Psychological factors not strength deficits are associated with severity of gluteal tendinopathy: A cross-sectional study

An EDucation and eXercise intervention for gluteal tendinopathy in an Irish setting: a protocol for a feasibility randomised clinical trial (LEAP-Ireland RCT)

Background

Gluteal tendinopathy (GT) is a degenerative tendon condition characterised by pain over the greater trochanter of the hip. A randomised controlled trial (RCT) in Australia found that 14 sessions of EDucation on load management plus eXercise (EDX) delivered over 8 weeks resulted in greater improvements in global rating of change and pain outcomes at 8 and 52 weeks, compared with corticosteroid injection or 'wait and see'. Typically, 5-6 physiotherapy sessions are provided in public and private physiotherapy settings in Ireland, therefore, the aim of this study is to examine the feasibility of conducting a future definitive RCT to investigate effectiveness of 6 sessions of the EDX programme compared to usual care.

Methods

We will randomly allocate 64 participants with GT to physiotherapist-administered EDX or usual care. The EDX intervention (EDX-Ireland) will be delivered in 6 sessions over 8 weeks.To determine feasibility of an RCT, we will assess recruitment and retention and outcome measure completion. The health status outcomes to be assessed at baseline, 8 weeks and 3 months include: Global Rating of Change, pain severity, the Victorian Institute of Sport Assessment-Gluteal Questionnaire (VISA-G), the Patient-Specific Functional Scale, the Pain Catastrophizing Scale, Patient Health Questionnaire (PHQ), Pain Self-Efficacy Questionnaire, the EQ-5D-5L, the Central Sensitisation Inventory and hip abductor muscle strength. We will explore acceptability of the EDX-Ireland intervention from the perspective of patients and treatment providers, and the perspective of referrers to the trial. A Study Within A Trial will be also applied to compare recording of exercise adherence using app-based technology to paper diaries.

Discussion

There is a need to establish effective treatments for GT that potentially can be implemented into existing health systems. The findings of this feasibility trial will inform development of a future definitive RCT.

Registration

The trial is registered prospectively on ClinicalTrials.gov ( NCT05516563, 27/10/2022).

Psychological factors show limited association with the severity of Achilles tendinopathy

BACKGROUND

This study aimed to investigate the association between psychosocial factors and the severity of Achilles tendinopathy, along with exploring their potential link to the pain's duration.

METHODS

A cross-sectional study involving 111 individuals with Achilles tendon pain was conducted.

METHODS

A cross-sectional study involving 111 individuals with Achilles tendon pain was conducted. Various psychological factors were assessed using the Pain Catastrophizing Scale, Chronic Pain Self-Efficacy Scale (CPSS), Tampa Scale for Kinesiophobia, and Hospital Anxiety and Depression Scale (HAD). Additionally, the severity of Achilles tendon pain was evaluated using the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A-Br). Regression analyses were employed to determine the association of these psychosocial factors with pain severity and duration.

RESULTS

Self-efficacy for chronic pain showed a slight association with Achilles tendon pain severity (β = 0.42 [95% CI: 0.06 to 0.16], p = 0.001), explaining only 19% of the dependent variable. The other variables, including anxiety, depression, pain catastrophizing, and fear of movement, did not exhibit significant associations.

CONCLUSION

The study suggests that psychological factors demonstrate limited association with the severity of Achilles tendinopathy. While self-efficacy for chronic pain was weakly associated, its clinical relevance remains uncertain. Future research, particularly longitudinal studies, should explore the influence of psychosocial factors on treatment adherence and response to enhance management strategies for Achilles tendon pain.

Which Psychological and Psychosocial Constructs Are Important to Measure in Future Tendinopathy Clinical Trials? A Modified International Delphi Study With Expert Clinician/Researchers and People With Tendinopathy

OBJECTIVE: To identify which psychological and psychosocial constructs to include in a core outcome set to guide future clinical trials in the tendinopathy field. DESIGN: Modified International Delphi study. METHODS: In 3 online Delphi rounds, we presented 35 psychological and psychosocial constructs to an international panel of 38 clinician/researchers and people with tendinopathy. Using a 9-point Likert scale (1 = not important to include, 9 = critical to include), consensus for construct inclusion required ≥70% of respondents rating "extremely critical to include" (score ≥7) and ≤15% rating "not important to include" (score ≤3). Consensus for exclusion required ≥70% of respondents rating "not important to include" (score ≤3) and ≤15% of rating "critical to include" (score ≥7). RESULTS: Thirty-six participants (95% of 38) completed round 1, 90% (n = 34) completed round 2, and 87% (n = 33) completed round 3. Four constructs were deemed important to include as part of a core outcome set: kinesiophobia (82%, median: 8, interquartile range [IQR]: 1.0), pain beliefs (76%, median: -7, IQR: 1.0), pain-related self-efficacy (71%, median: 7, IQR: 2.0), and fear-avoidance beliefs (73%, median: -7, IQR: 1.0). Six constructs were deemed not important to include: perceived injustice (82%), individual attitudes of family members (74%), social isolation and loneliness (73%), job satisfaction (73%), coping (70%), and educational attainment (70%). Clinician/researchers and people with tendinopathy reached consensus that kinesiophobia, pain beliefs, pain self-efficacy, and fear-avoidance beliefs were important psychological constructs to measure in tendinopathy clinical trials. J Orthop Sports Phys Ther 2024;54(1):1-12. Epub 20 September 2023. doi:10.2519/jospt.2023.11903.

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

Background

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.

Review questions

(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?

Methods

A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.

Results

Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.

Limitations

Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.

Conclusion

The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.

Future work

There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.

Study registration

This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

Characterising tibialis posterior tendinopathy using the International Classification of Functioning, Disability and Health: a cross sectional study

BACKGROUND

Tibialis posterior tendinopathy (TPT) is characterised by pain around the medial foot/ankle and difficulties weightbearing.

OBJECTIVE

Compare individuals who have TPT with asymptomatic controls across the International Classification of Functioning, Disability and Health (ICF) domains of body structure and function, activity, participation and personal factors.

METHODS

Twenty-two individuals meeting the selection criteria for TPT (86% female, mean ± SD age:43 ± 13 years; body mass index [BMI]:28 ± 7 kg/m²) were compared to 27 controls (93% female, age:44 ± 16 years, BMI:23 ± 5 kg/m²). Standardised differences (and 95% confidence intervals [CIs]) between groups were estimated for outcomes under each ICF domain using Cliff's delta to allow for comparison of the magnitude of deficits across outcomes (>0.47 considered large).

RESULTS

Impairments in body structure and function in individuals with TPT were accompanied by activity limitations including difficulties due to foot problems (-1.0 (-1.0, -1.0)) and with independent living (-0.8 (-1.0, -0.3)) and greater time to complete stair descent/ascent (-0.6 (-0.8, -0.3)). Considering participation, overall foot-related function (-1.0 (-1.0, -1.0)), ability to participate in activities (-0.7 (-0.08, -0.3)), social restrictions (-0.8 (-1.0, -0.4)) and quality of life (-0.7 (-0.9, -0.5)) were poorer in individuals with TPT.

CONCLUSION

Individuals with TPT have large impairments in body structure and function, activity limitations and participation restrictions, particularly relating to independent living, mental health and pain. Personal factors appear to contribute to a lesser extent to the TPT presentation. Treatment plans should consider activity and participation limitations in addition to body structure and function.

Self-reported bio-psycho-social factors partially distinguish patellar tendinopathy from other knee problems and explain patellar tendinopathy severity in jumping athletes: A case-control study

OBJECTIVE

To determine what combinations of self-reported factors distinguish patellar tendinopathy (PT) from other knee problems, and explain PT severity variance.

DESIGN

Case-control study.

SETTING

Social media, private practice and National Health Service.

PARTICIPANTS

An international sample of jumping athletes diagnosed with either PT (n = 132; 30.7 ± 8.9 years; 80 males; VISA-P = 61.6 ± 16.0) or another musculoskeletal knee condition (n = 89; 31.8 ± 9.9 years; 47 males; VISA-P = 62.9 ± 21.2) by a clinician in the last 6 months.

MAIN OUTCOME MEASURES

We considered clinical diagnosis (case = having PT vs control = having other knee problems) as the dependent variable. Severity and sporting impact were defined by VISA-P and availability, respectively.

RESULTS

A model comprising seven factors distinguished PT from other knee problems; training duration (OR = 1.10), sport type (OR = 2.31), injured side (OR = 2.28), pain onset (OR = 1.97), morning pain (OR = 1.89), condition acceptability (OR = 0.39) and swelling (OR = 0.37). Sports-specific function (OR = 1.02) and player level (OR = 4.11) explained sporting availability. 44% of PT severity variance was explained by quality of life (β = 0.32), sports-specific function (β = 0.38) and age (β = -0.17).

CONCLUSION

Sports-specific, biomedical and psychological factors partially distinguish PT from other knee problems. Availability is mainly explained by sports-specific factors, while psychosocial factors impact on severity. Adding sports-specific and bio-psycho-social factors into assessments could help better identification and management of jumping athletes with PT.

Do people with musculoskeletal pain differ from healthy cohorts in terms of global measures of strength? A systematic review and meta-analysis

OBJECTIVE

It is currently unknown if people with musculoskeletal pain display different multi-joint strength capacities than healthy cohorts. The aim was to investigate whether people with musculoskeletal pain show differences in global measures of strength in comparison to healthy cohorts.

DATA SOURCES

A systematic review was conducted using three databases (Medline, CINAHL and SPORTDiscus) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

REVIEW METHODS

Studies involving participants with painful musculoskeletal conditions and multi-joint strength assessment measured at baseline were included. A meta-analysis was also performed to compute standardized mean differences (± 95% confidence intervals), using Hedge's g, and examined the differences in multi-joint strength at baseline between participants with painful musculoskeletal conditions and healthy participants.

RESULTS

In total, 5043 articles were identified, of which 20 articles met the inclusion criteria and were included in the qualitative analysis. The available evidence revealed that multi-joint strength values were limited to knee osteoarthritis, fibromyalgia, chronic low back pain, and rheumatoid arthritis. Only four studies were included in the quantitative synthesis and revealed that only small differences in both chest press (g = -0.34, 95% CI [-0.64, -0.03]) and leg press (g = -0.25, 95% CI [-0.49, -0.02]) existed between adult women with fibromyalgia and active community women.

CONCLUSION

There is a paucity of multi-joint strength values in participants with musculoskeletal pain. Quantitative comparison with healthy cohorts was limited, except for those with fibromyalgia. Adult women with fibromyalgia displayed reduced multi-joint strength values in comparison to active community women.

Digital Care Programs for Chronic Hip Pain: A Prospective Longitudinal Cohort Study

Chronic hip pain is a cause of disability worldwide. Digital interventions (DI) may promote access while providing proper management. This single-arm interventional study assesses the clinical outcomes and engagement of a completely remote multimodal DI in patients with chronic hip pain. This home-based DI consisted of exercise (with real-time biofeedback), education, and cognitive-behavioral therapy. Outcomes were calculated between baseline and program end, using latent growth curve analysis. Primary outcome was the Hip Disability and Osteoarthritis Outcome Score (HOOS). Secondary outcomes were pain, intent to undergo surgery, mental health, productivity, patient engagement (exercise sessions frequency), and satisfaction. Treatment response was assessed using a 30% pain change cut-off. A completion rate of 74.2% (396/534), alongside high patient engagement (2.9 exercise sessions/week, SD 1.1) and satisfaction (8.7/10, SD 1.6) were observed. Significant improvements were observed across all HOOS sub-scales (14.7−26.8%, p < 0.05), with 66.8% treatment responders considering pain. Marked improvements were observed in surgery intent (70.1%), mental health (54%), and productivity impairment (60.5%) (all p < 0.001). The high engagement and satisfaction reported after this DI, alongside the clinical outcome improvement, support the potential of remote care in the management of chronic hip conditions.

Biopsychosocial approach to tendinopathy

Tendinopathy describes a spectrum of changes that occur in damaged tendons, leading to pain and reduced function that remains extremely challenging for all clinicians. There is an increasing awareness of the influence that psychological and psychosocial components, such as self-efficacy and fear-avoidance, have on rehabilitation outcomes in musculoskeletal medicine. Although it is widely accepted that psychological/psychosocial factors exist in tendinopathy, there is currently a distinct lack of trials measuring how these factors affect clinical outcomes. Biopsychosocial treatments acknowledge and address the biological, psychological and social contributions to pain and disability are currently seen as the most efficacious approach to chronic pain. Addressing and modulating these factors are crucial in the pathway of personalised treatments in tendinopathy and offer a real opportunity to drive positive outcomes in patients. In this education review, we also provide the current evidence-based guidance on psychological and psychosocial developments in musculoskeletal medicine and how these may be translated to treating tendinopathy using a biopsychosocial model.

ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Scoping Review of Psychological and Psychosocial Constructs and Outcome Measures Reported in Tendinopathy Clinical Trials

OBJECTIVE

To identify and describe the psychological and psychosocial constructs and outcome measures used in tendinopathy research.

DESIGN

Scoping review.

LITERATURE SEARCH

We searched the PubMed, EMBASE, Scopus, Web of Science, PEDro, CINAHL, and APA PsychNet databases on July 10, 2021, for all published studies of tendinopathy populations measuring psychological and psychosocial factors.

STUDY SELECTION

Studies using a clinical diagnosis of tendinopathy or synonyms (eg, jumper's knee or subacromial impingement) with or without imaging confirmation.

DATA SYNTHESIS

We described the volume, nature, distribution, and characteristics of psychological and psychosocial outcomes reported in the tendinopathy field.

RESULTS

Twenty-nine constructs were identified, including 16 psychological and 13 psychosocial constructs. The most frequently-reported constructs were work-related outcomes (32%), quality of life (31%), depression (30%), anxiety (18%), and fear (14%). Outcome measures consisted of validated and nonvalidated questionnaires and 1-item custom questions (including demographics). The number of different outcome measures used to assess an individual construct ranged between 1 (emotional distress) and 11 (quality of life) per construct.

CONCLUSION

There was a large variability in constructs and outcome measures reported in tendinopathy research, which limits conclusions about the relationship between psychological and psychosocial constructs, outcome measures, and tendinopathies. Given the wide range of psychological and psychosocial constructs reported, there is an urgent need to develop a core outcome set in tendinopathy. J Orthop Sports Phys Ther 2022;52(6):375-388. doi:10.2519/jospt.2022.11005.

How do middle-aged and older adults with chronic hip pain view their health problem and its care? A protocol for a systematic review and qualitative evidence synthesis

INTRODUCTION

Chronic hip pain in middle-aged and older adults is common and disabling. Patient-centred care of chronic hip pain requires a comprehensive understanding of how people with chronic hip pain view their health problem and its care. This paper outlines a protocol to synthesise qualitative evidence of middle-aged and older adults' views, beliefs, expectations and preferences about their chronic hip pain and its care.

METHODS AND ANALYSIS

We will perform a qualitative evidence synthesis using a framework approach. We will conduct this study in accord with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement and the Enhancing Transparency in Reporting the synthesis of Qualitative research checklist. We will search MEDLINE, CINAHL, The Cochrane Central Register of Controlled Trials, EMBASE and PsycINFO using a comprehensive search strategy. A priori selection criteria include qualitative studies involving samples with a mean age over 45 and where 80% or more have chronic hip pain. Two or more reviewers will independently screen studies for eligibility, assess methodological strengths and limitations using the Critical Appraisal Skills Programme qualitative studies checklist, perform data extraction and synthesis and determine ratings of confidence in each review finding using the Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research approach. Data extraction and synthesis will be guided by the Common-Sense Model of Self-Regulation. All authors will contribute to interpreting, refining and finalising review findings. This protocol is registered on PROSPERO and reported according to the PRISMA Statement for Protocols (PRISMA-P) checklist.

ETHICS AND DISSEMINATION

Ethics approval is not required for this systematic review as primary data will not be collected. The findings of the review will be disseminated through publication in an academic journal and scientific conferences.

PROSPERO REGISTRATION NUMBER

PROSPERO registration number: CRD42021246305.

Combined extracorporeal shockwave therapy and exercise for the treatment of tendinopathy: A narrative review

Tendinopathy is a chronic degenerative musculoskeletal disorder that is common in both athletes and the general population. Exercise and extracorporeal shockwave therapy (ESWT) is among the most common treatments used to mediate tendon healing and regeneration. The review presents the current understanding of mechanisms of action of ESWT and exercise in isolation and briefly synthesises evidence of their effectiveness for various tendinopathies. The central purpose of the review is to synthesize research findings investigating the combination of ESWT and exercise for five common tendinopathies (plantar heel pain, rotator cuff, lateral elbow, Achilles, and patellar tendinopathy) and provide recommendations on clinical applicability. Collectively, the available evidence indicates that ESWT combined with exercise in the form of eccentric training, tissue-specific stretching, or heavy slow resistance training are effective for specific tendinopathies and can therefore be recommended in treatment. Whilst there are at present a limited number of studies investigating combined EWST and exercise approaches, there is evidence to suggest that the combination improves outcomes in the treatment of plantar heel pain, Achilles, lateral elbow, and rotator cuff tendinopathy. However, despite overall positive outcomes in patellar tendinopathy, the combined treatment has not been shown at present to offer additional benefit over eccentric exercise alone.

Platelet-rich plasma versus steroids injections for greater trochanter pain syndrome: a systematic review and meta-analysis

INTRODUCTION

Greater trochanter pain syndrome (GTPS) is characterized by a persistent and debilitating pain around the greater trochanter. GTPS can be caused by a combination of gluteus medius or minimus tendinopathy, snapping hip or trochanteric bursitis.

SOURCE OF DATA

Recent published literatures identified from PubMed, EMBASE, Google Scholar, Scopus.

AREAS OF AGREEMENT

Platelet rich plasma (PRP) and corticosteroids (CCS) injections are useful options to manage symptoms of GTPS.

AREAS OF CONTROVERSY

Whether PRP leads to superior outcomes compared to CCS injections is unclear.

GROWING POINTS

A systematic review and meta-analysis comparing PRP versus CCS in the management of GTPS was conducted.

AREAS TIMELY FOR DEVELOPING RESEARCH

PRP injections are more effective than CCS at approximately 2 years follow-up.

Psychological factors during rehabilitation of patients with Achilles or patellar tendinopathy: a cross-sectional study

OBJECTIVE

to examine psychological factors during rehabilitation of patients with Achilles or patellar tendinopathy as well as the association between psychological factors and tendinopathy severity, sport participation, and satisfaction with activity level and tendon function.

DESIGN

cross-sectional study.

SETTING

online survey platform.

PARTICIPANTS

119 patients (mean age: 44 years (SD 14)) diagnosed with Achilles or patellar tendinopathy.

MAIN OUTCOME MEASURES

A range of patient-reported psychological and outcome measures were recorded. Multivariate regression analyses were performed to establish the association between each psychological factor and outcome measures, adjusted for relevant confounders.

RESULTS

Psychological readiness and confidence to return to sports (I-PRRS) and pain catastrophizing (PCS) were significantly associated with tendinopathy severity (modified VISA), sport participation(OSTRC-O), and satisfaction. Kinesiophobia (TSK) and the importance to patients of returning to pre-injury activity level were significantly associated with sports participation and satisfaction.

CONCLUSION

The current study provides evidence of impairments in psychological factors during rehabilitation of patients with Achilles and patellar tendinopathy. Most investigated psychological factors were associated with tendinopathy severity, function, participation, and satisfaction. Physical therapists should recognize patients with lack of psychological readiness to return to sports and also patients with kinesiophobia or catastrophizing thoughts when experiencing pain.

Participant characteristics are poorly reported in exercise trials in tendinopathy: A systematic review

OBJECTIVE

To evaluate the reporting of eligibility criteria and baseline participant characteristics in randomised controlled trials investigating the effects of exercise interventions in tendinopathy.

METHODS

Randomised controlled trials investigating the effects of exercise therapy compared to a non-exercising intervention in upper and lower limb tendinopathy were included. Data extraction was categorised into the following domains: participant demographics, tendinopathy descriptors, general health, participant recruitment and eligibility criteria.

RESULTS

The review included the following tendinopathies: Achilles (n = 9), gluteal (n = 2), lateral elbow tendinopathy (n = 15), patellar (n = 3) plantar (n = 3), and rotator cuff (n = 13). Age, sex, duration of symptoms and symptom severity were commonly reported across the review, while prior history of tendinopathy was poorly reported (6/45). Variables such as physical activity level (17/45), sleep (0/45), psychological factors (2/45), medication at baseline (8/45), co morbid health complaints (10/45) and sociodemographic factors (11/45) were poorly reported across the included studies. Substantial variation existed between studies in the specific eligibility criteria used.

CONCLUSION

The findings of this systematic review demonstrate that participant characteristics are poorly reported in exercise trials in tendinopathy. To improve effectiveness of exercise interventions in tendinopathy, improved reporting of participant characteristics may allow better comparisons and targeted interventions for specific subgroups.

The strength of association between psychological factors and clinical outcome in tendinopathy: A systematic review

Objective

Tendinopathy is often a disabling, and persistent musculoskeletal disorder. Psychological factors appear to play a role in the perpetuation of symptoms and influence recovery in musculoskeletal pain. To date, the impact of psychological factors on clinical outcome in tendinopathy remains unclear. Therefore, the purpose of this systematic review was to investigate the strength of association between psychological factors and clinical outcome in tendinopathy.

Methods

A systematic review of the literature and qualitative synthesis of published trials was conducted. Electronic searches of ovid MEDLINE, ovid EMBASE, PsychINFO, CINAHL and Cochrane Library was undertaken from their inception to June 2020. Eligibility criteria included RCT’s and studies of observational design incorporating measurements of psychological factors and pain, disability and physical functional outcomes in people with tendinopathy. Risk of Bias was assessed by two authors using a modified version of the Newcastle Ottawa Scale. High or low certainty evidence was examined using the GRADE criteria.

Results

Ten studies of observational design (6-cross sectional and 4 prospective studies), involving a sample of 719 participants with tendinopathy were included. Risk of bias for the included studies ranged from 12/21 to 21/21. Cross-sectional studies of low to very low level of certainty evidence revealed significant weak to moderate strength of association (r = 0.24 to 0.53) between psychological factors and clinical outcomes. Prospective baseline data of very low certainty evidence showed weak strength of association between psychological factors and clinical outcome. However, prospective studies were inconsistent in showing a predictive relationship between baseline psychological factors on long-term outcome. Cross sectional studies report similar strengths of association between psychological factors and clinical outcomes in tendinopathy to those found in other musculoskeletal conditions.

Conclusion

The overall body of the evidence after applying the GRADE criteria was low to very low certainty evidence, due to risk of bias, imprecision and indirectness found across included studies. Future, high quality longitudinal cohort studies are required to investigate the predictive value of baseline psychological factors on long-term clinical outcome.

Cross-cultural adaptation and validation of the Victorian Institute of Sports Assessment for gluteal tendinopathy questionnaire in Italian and investigation of the association between tendinopathy-related disability and pain

BACKGROUND

The Victorian Institute of Sports Assessment for gluteal tendinopathy (VISA-G) questionnaire has recently been proposed as a condition-specific patient reported outcome measurement tool to assess the tendinopathy-related disability.

AIM

The aim was to evaluate the reliability of the Italian version of the VISA-G questionnaire and its construct validity and to investigate the association between tendinopathy-related disability and pain.

DESIGN

It consists in a cross-sectional study.

SETTING

The location of the study was a university laboratory.

POPULATION

We evaluated patients with gluteal tendinopathy (N.=38) and healthy controls (N.=38).

METHODS

Subjects were asked to fill the VISA-G questionnaire twice to evaluate its reliability. The construct validity was evaluated by comparing the VISA score with the Oswestry Disability Index score. Moreover, pain intensity, extent and location were also investigated.

RESULTS

The VISA-G scores showed non-significant changes in the median values and the values of intraclass correlation coefficient showed very high correlation between the first and second administration (ICC>0.90 in both populations). No significant correlations were found between VISA-G score and either pain extent (R=-0.05, P=0.76), or resting pain intensity (R=-0.13, P=0.45), or palpation pain intensity (R= 0.01, P=0.97). Conversely, a high (and significant) negative correlation was obtained between VISA-G score and Oswestry Disability Index score (R=-0.80, P<0.0001).

CONCLUSIONS

These results indicated that the VISA-G Italian version presents excellent test-retest reliability.

CLINICAL REHABILITATION IMPACT

The evaluation of gluteal tendinopathy-related disability through VISA-G can be useful for the prognostic assessment and/or follow-up of tendinopathy patients in combination with the pain drawing assessment of pain extent.

'My hip is damaged': a qualitative investigation of people seeking care for persistent hip pain

OBJECTIVES

Clinicians who use the biopsychosocial approach to manage musculoskeletal pain disorders aim to understand how patients make sense of their symptoms. Treatment includes targeting the negative beliefs and coping responses that can lead to progressive pain and disability. We aimed to explore how people seeking care for persistent hip pain and disability make sense of their symptoms.

METHODS

Cross-sectional qualitative study. People were eligible if they were aged ≥18 years, were consulting an orthopaedic surgeon for persistent hip pain and offered a non-surgical intervention. Data were collected through interviews that explored patients' beliefs about the identity (diagnosis), causes, consequences, timeline and controllability of their symptoms, their strategies to cope with pain and their experiences in seeking healthcare. Transcribed interview data were analysed thematically using a framework approach.

RESULTS

Sixteen people (median age=51, range=33-73 years; median duration hip pain=3 years, range=3 months-20 years) participated. Most participants (10/16) believed their pain was caused by an exercise-related injury. Because of the results of imaging and interactions with healthcare professionals, all participants believed they had damaged hip structures. All described ineffective strategies to manage their pain and multiple failed treatments. For many (7/16), a lack of control over symptoms threatened their physical and mental health.

CONCLUSIONS

The way participants with persistent hip pain and disability made sense of their symptoms contributed to them avoiding physical activity, and it impaired their sleep, emotional well-being and physical health.

Do features of central sensitisation exist in Greater Trochanteric Pain Syndrome (GTPS)? A case control study

BACKGROUND

Greater Trochanteric Pain Syndrome (GTPS), which is commonly due to Gluteal Tendinopathy, refers to pain over the lateral hip that can become persistent and disabling. Central nervous sensitisation has been implicated in upper limb tendinopathy, but no studies have investigated if it plays a role in GTPS.

OBJECTIVES

To investigate if features of central sensitisation were present in people with GTPS.

METHODS

Eighteen people with GTPS were matched with 18 healthy controls in this cross-sectional study. The VISA-G and Central Sensitisation Inventory (CSI) self-report questionnaires were completed and pressure pain detection thresholds (PPDTs) at local and remote sites were measured in all participants. Data were analysed for between-group differences using Mann-Whitney U tests. Correlation between CSI and PPDTs were assessed using Pearson correlation co-efficients.

RESULTS

PPDT values were lower at local (symptomatic greater trochanter) and remote sites in the GTPS group, indicative of central sensitisation, resulting in statistically significant between-group differences. 44.4% of the GTPS group were classified as having symptoms of central sensitisation, based on the CSI.

CONCLUSION

There is preliminary evidence of central sensitisation in people with GTPS. Results need to be validated using other objective quantitative sensory testing measures in larger samples.

Isometric versus isotonic exercise for greater trochanteric pain syndrome: a randomised controlled pilot study

Objectives

Greater trochanteric pain syndrome (GTPS) is a common cause of lateral hip pain. Limited evidence exists for the effectiveness of exercise for GTPS. This study aimed to compare the effectiveness of isometric and isotonic exercise for individuals with GTPS.

Methods

This randomised controlled pilot trial recruited 30 participants with GTPS. Both programmes consisted of daily, progressive home exercise for 12 weeks with 8 individual physiotherapy sessions over the trial period. The primary outcome measure was the Victorian Institute of Sport Assessment-Gluteal (VISA-G) and secondary outcome measures included the Numeric Pain Rating Scale (0–10) and an 11-point Global Rating of Change Scale. Outcome measures were assessed at baseline, 4 and 12 weeks.

Results

Twenty-three participants completed the trial. After 12 weeks, mean VISA-G scores improved in both groups; 55–65 in the isometric group and 62–72 in the isotonic group. 55% of the isometric group and 58% of the isotonic group achieved a reduction in pain of at least 2 points (minimally clinically important difference (MCID)) on the Numeric Pain Rating Scale. 64% of the isometric group and 75% of the isotonic group had improved by at least 2 points (MCID) on the Global Rating of Change Scale.

Conclusion

Isometric and isotonic exercise programmes appear to be effective for individuals with GTPS and should be considered in the loading management of patients with this condition.

ICON PART-T 2019-International Scientific Tendinopathy Symposium Consensus: recommended standards for reporting participant characteristics in tendinopathy research (PART-T)

We aimed to establish consensus for reporting recommendations relating to participant characteristics in tendon research. A scoping literature review of tendinopathy studies (Achilles, patellar, hamstring, gluteal and elbow) was followed by an online survey and face-to-face consensus meeting with expert healthcare professionals (HCPs) at the International Scientific Tendon Symposium, Groningen 2018. We reviewed 263 papers to form statements for consensus and invited 30 HCPs from different disciplines and geographical locations; 28 completed the survey and 15 attended the meeting. There was consensus that the following data should be reported for cases and controls: sex, age, standing height, body mass, history of tendinopathy, whether imaging was used to confirm pathology, loading tests, pain location, symptom duration and severity, level of disability, comorbidities, physical activity level, recruitment source and strategies, and medication use history. Standardised reporting of participant characteristics aims to benefit patients and clinicians by guiding researchers in the conduct of their studies. We provide free resources to facilitate researchers adopting our recommendations.

A survey of physiotherapy practice (2018) in the United Kingdom for patients with greater trochanteric pain syndrome

PURPOSE

Greater Trochanteric Pain syndrome (GTPS) is a debilitating condition causing lateral hip pain. It affects up to 23.5% of women and 8% of men between 50 and 75 years old. Sufferers report comparable quality of life and functional performance to patients with end stage osteoarthritis of the hip. Understanding of optimal management strategies for GTPS remains limited. Hence, the purpose of this cross-sectional survey was to describe current UK physiotherapy practice so as to understand current practice and inform the systematic development of a physiotherapy intervention.

METHODS

An online survey was developed and distributed via Twitter, the interactive Chartered Society of Physiotherapy website, Musculoskeletal Association of Chartered Physiotherapists and the professional networks of the authors via email. Responses were collected over a four-week period, this was finalised in April 2018.

RESULTS

A total of 409 surveys were submitted; 382 were eligible for use. Nearly all physiotherapists were either somewhat, or very confident diagnosing (372/382; 97.4%) and treating (372/382; 97.4%) patients with GTPS. The management strategies most commonly used were: education on load management (377/381; 98.7%) and self-management strategies (375/381; 98.4%). Strengthening exercises (376/382; 98.4%) were commonly used and targeted to the hip abductors (355/379; 93.7%). Most frequently these exercises were delivered using a combination of home exercise programme (380/380; 100%) and one-to-one exercise sessions (344/377; 91.2%).

CONCLUSION

The data from this large survey highlights that physiotherapists in the UK most commonly use education on load management and self-management strategies, alongside strengthening exercises targeting the hip abductors for patients with GTPS.

Potential Nervous System Sensitization in Patients With Persistent Lower Extremity Tendinopathies: 3 Case Reports

BACKGROUND

Tendinopathy is a condition often associated with pain and functional and sport performance limitations. While targeted exercise prescriptions are often effective, many patients with tendinopathy develop persistent symptoms. Emerging evidence suggests a possible link between nervous system sensitization and tendinopathy. If so, identifying and treating specific pain mechanisms may improve outcomes.

CASE DESCRIPTION

Three patients were seen in physical therapy for complaints of ongoing chronic tendon pain and self-reported disability, despite being treated previously and receiving evidence-informed care. Upon examination, each patient demonstrated signs consistent with possible dysfunction of central pain mechanisms. Joint mobilization, pain neuroscience education, and aerobic exercise were primary interventions in each case to decrease pain and improve function.

OUTCOMES

The 3 patients were treated for 5 sessions over the course of 8 weeks. Clinically significant improvement was noted in measures of pain, self-reported function, and pressure pain thresholds. At discharge, all patients were able to run without symptoms, and improvement was maintained at 1-year follow-up.

DISCUSSION

Tendinopathy, while often described as local pain and dysfunction, may be associated with dysfunction of the nervous system. Identifying and treating pain mechanisms in addition to relevant impairments may be an appropriate intervention approach for individuals with tendinopathy.

LEVEL OF EVIDENCE

Therapy, level 4. J Orthop Sports Phys Ther 2019;49(4):272-279. Epub 13 Feb 2019. doi:10.2519/jospt.2019.8600.

Strength and range of movement deficits are associated with symptom severity in people scheduled for hip arthroscopy

BACKGROUND

Identifying the physical impairments associated with worse symptoms and greater functional limitations in people with hip pain could enable targeted rehabilitation programmes designed to improve quality of life. The objective of this study was to compare physical characteristics between subgroups of symptoms and functional limitation severity in individuals with hip pain scheduled for arthroscopic surgery.

METHODS

Hip range of motion (ROM) and muscle strength were measured in 114 individuals (48 women; aged 32 ± 8 years) with hip pain scheduled for hip arthroscopy. Pain and disability were measured with the International Hip Outcome Tool (iHOT33) subscale of Symptoms and Functional Limitation, and a cluster analysis was used to identify mild, moderate and severe subgroups. Between-group differences were then evaluated using multivariate analysis of covariance, including sex as a covariate, followed by post hoc testing. Significance was set at 0.05.

RESULTS

Lesser hip muscle strength in all directions was reported in the severe symptoms and functional limitation group compared to the mild group. Hip flexion ROM differed when comparing the moderate to both the mild and severe subgroups. Hip internal rotation did not differ between subgroups of severity.

CONCLUSIONS

Individuals with hip pain and severe scores in the iHOT33 subscale of symptoms and functional limitations present with significantly lesser hip muscle strength and hip flexion ROM than individuals with moderate or mild scores. Targeted programmes to improve hip strength and flexion ROM in more severe patients may help reduce symptoms and improve function.

SIGNIFICANCE

Individuals with severe hip pain and functional limitation possess significantly lesser muscle strength and flexion ROM than individuals with moderate or mild scores.

Obesity, depression and hip pain

INTRODUCTION

Up to 64% of the general population reports experiencing chronic pain, with the hip being one of the most frequent sites. An association has been shown between chronic back pain, obesity and depression. To date, a similar association has not been investigated with chronic hip pain.

METHODS

A total of 2,515 subjects were chosen as a representative cross-section of the German population. Each was provided with a questionnaire that included the Regional Pain Scale, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), Beck Depression Inventory-Primary Care and Winkler social class index. Participant height and weight values were obtained from self-reports. Using logistic regression methodology, we analysed the association between hip pain, obesity and increased depression scores.

RESULTS

A total of 124 (4.9%) subjects reported chronic hip pain and an additional 39 (1.5%) reported chronic hip pain that was disabling. Hip pain affected 1-5 sites (oligolocular) in 47% of cases, and was widespread (6-19 sites) in 50%. Obesity and increased values on the depression scale were associated with an increased likelihood of chronic hip pain (odds ratio [OR] 2.55 and 8.53, respectively) compared with subjects without pain. Increased values on the depression scale (OR 28.22) increased the likelihood of experiencing disabling chronic hip pain in comparison with pain free individuals.

CONCLUSIONS

Hip pain is rarely the sole site of pain. Obesity and increased values on the depression scale are associated with chronic hip pain. Increased values on the depression scale are associated with disabling chronic hip pain.