and subjected to 15 minutes cyclic strain at 10 Hz or 1 Hz. Tenocytes from healthy tendon showed increased expression of all analyzed genes in response to loading, with significantly increased expression of inflammatory and degradative genes with 10 Hz, relative to 1 Hz loading. By contrast, whilst the response of tenocytes from tendinopathy tendon also increased with 10 Hz loading, the overall response profile was more varied and less intense, possibly indicative of an altered healing response. Through inhibition of the pathway, IL1 was shown to be involved in the degradative and catabolic response of cells to high-frequency loading, abrogating the loading response. This study has demonstrated for the first time that loading at a frequency of 10 Hz may enhance the metabolic response of tenocytes by initiating an immediate degradatory and inflammatory cell response through the IL1 pathway, perhaps as an initial stage of tendon healing.
Collapse
Affiliation(s)
- Chineye P Udeze
- School of Engineering and Material Science, Queen Mary University of London, London, UK
| | | | | | - Dylan Morrissey
- Sport and Exercise Medicine, Queen Mary University of London, London, UK.,Physiotherapy Department, Bart's Health NHS Trust, London, UK
| | - Hazel R C Screen
- School of Engineering and Material Science, Queen Mary University of London, London, UK
| |
Collapse
|
6
|
Gaulke R, Krettek C. [Tendinopathies of the foot and ankle : Evidence for the origin, diagnostics and therapy]. Unfallchirurg 2017; 120:205-213. [PMID: 28120032 DOI: 10.1007/s00113-016-0301-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Tendinopathies of the foot and ankle result in substantial impairment of the mobility of patients and have a high clinical significance. Knowledge of the origin of these diseases has been accumulated over decades from the multitude of intrinsic and extrinsic triggering factors based on biomechanical considerations with an evidence-based medicine (EBM) level 5. A high correlation between tendinopathy and hypervascularization of the Achilles tendon was found in a double-blind randomized prospective study using Doppler ultrasound (EBM level 1) but these results were not reproducible; therefore, the importance of these findings is unclear. Inspection and clinical examination supplemented by ultrasound and magnetic resonance imaging (MRI) are essential to achieve the correct diagnosis. The varying extent of load-dependent irritation of tendons and the surrounding tissues and the individual variation in experience of investigators mean that the results of clinical examinations are difficult to collate or not reproducible and cannot be investigated in studies. The expression of the varying results is difficult to assess even by the use of sonography and magnetic resonance imaging (MRI). Conservative treatment of tendinopathy is based on medical experience (EBM level 5). The effectiveness of physiotherapeutic eccentric loading and extracorporal shock wave treatment (ESWT) for Achilles tendinopathy was demonstrated in several case control studies and series (EBM level 3). Due to the high rate of healing with physiotherapy, surgery should only be performed following a minimum of 6-12 weeks of unsuccessful conservative treatment, because formation of scar tissue on the foot can result in permanent complaints (EBM level 4).
Collapse
Affiliation(s)
- Ralph Gaulke
- Sektion Obere Extremität, Fuß- und Rheumachirurgie, Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - Christian Krettek
- Sektion Obere Extremität, Fuß- und Rheumachirurgie, Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| |
Collapse
|
7
|
Iversen JV, Bartels EM, Jørgensen JE, Nielsen TG, Ginnerup C, Lind MC, Langberg H. Danish VISA-A questionnaire with validation and reliability testing for Danish-speaking Achilles tendinopathy patients. Scand J Med Sci Sports 2015; 26:1423-1427. [PMID: 26648348 DOI: 10.1111/sms.12576] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2015] [Indexed: 12/16/2022]
Abstract
The VISA-A questionnaire has proven to be a valid and reliable tool for assessing severity of Achilles tendinopathy (AT). The aim was to translate and cross-culturally adapt the VISA-A questionnaire for a Danish-speaking AT population, and subsequently perform validity and reliability tests. Translation and following cross-cultural adaptation was performed as translation, synthesis, reverse translation, expert review, and pretesting. The final Danish version (VISA-A-DK) was tested for reliability on healthy controls (n = 75) and patients (n = 36). Tests for internal consistency, validity, and structure were performed on 71 patients. VISA-A-DK showed good reliability for patients (r = 0.80 ICC = 0.79) and healthy individuals (r = 0.98 ICC = 0.97). Internal consistency was 0.73 (Cronbach's alpha). The mean VISA-A-DK score in AT patients was 51 [47-55]. This was significantly lower than healthy controls with a score of 93 (90-95). Criterion validity was considered good when comparing the scores of the Danish version with the original version in both healthy individuals and patients. VISA-A-DK is a valid and reliable instrument and has shown compatible to the original version in assessment of AT patients. VISA-A-DK is a useful tool in the assessment of AT, both in research and in a clinical setting.
Collapse
Affiliation(s)
- J V Iversen
- Department of Orthopaedic Surgery, Bispebjerg University Hospital, Copenhagen, Denmark
| | - E M Bartels
- The Parker Institute, Copenhagen University Hospital, Frederiksberg, Denmark
| | | | - T G Nielsen
- Department of Orthopaedic Surgery, University Hospital of Århus, Århus, Denmark
| | - C Ginnerup
- Department of Orthopaedic Surgery, University Hospital of Århus, Århus, Denmark
| | - M C Lind
- Department of Orthopaedic Surgery, University Hospital of Århus, Århus, Denmark
| | - H Langberg
- Section of Social Medicine, Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
8
|
Frizziero A, Trainito S, Oliva F, Nicoli Aldini N, Masiero S, Maffulli N. The role of eccentric exercise in sport injuries rehabilitation. Br Med Bull 2014; 110:47-75. [PMID: 24736013 DOI: 10.1093/bmb/ldu006] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Sports injuries frequently involve tendons, muscles and ligaments. The variable outcome of surgery and medical treatment support early functional treatments. Eccentric exercise (EE) showed effectiveness in the management of Achilles tendinopathy (AT), patellar tendinopathy (PT) and lateral epicondyle tendinopathy (LET). Preliminary results of EE in other tendinopathies and sports injuries suggest its wide prescription in the sport rehabilitation field. SOURCES OF DATA A comprehensive search of PubMed, Web of Science, the Cochrane Collaboration Database, Physiotherapy Evidence Database (PEDro), Evidence Based Medicine (EBM) Search review, National Guidelines, Scopus and Google Scholar was performed using keywords such as 'eccentric exercise', 'sports injuries rehabilitation', 'tendinopathy', 'hamstrings strain' 'adductor injuries' and 'ACL reconstruction rehabilitation'. AREAS OF AGREEMENT EE, alone or associated with other therapies, represents a feasible, cost-effective and successful tool in the treatment of well-known targets and might be promising in shoulder tendinopathy, adductor-related groin pain, hamstring strains, and ACL rehabilitation. AREA OF CONTROVERSY The lack of standardization of protocols, the variable amount, quality and follow-up of studies, the different anatomy and pathophysiology of the therapeutic targets limit the evidence of applicability of EE to sports injuries. GROWING POINTS The role of pathology and biomechanics in the response to EE should be further investigated. AREAS TIMELY FOR DEVELOPING RESEARCH New randomized controlled trials should test the effectiveness of standardized EE regimens to various sites of sports injuries.
Collapse
Affiliation(s)
- Antonio Frizziero
- Department of Physical and Rehabilitation Medicine, University of Padova, Italy
| | - Sabina Trainito
- Department of Physical and Rehabilitation Medicine, University of Padova, Italy
| | - Francesco Oliva
- Department of Orthopaedics and Traumatology, University of Rome 'Tor Vergata' School of Medicine, Rome, Italy
| | - Nicolò Nicoli Aldini
- Department Rizzoli RIT, Laboratory of Biocompatibility, Technological Innovations and Advanced Therapies, Rizzoli Orthopedic Institute, Bologna, Italy
| | - Stefano Masiero
- Department of Physical and Rehabilitation Medicine, University of Padova, Italy
| | - Nicola Maffulli
- Department of Physical and Rehabilitation Medicine, University of Salerno, Italy Centre for Sports and Exercise Medicine, Queen Mary University of London, Mile End Hospital Mann Ward, 275 Bancroft Road, London E1 4DG, UK Barts and The London School of Medicine and Dentistry, Mile End Hospital, London, UK
| |
Collapse
|
9
|
Abstract
CONTEXT Tendinopathy is increasing in prevalence and accounts for a substantial part of all sports injuries and occupational disorders. Despite the magnitude of the disorder, high-quality scientific data on etiology and available treatments have been limited. EVIDENCE ACQUISITION The authors conducted a MEDLINE search on tendinopathy, or "tendonitis" or "tendinosis" or "epicondylitis" or "jumpers knee" from 1980 to 2011. The emphasis was placed on updates on epidemiology, etiology, and recent patient-oriented Level 1 literature. RESULTS Repetitive exposure in combination with recently discovered intrinsic factors, such as genetic variants of matrix proteins, and metabolic disorders is a risk factor for the development of tendinopathy. Recent findings demonstrate that tendinosis is characterized by a fibrotic, failed healing response associated with pathological vessel and sensory nerve ingrowth. This aberrant sensory nerve sprouting may partly explain increased pain signaling and partly, by release of neuronal mediators, contribute to the fibrotic alterations observed in tendinopathy. The initial nonoperative treatment should involve eccentric exercise, which should be the cornerstone (basis) of treatment of tendinopathy. Eccentric training combined with extracorporeal shockwave treatment has in some reports shown higher success rates compared to any therapies alone. Injection therapies (cortisone, sclerosing agents, blood products including platelet-rich plasma) may have short-term effects but have no proven long-term treatment effects or meta-analyses to support them. For epicondylitis, cortisone injections have demonstrated poorer long-time results than conservative physiotherapy. Today surgery is less indicated because of successful conservative therapies. New minioperative procedures that, via the endoscope, remove pathologic tissue or abnormal neoinnervation demonstrate promising results but need confirmation by Level 1 studies. CONCLUSIONS Novel targeted therapies are emerging, but multicenter trials are needed to confirm the results of exercise and mini-invasive treatments.
Collapse
Affiliation(s)
- Paul W Ackermann
- Section of Orthopedics and Sports Medicine, Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden
| | | |
Collapse
|