The association of working alliance, outcome expectation, adherence and self-efficacy with clinical outcomes for Achilles tendinopathy: A feasibility cohort study (the MAP study)

The relationship between psychological, cognitive, and contextual factors and rehabilitation outcomes in Achilles tendinopathy: A prospective feasibility cohort study

OBJECTIVES

This study aimed to investigate the feasibility of conducting a full-scale study investigating the influence of patient-related factors on rehabilitation outcomes in Achilles tendinopathy (AT). A secondary aim was to investigate preliminary relationships between patient-related factors and clinical outcomes at 12- and 26- weeks.

DESIGN

feasibility cohort.

SETTING

Australian healthcare settings.

METHODS

Participants with AT receiving physiotherapy in Australia were recruited via treating physiotherapists and online. Data were collected online at baseline, 12- and 26-weeks. Progression criteria for a full-scale study were recruitment rate of ≥10 per month, conversion rate ≥20%, and response rate to questionnaires ≥80%. The relationship between patient-related factors and clinical outcomes was investigated using Spearman's rho correlation coefficient.

RESULTS

The average recruitment rate was 5/month, conversion rate was 97%, and response rate to questionnaires was ≥97% at all timepoints. There was a fair to moderate correlation (rho = 0.225 to 0.683) between patient-related factors and clinical outcomes at the 12-week, but no to weak correlation at the 26-week (rho = 0.002 to 0.284).

CONCLUSIONS

Feasibility outcomes suggest a future full-scale cohort study is feasible with the caveat of utilizing strategies to improve recruitment rate. Preliminary bivariate correlations at 12-weeks warrant further investigations in larger studies.

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 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.

Patient perspectives on participation in exercise-based rehabilitation for Achilles tendinopathy: A qualitative study

BACKGROUND

Achilles tendinopathy (AT) is common, and can be traumatic or insidious in onset and short-lasting or persistent in nature. Factors influencing the experience of pain are poorly understood; little is known about mechanisms driving pain and the response (or lack of) to rehabilitation. Despite this, there is a growing body of evidence supporting the use of exercise to manage AT. Interestingly, variation in exercise approach does not appear to significantly impact outcome. Patients' perceptions of factors related to rehabilitation that may influence outcome could provide a valuable addition to help guide future research and practice.

OBJECTIVES

The aim of this study is to gain an insight into patients' experiences of participating in an exercise-based rehabilitation programme for AT.

METHOD

A qualitative interpretive description design. Data generated from semi-structured interviews were analysed thematically using the guidelines set out by Braun and Clarke.

FINDINGS

This is the first study to use a qualitative method of inquiry to gain data on the experiences of people undertaking exercise-based rehabilitation for AT. The four major themes that were identified from the data were: (1) 'understanding the impact' (2) 'expectations' (3) 'what matters' and (4) 'the burden of exercise'.

CONCLUSIONS

Given the uncertainty surrounding the mechanisms of effect of our treatments, the insights provide a platform from which researchers and clinicians can consider further in the management of people with Achilles tendinopathy. Specifically, it has highlighted that patients value a flexible, supportive approach embracing the biopsychosocial impact of AT on the individual.

Self-reported pain with single leg heel raise or single leg hop offer distinct information as measures of severity in men with midportion and insertional Achilles tendinopathy: An observational cross-sectional study

OBJECTIVES

To investigate if self-reported pain with single leg heel raise (SLHR) or single leg hop (SLH) are concurrently valid to assess midportion (MPAT) or insertional Achilles tendinopathy (IAT) symptom severity, compared to the VISA-A. Additionally, if SLHR or SLH pain accounts for VISA-A variability, and if they are associated with psychological factors.

PARTICIPANTS

60 men with MPAT, 26 men with IAT.

MAIN OUTCOMES

Participants rated SLHR and SLH pain on a numerical rating scale (0 = none, 10 = worst). We investigated relationships between loading task pain, VISA-A, VISA-A constructs, and psychological outcomes (Pearson's correlation coefficients). Linear regression determined best model accounting for VISA-A variability.

RESULTS

In MPAT, load tests shared fair-negative relationship with VISA-A, and VISA-A function. In IAT, SLHR had moderately strong-negative relationship with VISA-A, and pain and function constructs, and SLH shared fair-negative relationship with VISA-A, and pain and function constructs. Relationships were negligible between load tests and VISA-A activity in both conditions, and VISA-A pain in MPAT. In IAT, there was fair-positive relationship between pain catastrophising and load tests. Remaining psychological outcome relationships were negligible. Best model accounting for VISA-A included SLH in MPAT, and SLHR in IAT.

CONCLUSIONS

Despite VISA-A and selected VISA-A construct associations, self-reported SLHR and SLH pain appears to provide distinct information.