Intense pulsed light treatment of chronic mid-body Achilles tendinopathy

ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Systematic Review of Outcome Measures Reported in Clinical Trials of Achilles Tendinopathy

BACKGROUND

Nine core domains for tendinopathy have been identified. For Achilles tendinopathy there is large variation in outcome measures used, and how these fit into the core domains has not been investigated.

OBJECTIVE

To identify all available outcome measures outcome measures used to assess the clinical phenotype of Achilles tendinopathy in prospective studies and to map the outcomes measures into predefined health-related core domains.

DESIGN

Systematic review.

DATA SOURCES

Embase, MEDLINE (Ovid), Web of Science, CINAHL, The Cochrane Library, SPORTDiscus and Google Scholar.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Clinical diagnosis of Achilles tendinopathy, sample size ≥ ten participants, age ≥ 16 years, and the study design was a randomized or non-randomized clinical trial, observational cohort, single-arm intervention, or case series.

RESULTS

9376 studies were initially screened and 307 studies were finally included, totaling 13,248 participants. There were 233 (177 core domain) different outcome measures identified across all domains. For each core domain outcome measures were identified, with a range between 8 and 35 unique outcome measures utilized for each domain. The proportion of studies that included outcomes for predefined core domains ranged from 4% for the psychological factors domain to 72% for the disability domain.

CONCLUSION

233 unique outcome measures for Achilles tendinopathy were identified. Most frequently, outcome measures were used within the disability domain. Outcome measures assessing psychological factors were scarcely used. The next step in developing a core outcome set for Achilles tendinopathy is to engage patients, clinicians and researchers to reach consensus on key outcomes measures.

PROSPERO REGISTRATION

CRD42020156763.

Which treatment is most effective for patients with Achilles tendinopathy? A living systematic review with network meta-analysis of 29 randomised controlled trials

OBJECTIVE

To provide a consistently updated overview of the comparative effectiveness of treatments for Achilles tendinopathy.

DESIGN

Living systematic review and network meta-analysis.

DATA SOURCES

Multiple databases including grey literature sources were searched up to February 2019.

STUDY ELIGIBILITY CRITERIA

Randomised controlled trials examining the effectiveness of any treatment in patients with both insertional and/or midportion Achilles tendinopathy. We excluded trials with 10 or fewer participants per treatment arm or trials investigating tendon ruptures.

DATA EXTRACTION AND SYNTHESIS

Reviewers independently extracted data and assessed the risk of bias. We used the Grading of Recommendations Assessment, Development and Evaluation to appraise the certainty of evidence.

PRIMARY OUTCOME MEASURE

The validated patient-reported Victorian Institute of Sport Assessment-Achilles questionnaire.

RESULTS

29 trials investigating 42 different treatments were included. 22 trials (76%) were at high risk of bias and 7 (24%) had some concerns. Most trials included patients with midportion tendinopathy (86%). Any treatment class seemed superior to wait-and-see for midportion Achilles tendinopathy at 3 months (very low to low certainty of evidence). At 12 months, exercise therapy, exercise+injection therapy and exercise+night splint therapy were all comparable with injection therapy for midportion tendinopathy (very low to low certainty). No network meta-analysis could be performed for insertional Achilles tendinopathy.

SUMMARY/CONCLUSION

In our living network meta-analysis no trials were at low risk of bias and there was large uncertainty in the comparative estimates. For midportion Achilles tendinopathy, wait-and-see is not recommended as all active treatments seemed superior at 3-month follow-up. There seems to be no clinically relevant difference in effectiveness between different active treatments at either 3-month or 12-month follow-up. As exercise therapy is easy to prescribe, can be of low cost and has few harms, clinicians could consider starting treatment with a calf-muscle exercise programme.

PROSPERO REGISTRATION NUMBER

CRD42018086467.

Meta-analysis of Noninsertional Achilles Tendinopathy

BACKGROUND

Achilles tendinopathy is a common clinical problem that can be either insertional or noninsertional. A variety of treatment methods have been described, although little consensus exists on an optimal method or methods. We sought to investigate the current evidence on different treatment methods for noninsertional Achilles tendinopathy, with a focus on functional outcomes.

METHODS

We performed a review of the available literature in PubMed and the Cochrane Central Register of Controlled Trials. Data from included studies were categorized according to treatment method and analyzed with respect to functional outcome and complication rate.

RESULTS

In total, 1420 abstracts were reviewed, of which 72 articles containing 3523 patients met inclusion criteria. Within the 72 studies included, 6 operative techniques and 19 nonoperative treatments were evaluated.

CONCLUSION

A wide variety of treatments are available for noninsertional Achilles tendinopathy, although newer treatments and most operative methods lack high-level evidence. Eccentric exercise is the most thoroughly studied and supported nonoperative treatment, while tenotomy and debridement is the operative procedure with the most evidence of efficacy. Platelet-rich plasma injections and extracorporeal shockwave therapy have proven to be viable second-line nonoperative treatments. Gastrocnemius recession and flexor hallucis longus transfer have shown benefit in case series.

LEVEL OF EVIDENCE

Level II, systematic review.

In vitro tissue culture model validation-the influence of tissue culture components on IPL energy output

Intense pulsed light (IPL) has been used therapeutically in a number of clinical settings and has been shown to have a photobiomodulatory effect on connective tissue cells, such as those derived from skin and tendon. In vitro cell culture models are essential tools preclinically in investigating such treatment modalities, as they help in optimising parameters for successful treatment. However, as culture system components have been reported to absorb part of the irradiated energy, which in turn has a bearing on the amount of light reaching the cells, it is important to establish specific parameters for the particular in vitro model used. This study, therefore, investigates the effect of our tissue culture system components on the IPL energy delivered. Individual wells of multi-well plates were irradiated with IPL at different device settings and under variable culture conditions (e.g. in the absence or presence of cell culture media with or without the pH indicator dye, phenol red), and the energy lost through the culture system determined. Our data demonstrated that the IPL device delivered significantly lower outputs than those published, and energy absorption by the culture equipment would further reduce fluencies delivered to the cell monolayer. Furthermore, energy absorption by media containing phenol red was marginally greater than clear media and resulted in only a small increase in temperature, which would not be harmful to cells. The use of phenol red-containing media therefore is valid and physiologically relevant when examining light-culture system interactions.

Conservative Treatment of Chronic Achilles Tendinopathy: A Systematic Review

Achilles tendinopathy is a common musculoskeletal disorder. Athletes, runners and jumpers, and the sedentary are frequently affected. Numerous are the therapeutic choices to manage these kinds of disorders. The aim of this review is to analyze the available literature to document the up-to-date evidence on conservative management of Achilles tendinopathy. A systematic review of two medical electronic databases was performed by three independent authors, using the following inclusion criteria: conservative treatment consisted of pharmacologic, physical therapy without operative treatment, with more of 6 months symptoms and a minimum average of 6-months follow-up. Studies of any level of evidence, reporting clinical results, and dealing with Achilles tendinopathy and conservative treatment were searched for. A total of n = 1228 articles were found. At the end of the first screening, following the previously described selection criteria, we selected n = 94 articles eligible for full-text reading. Ultimately, after full-text reading and a reference list check, we selected n = 29 articles. Achilles tendinopathy is a frequent musculoskeletal disorder and several conservative treatments have been proposed, but no therapy is universally accepted, except for eccentric exercise training, which is the gold standard and a commonly used protocol.

Efficacy of heel lifts versus calf muscle eccentric exercise for mid-portion Achilles tendinopathy (the HEALTHY trial): study protocol for a randomised trial

Background

Mid-portion Achilles tendinopathy is a common musculoskeletal condition characterised by degeneration of the Achilles tendon, which causes pain and disability. Multiple non-surgical treatments have been advocated for this condition including calf muscle eccentric exercise and in-shoe heel lifts. Although adherence is challenging, there is evidence to suggest that calf muscle eccentric exercise is effective in decreasing pain and improving function in people with Achilles tendinopathy. Heel lifts reduce ankle joint dorsiflexion and Achilles tendon strain, however their efficacy in the management of Achilles tendinopathy is unclear. This article describes the design of a parallel-group randomised trial comparing the efficacy of heel lifts to calf muscle eccentric exercise for Achilles tendinopathy.

Methods

Ninety-two participants with Achilles tendinopathy will be randomised to one of two groups: (i) a heel lift group that will receive pre-fabricated 12 mm in-shoe heel lifts (Clearly Adjustable®), or (ii) an exercise group that will be advised to carry out a calf muscle eccentric exercise program (twice a day, 7 days a week, for 12 weeks). Outcome measures will be obtained at baseline, 2, 6 and 12 weeks; the primary endpoint for assessing efficacy being 12 weeks. The primary outcome measure will be the total score of the Victorian Institute of Sport Assessment - Achilles (VISA-A) questionnaire. Secondary outcome measures will include thickness and integrity of the Achilles tendon (using ultrasound tissue characterisation [UTC]), participant perception of treatment effect on pain and function (using the 7-point Patient Global Impression of Change scale), severity of pain at the Achilles tendon (using a 100 mm visual analogue scale) in the previous week, health status (using the EuroQol-5D-5L™ questionnaire), physical activity levels (using the 7-day Recall Physical Activity Questionnaire) and calf muscle function (using the standing heel rise test). Data will be analysed using the intention to treat principle.

Discussion

The HEALTHY trial (Heel lifts versus calf muscle eccentric Exercise for AchiLles TendinopatHY) is the first randomised trial to compare the efficacy of heel lifts to calf muscle eccentric exercise in reducing pain and improving function in people with Achilles tendinopathy. A pragmatically designed trial was developed to ensure that if the interventions are found to be effective, the findings can be readily implemented in clinical practice.

Trial registration

Australian New Zealand Clinical Trials Registry: ACTRN12617001225303. Registered on August 22nd, 2017.

The effects of a new Tendo-Achilles Pathway (TAP) on an orthopaedic department- A quality improvement study

BACKGROUND

Achilles tendinopathy is a common pathology that is considered difficult to treat. At a time of austerity in the NHS it is essential to have carefully designed pathways that are monitored in terms of cost and effectiveness. However, a paucity of evidence exists for what the "best value" dedicated "joined up" pathway of care is for this difficult condition.

OBJECTIVES

Design, implement and evaluate the impact of a new therapist lead pathway for Tendon- Achilles Pain (TAP).  METHODS: Process mapping, driver diagrams, stakeholder analysis and a series of Plan-Do-Study-Act cycles were used to design and implement TAP. To assess the impact of TAP, data was compared on whole system measures for 46 patients treated with referral to the traditional service (without TAP) and 46 patients managed according to the newly designed pathway (with TAP). A cost analysis was also conducted.

RESULTS

A quality improvement approach led to the successful design and implementation of a therapist lead TAP. The impact of TAP included positive effects on patient satisfaction, a decrease in duplication of treatments, investigations and inappropriate reviews with consultants. No safety concerns were found. TAP was also £44,000 cheaper per annum than the previous service.

CONCLUSION

Collaboration between orthopaedic and therapy services has resulted in a standardised pathway of care for patients with an Achilles tendinopathy.  It has removed unwanted variation, provided an opportunity to monitor the outcomes of treatments and resulted in decreased cost for the health board.

Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to midportion Achilles tendinopathy. J Orthop Sports Phys Ther 2018;48(5):A1-A38. doi:10.2519/jospt.2018.0302.

Evidence-Based Evaluation of Practice and Innovation in Physical Therapy Using the IDEAL-Physio Framework

The IDEAL framework is an established method for initial and ongoing evaluations of innovation and practice for complex health care interventions. First derived for surgical sciences and embedded at a global level for evaluating surgery/surgical devices, the IDEAL framework is based on the principle that innovation and evaluation in clinical practice can, and should, evolve together in an ordered manner: from conception to development and then to validation by appropriate clinical studies and, finally, longer-term follow-up. This framework is highly suited to other complex, nonpharmacological interventions, such as physical therapist interventions. This perspective outlines the application of IDEAL to physical therapy in the new IDEAL-Physio framework. The IDEAL-Physio framework comprises 5 stages. In stage 1, the idea phase, formal data collection should begin. Stage 2a is the phase for iterative improvement and adjustment with thorough data recording. Stage 2b involves the onset of formal evaluation using systematically collected group or cohort data. Stage 3 is the phase for formal comparative assessment of treatment, usually involving randomized studies. Stage 4 involves long-term follow-up. The IDEAL-Physio framework is recommended as a method for guiding and evaluating both innovation and practice in physical therapy, with the overall goal of providing better evidence-based care.

In vitro studies to evaluate the effect of varying culture conditions and IPL fluencies on tenocyte activities

Tendons are dense, fibrous connective tissues which carry out the essential physiological role of transmitting mechanical forces from skeletal muscle to bone. From a clinical perspective, tendinopathy is very common, both within the sporting arena and amongst the sedentary population. Studies have shown that light therapy may stimulate tendon healing, and more recently, intense pulsed light (IPL) has attracted attention as a potential treatment modality for tendinopathy; however, its mechanism of action and effect on the tendon cells (tenocytes) is poorly understood. The present study therefore investigates the influence of IPL on an in vitro bovine tendon model. Tenocytes were irradiated with IPL at different devise settings and under variable culture conditions (e.g. utilising cell culture media with or without the pH indicator dye phenol red), and changes in tenocyte viability and migration were subsequently investigated using Alamar blue and scratch assays, respectively. Our data demonstrated that IPL fluencies of up to 15.9 J/cm² proved harmless to the tenocyte cultures (this was the case using culture media with or without phenol red) and resulted in a significant increase in cell viability under certain culture conditions. Furthermore, IPL treatment of tenocytes did not affect the rate of cell migration. This study demonstrates that irradiation with IPL is not detrimental to the tenocytes and may increase their viability under certain conditions, thus validating our in vitro model. Further studies are required to elucidate the effects of IPL application in the clinical situation.

Effectiveness of dry needling and high-volume image-guided injection in the management of chronic mid-portion Achilles tendinopathy in adult population: a literature review

Achilles tendinopathy is a common overuse condition affecting the adult population. The incidence is on the rise because of greater participation of people in recreational or competitive sporting activities. There are several treatment options available both non-operative and operative. Ultrasound-guided dry needling and high-volume image-guided injection is relatively a new procedure. The aim of this study was to find out the effectiveness of dry needling and HVIGI in the management of mid-portion chronic Achilles tendinopathy by performing a literature review. Search strategy was devised to find the suitable articles for critical appraisal using the electronic databases. Four articles were selected for critical appraisal, and these papers showed good short- to long-term results of image-guided high-volume injection in the management of Achilles tendinopathy. We conclude that high-volume image-guided injection is effective in the management of Achilles tendinopathy. It provides good short- and medium-term relief of symptoms. It should be considered as one of the many options available for this condition.

Danish VISA-A questionnaire with validation and reliability testing for Danish-speaking Achilles tendinopathy patients

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.

From needle to knife

Trauma and Orthopaedic care has been through a rapid evolution over the past few decades. This Editorial discusses some of the advances.

Cite this article: Bone Joint J 2015;97-B:1–2.

Effectiveness of the Alfredson protocol compared with a lower repetition-volume protocol for midportion Achilles tendinopathy: a randomized controlled trial

STUDY DESIGN

Randomized clinical trial.

OBJECTIVES

To compare the effectiveness of the Alfredson eccentric heel-drop protocol with a "do-as-tolerated" protocol for nonathletic individuals with midportion Achilles tendinopathy.

BACKGROUND

The Alfredson protocol recommends the completion of 180 eccentric heel drops a day. However, completing this large number of repetitions is time consuming and potentially uncomfortable. There is a need to investigate varying exercise dosages that minimize the discomfort yet retain the clinical benefits.

METHODS

Twenty-eight individuals from outpatient physiotherapy departments were randomized to either the standard (n = 15) or the do-as-tolerated (n = 13) 6-week intervention protocol. Apart from repetition volume, all other aspects of management were standardized between groups. Tendinopathy clinical severity was assessed with the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire. Pain intensity was assessed using a visual analog scale (VAS). Both were assessed at baseline, 3 weeks, and 6 weeks. Treatment satisfaction was assessed at week 6. Adverse effects were also monitored.

RESULTS

There was a statistically significant within-group improvement in VISA-A score for both groups (standard, P = .03; do as tolerated, P<.001) and VAS pain for the do-as-tolerated group (P = .001) at week 6, based on the intention-to-treat analysis. There was a statistically significant between-group difference in VISA-A scores at week 3, based on both the intention-to-treat (P = .004) and per-protocol analyses (P = .007), partly due to a within-group deterioration at week 3 in the standard group. There were no statistically significant between-group differences for VISA-A and VAS pain scores at week 6, the completion of the intervention. There was no significant association between satisfaction and treatment groups at week 6. No adverse effects were reported.

CONCLUSION

Performing a 6-week do-as-tolerated program of eccentric heel-drop exercises, compared to the recommended 180 repetitions per day, did not lead to lesser improvement for individuals with midportion Achilles tendinopathy, based on VISA-A and VAS scores.