1. Hayley Carter Nikki Christopher Danielle Fashler Ryan Hill Christine Reid Drew Teskey

2. Introduction Methods Results Discussion Conclusion

3. Background Information and Research Questions

4.  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)

5.  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. 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:

7.  Failed healing response?  Neovasculature and nerve proliferation ↓ neovessels ↓ pain Scott, A., (2010)

8.  Ultrasound  Shock-wave therapy  Corticosteroid injections  Surgery  NSAIDs  Eccentric Exercise

9.  Conservative approach  Low-cost  No equipment  Self-management  Effective Mechanical sclerosing Collagen remodelling Mechanism?

10. 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?

11. Search Strategy, Selection Criteria and Quality Assessment

12. Population Adults (18-65) with chronic (≥ 3months) mid- portion Achilles Tendinopathy Intervention Eccentric heel drop protocol ≥ 6wk duration Comparison Other treatment (including no treatment) Outcome Pain (Primary) Function and Patient Satisfaction (Secondary)

13. MEDLINE (1950 – Present)EMBASE (1980 – Present)CINAHL (1982 – Present) PubMed (1949 – Present) PEDro (1929 – Present)Wed of Science Grey Literature (eg. TRIP, SUMSearch, Toby)

14. AND Achilles OR Achilles Tendon (Thesaurus) Tend* OR Tendinitis – focus (Thesaurus) Eccentric OR Eccentric Muscle Contraction – explode (Thesaurus) RCT filter = (random* AND control* AND trial*) OR (RCT*) Example: EMBASE

15. 284 (with duplicates) EMBASE 16 CINAHL 17 Other 155 PEDro 15 PubMed 24 Medline 25 Web of Science 32

16. 1) Randomized control trial 2) Human participants, mean age 18-65, with chronic (≥ 3 months) mid-portion AT 3) 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

17. 1) Not available in full text 2) Not available in English 3) Retrospective or non-original studies 4) In-vitro studies 5) Animal subjects 6) Comparison group included an eccentric protocol

18. Study Selection INCLUDED IN REVIEW Third level screen Full text Second level screen Abstract First level screen Title TOTAL HITS 284 21 remain 11 remain 5 total

19.  Sackett’s Level of Evidence & PEDro Scores: Study Sackett’s Level of Evidence PEDro criteria*PEDro score (/11) 1234567891011 ChesterII (n=16)  XXX  XX  6 HerringtonII (n=25)  X  XX  X7 MafiII (n=44)  XXX  X  7 PetersonI (n=72)  XXX  8 RompeI (n=75)  XX  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

20. Description of Review Findings

21.  Insufficient homogeneity for meta-analysis 1. Different comparators StudyComparison 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

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. *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 ComparisonOutcome MeasureEccentrics better? EE vs. UltrasoundVAS*No (all) EE vs. AirHeel BraceVASYes (rest; P<0.001) No *** (walking) No (sport) EE vs. Concentric Exercise VASYes (walking; P<0.001) EE vs. ShockwaveAuthor designed**No EE vs. Wait and SeeAuthor designedYes (P<0.001)

24. ComparisonOutcome MeasureEccentrics Better? EE vs. UltrasoundFILLANo EE vs. AirHeel BraceAOFASNo EE vs. Shockwave Therapy VISA-ANo EE vs. Standard CareVISA-AYes (P = 0.014) EE vs. Wait-and-SeeVISA-AYes (P < 0.001)

25. ComparisonOutcome MeasureEccentrics Better? EE vs. UltrasoundEuroQolNo EE vs. AirHeel BraceSF-36 Return to Sport No EE vs. Shockwave Therapy Likert ScaleNo EE vs. Concentric Exercise Return to SportYes (P = 0.002) EE vs. Wait-and-SeeLikert ScaleYes (P < 0.001)

26. ComparisonOutcome MeasureEccentrics better? EE vs. UltrasoundVAS*No (all) EE vs. AirHeel BraceVASYes (rest; P<0.001) No # (walking) No (sport) EE vs. Concentric ExerciseVASYes (walking; P<0.001) EE vs. ShockwaveAuthor designed**No EE vs. Wait and SeeAuthor designedYes (P<0.001) ComparisonOutcome MeasureEccentrics Better? EE vs. UltrasoundFILLANo EE vs. AirHeel BraceAOFASNo EE vs. Shockwave TherapyVISA-ANo EE vs. Standard CareVISA-AYes (P = 0.014) EE vs. Wait-and-SeeVISA-AYes (P < 0.001) ComparisonOutcome MeasureEccentrics Better? EE vs. UltrasoundEuroQolNo EE vs. AirHeel BraceSF-36 Return to Sport No EE vs. Shockwave TherapyLikert ScaleNo EE vs. Concentric ExerciseReturn to SportYes (P = 0.002) EE vs. Wait-and-SeeLikert ScaleYes (P < 0.001) PAIN SATISFACTION FUNCTION

27. ComparisonOutcome MeasureEccentrics better? EE vs. UltrasoundVAS*No (all) EE vs. AirHeel BraceVASYes (rest; P<0.001) No # (walking) No (sport) EE vs. Concentric ExerciseVASYes (walking; P<0.001) EE vs. ShockwaveAuthor designed**No EE vs. Wait and SeeAuthor designedYes (P<0.001) ComparisonOutcome MeasureEccentrics Better? EE vs. UltrasoundFILLANo EE vs. AirHeel BraceAOFASNo EE vs. Shockwave TherapyVISA-ANo EE vs. Standard CareVISA-AYes (P = 0.014) EE vs. Wait-and-SeeVISA-AYes (P < 0.001) ComparisonOutcome MeasureEccentrics Better? EE vs. UltrasoundEuroQolNo EE vs. AirHeel BraceSF-36 Return to Sport No EE vs. Shockwave TherapyLikert ScaleNo EE vs. Concentric ExerciseReturn to SportYes (P = 0.002) EE vs. Wait-and-SeeLikert ScaleYes (P < 0.001) PAIN SATISFACTION FUNCTION

28. ComparisonOutcome MeasureEccentrics better? EE vs. UltrasoundVAS*No (all) EE vs. AirHeel BraceVASYes (rest; P<0.001) No # (walking) No (sport) EE vs. Concentric ExerciseVASYes (walking; P<0.001) EE vs. ShockwaveAuthor designed**No EE vs. Wait and SeeAuthor designedYes (P<0.001) ComparisonOutcome MeasureEccentrics Better? EE vs. UltrasoundFILLANo EE vs. AirHeel BraceAOFASNo EE vs. Shockwave TherapyVISA-ANo EE vs. Standard CareVISA-AYes (P = 0.014) EE vs. Wait-and-SeeVISA-AYes (P < 0.001) ComparisonOutcome MeasureEccentrics Better? EE vs. UltrasoundEuroQolNo EE vs. AirHeel BraceSF-36 Return to Sport No EE vs. Shockwave TherapyLikert ScaleNo EE vs. Concentric ExerciseReturn to SportYes (P = 0.002) EE vs. Wait-and-SeeLikert ScaleYes (P < 0.001) PAIN SATISFACTION FUNCTION

29. ComparisonOutcome MeasureEccentrics better? EE vs. UltrasoundVAS*No (all) EE vs. AirHeel BraceVASYes (rest; P<0.001) No # (walking) No (sport) EE vs. Concentric ExerciseVASYes (walking; P<0.001) EE vs. ShockwaveAuthor designed**No EE vs. Wait and SeeAuthor designedYes (P<0.001) ComparisonOutcome MeasureEccentrics Better? EE vs. UltrasoundFILLANo EE vs. AirHeel BraceAOFASNo EE vs. Shockwave TherapyVISA-ANo EE vs. Standard CareVISA-AYes (P = 0.014) EE vs. Wait-and-SeeVISA-AYes (P < 0.001) ComparisonOutcome MeasureEccentrics Better? EE vs. UltrasoundEuroQolNo EE vs. AirHeel BraceSF-36 Return to Sport No EE vs. Shockwave TherapyLikert ScaleNo EE vs. Concentric ExerciseReturn to SportYes (P = 0.002) EE vs. Wait-and-SeeLikert ScaleYes (P < 0.001) PAIN SATISFACTION FUNCTION

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

31.  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.

32.  PEDro Scores  Subject & therapist blinding  Assessor blinding  Conflict of Interest?

33. PEDro Scores: Study Sackett’s Level of Evidence PEDro criteria*PEDro score (/11) 1234567891011 ChesterII (n=16)  XXX  XX  6 HerringtonII (n=25)  X  XX  X7 MafiII (n=44)  XXX  X  7 PetersonI (n=72)  XXX  8 RompeI (n=75)  XX  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

34.  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.  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.  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.  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 Lowest QualityHighest Quality Pain FunctionFILLAAOFASVISA-A Patient Satisfaction “Yes/No” Questionnaires EuroQolSF-36Specific Likert Scales VAS Load-induced pain Pain threshold Tenderness on palpation

39. Larger sample size Blinding of assessors Lack of high quality studies Include 3, 6, 12 month follow-ups of participants Lack of follow-up Use standardized outcome measures, with high sensitivity and specificity (Eg. VISA-A, Likert) Include measure of participant compliance Lack of comparable outcome measures Identify optimal dosage (set, reps, intensity, pain) Identify optimal duration of training Unclear exercise parameters

40. 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

41. 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

42. Take home message

43. Trends: Patient population: Athletic >> sedentary Exercise intensity: higher >> lower EE is at least as effective as other treatments

44. 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-Ambrose Other contributors: Dr. Alex Scott Dr. Elizabeth Dean Dr. Darlene Reid Charlotte Beck Dean Giustini

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49. Questions?