The effect of isometric exercise on pain in individuals with plantar fasciopathy: A randomized crossover trial

Does a corticosteroid injection plus exercise or exercise alone add to the effect of patient advice and a heel cup for patients with plantar fasciopathy? A randomised clinical trial

OBJECTIVE

To compare the effectiveness of patient advice plus heel cup alone (PA) versus PA and lower limb exercise (PAX) versus PAX plus corticosteroid injection (PAXI) to improve self-reported pain in patients with plantar fasciopathy.

METHODS

We recruited 180 adults with plantar fasciopathy confirmed by ultrasonography for this prospectively registered three-armed, randomised, single-blinded superiority trial. Patients were randomly allocated to PA (n=62), PA plus self-dosed lower limb heavy-slow resistance training consisting of heel raises (PAX) (n=59), or PAX plus an ultrasound-guided injection of 1 mL triamcinolone 20 mg/mL (PAXI) (n=59). The primary outcome was changed in the pain domain of the Foot Health Status Questionnaire (ranging from 0 'worst' to 100 'best') from baseline to the 12-week follow-up. The minimal important difference in the pain domain is 14.1 points. The outcome was collected at baseline and at 4, 12, 26, and 52 weeks.

RESULTS

The primary analysis found a statistically significant difference between PA and PAXI after 12 weeks favouring PAXI (adjusted mean difference: -9.1 (95% CI -16.8 to -1.3; p=0.023)) and over 52 weeks (adjusted mean difference: -5.2 (95% CI -10.4 to -0.1; p=0.045)). At no follow-up did the mean difference between groups exceed the pre-specified minimal important difference. No statistically significant difference was found between PAX and PAXI or between PA and PAX at any time.

CONCLUSION

No clinically relevant between-group differences were found after 12 weeks. The results indicate that combining a corticosteroid injection with exercise is not superior to exercise or no exercise.

TRIAL REGISTRATION NUMBER

NCT03804008.

MAINTAINING COMPETITIVE ACTIVITY IN ELITE SPORTS WITH ACUTE PLANTAR FASCIITIS

Competition in the modern pentathlon in the new 2024 Olympic program are tense and high intensity. Before reaching the final the athlete must go through 8 types of events in 4 days performs before 5 events in final competitions. It's quit difficult to restore the function of damaged link of the musculoskeletal system during competition in a short time. The time of breaks for rest and recovery in the competitive activity of an all-around athlete in the modern pentathlon is limited. The presented rehabilitation program after an acute injury was implemented at modern pentathlon competitions. A distinctive feature of the effects is the practice of rehabilitation and recovery after physical exertion. The peculiarity was in short periods of rest during intense multi-day competitive activity. There was a clear organization in the procedures, a strict sequence of methods and techniques. The presented material rather as an exception confirms the possibilities of the applied systemic rehabilitation techniques. This made it possible to continue competitive activity in modern pentathlon after an acute injury without compromising the athlete's health.

The effects of pain science education plus exercise on pain and function in chronic Achilles tendinopathy: a blinded, placebo-controlled, explanatory, randomized trial

ABSTRACT

Exercise is the standard of care for Achilles tendinopathy (AT), but 20% to 50% of patients continue to have pain following rehabilitation. The addition of pain science education (PSE) to an exercise program may enhance clinical outcomes, yet this has not been examined in patients with AT. Furthermore, little is known about how rehabilitation for AT alters the fear of movement and central nervous system nociceptive processing. Participants with chronic AT (N = 66) were randomized to receive education about AT either from a biopsychosocial (PSE) or from a biomedical (pathoanatomical education [PAE]) perspective. Simultaneously, all participants completed an exercise program over 8 weeks. Linear mixed models indicated that there were no differences between groups in (1) movement-evoked pain with both groups achieving a clinically meaningful reduction (mean change [95% CI], PSE: -3.0 [-3.8 to -2.2], PAE = -3.6 [-4.4 to -2.8]) and (2) self-reported function, with neither group achieving a clinically meaningful improvement (Patient-Reported Outcomes Measurement Information System Physical Function-PSE: 1.8 [0.3-3.4], PAE: 2.5 [0.8-4.2]). After rehabilitation, performance-based function improved (number of heel raises: 5.2 [1.6-8.8]), central nervous system nociceptive processing remained the same (conditioned pain modulation: -11.4% [0.2 to -17.3]), and fear of movement decreased (Tampa Scale of Kinesiophobia, TSK-17: -6.5 [-4.4 to -8.6]). Linear regression models indicated that baseline levels of pain and function along with improvements in self-efficacy and knowledge gain were associated with a greater improvement in pain and function, respectively. Thus, acquiring skills for symptom self-management and the process of learning may be more important than the specific educational approach for short-term clinical outcomes in patients with AT.

Effects of a single exercise session on pain intensity in adults with chronic pain: a systematic review and meta-analysis

BACKGROUND

Chronic pain is prevalent amongst society, making it necessary to find strategies to manage chronic pain. Regular exercise is efficacious; however, pain is a barrier to initiating exercise. A single exercise session is also believed to acutely reduce pain, however, the evidence for this is less robust.

OBJECTIVES

This systematic review and meta-analysis aimed to identify the effect of a single exercise session on pain intensity in adults with chronic pain.

METHODS

We searched eight databases and trial registries to identify randomised controlled trials evaluating the effect of a single exercise session on pain intensity in adults with chronic pain compared to a non-exercise control. Literature screening, data extraction, risk of bias (Cochrane 2.0) and quality assessment (GRADE) were conducted independently and in duplicate. Random-effects meta-analyses were performed using the metafor package in R.

RESULTS

We included 17 trials (46 study arms with 664 adults [44% female]). There were no significant differences in pain intensity (mean difference on a 0-10 scale) immediately post-exercise -0.02 (95% CI = -0.06, 0.62; I² = 77.1%) or up to 45-min post-exercise -0.17 (95% CI = -0.49, 0.16; I² = 34.2%). All trials were at high risk of bias and the overall confidence in these findings was very low.

CONCLUSION

A single exercise session did not reduce pain intensity up to 1-h post-exercise. Notably, increases in pain were not observed either, suggesting that while pain can be a barrier to initiating exercise, clinicians can educate patients on the unlikelihood of exercise acutely increasing pain intensity.

Assessment of the reporting quality of resistance training interventions in randomised controlled trials for lower limb tendinopathy: A systematic review

OBJECTIVES

1. To describe what exercises and intervention variables are used in resistance training interventions in randomised controlled trials for lower limb tendinopathy 2. To assess completeness of reporting as assessed by the Consensus on Exercise Reporting Template (CERT) and the Toigo and Boutellier framework. 3. To assess the implementation of scientific resistance training principles. 4. To assess therapeutic quality of exercise interventions with the i-CONTENT tool.

DATA SOURCES

We searched MEDLINE, CINAHL, AMED, EMBase, SPORTDiscus, and the Cochrane library databases.

REVIEW METHODS

Systematic review of randomised controlled trials that reported using resistance exercises for lower limb tendinopathies.

RESULTS

We included 109 RCTs. Eccentric heel drops were the most common exercise (43 studies), followed by isotonic heel raises (21), and single leg eccentric decline squats (18). Reporting of exercise descriptor items from the Toigo and Boutellier framework ranged from 0-13, with an average score of 9/13, and only 7 studies achieved a full 13/13. Reporting of items from the CERT ranged from 0-18, with an average score of 14/19. No study achieved a full 19/19, however 5 achieved 18/19. Scoring for resistance training principles ranged from 1-10, with only 11 studies achieving 10/10. Reporting across studies for the i-CONTENT tool ranged from 2-7, with an average score of 5 across included studies. A total of 19 studies achieved a full 7/7 score. Less than 50% of studies achieved an overall low risk of bias, highlighting the methodological concerns throughout studies.

CONCLUSION

The reporting of exercise descriptors and intervention content was generally high across RCTs for lower limb tendinopathy, with most allowing exercise replication. However, reporting for some tendinopathies and content items such as adherence was poor, limiting optimal translation to clinical practice.

Resistance Training Interventions for Lower Limb Tendinopathies: A Scoping Review of Resistance Training Reporting Content, Quality, and Scientific Implementation

The objectives of this scoping review were as follows: (1) to describe what exercises and intervention variables are used in resistance training interventions for lower limb tendinopathy,  (2) to assess the completeness of reporting as assessed by the Consensus on Exercise Reporting Template (CERT) and the Toigo and Boutellier framework, and (3) to assess the implementation of scientific resistance training principles. We searched MEDLINE, CINAHL, AMED, Embase, SPORTDiscus, and Cochrane Library databases. Randomized controlled trials, cohort studies, case series, case reports, and observational studies that reported using resistance exercises for lower limb tendinopathies were considered for inclusion, with 194 studies meeting the inclusion criteria. Completeness of the reporting of exercise descriptors and programme variables was assessed by the CERT and the Toigo and Boutellier framework. Reporting of exercise descriptor items from the Toigo and Boutellier framework ranged from 0 to 13, with an average score of 9/13, with only 9 studies achieving a full 13/13. Reporting of items from the CERT ranged from 0 to 18, with an average score of 13/19. No study achieved a full 19/19; however, 8 achieved 18/19. Scoring for resistance training principles ranged from 1 to 10, with only 14 studies achieving 10/10. Eccentric heel-drops were the most common exercise (75 studies), followed by isotonic heel raises (38), and single-leg eccentric decline squats (27). The reporting of exercise descriptors and intervention content was high across studies, with most allowing exercise replication, particularly for Achilles and patellar tendinopathy. However, reporting for some tendinopathies and content items such as adherence was poor, limiting optimal translation to clinical practice.

Putting "Heavy" into Heavy Slow Resistance

The body of literature on tendinopathy management has come a long way in the last few decades and a variety of changes in the clinical approach have emerged from this research. One particular approach that shows promise has been called "heavy slow resistance" (HSR), and this has been the subject of investigation in a number of randomized controlled trials. While the premise for this approach is defensible, a critical examination of the implementation of these HSR protocols results in some concerns when compared to basic exercise science principles. This article lays out some considerations that will help future investigators to improve their exercise prescription approaches in this area.

Evidence of Widespread Mechanical Hyperalgesia but Not Exercise-Induced Analgesia in Athletes With Mild Patellar Tendinopathy Compared With Pain-Free Matched Controls: A Blinded Exploratory Study

OBJECTIVE

The aim of the study was to assess centrally induced pain processing with pressure pain thresholds bilaterally and remotely in active volleyball and basketball athletes with mild patellar tendinopathy compared with asymptomatic control athletes. Secondary objective was to explore the role of exercise-induced analgesia during a training session in athletes with patellar tendinopathy.

DESIGN

In this exploratory study, pressure pain thresholds of 21 patellar tendinopathy athletes and 16 age- and sex-matched asymptomatic team members were measured by a blinded assessor bilaterally on the patellar tendon and unilaterally on the elbow extensor tendon with a pressure algometer before, during, and after a regular training session.

RESULTS

Patellar tendinopathy athletes had a significantly higher average body mass index compared with asymptomatic athletes (mean difference 1.75 kg/m2; 95% confidence interval = 0.35-3.15, P = 0.02). At baseline, athletes with patellar tendinopathy showed lowered pressure pain thresholds in the affected knee (P = 0.001), unaffected knee (P < 0.001), and elbow (P = 0.01) compared with controls. No clear patterns were identified to explain between-group differences in pressure pain thresholds before, during, and after exercise.

CONCLUSIONS

This exploratory study found primary and secondary mechanical hyperalgesia in athletes with patellar tendinopathy compared with asymptomatic athletes. Further research is required on the effects of an acute exercise bout on pain thresholds in this population.

Autoregulation in Resistance Training for Lower Limb Tendinopathy: A Potential Method for Addressing Individual Factors, Intervention Issues, and Inadequate Outcomes

Musculoskeletal disorders, such as tendinopathy, are placing an increasing burden on society and health systems. Tendinopathy accounts for up to 30% of musculoskeletal disorders, with a high incidence in athletes and the general population. Although resistance training has shown short-term effectiveness in the treatment of lower limb tendinopathy, more comprehensive exercise protocols and progression methods are required due to poor long-term outcomes. The most common resistance training protocols are predetermined and standardized, which presents significant limitations. Current standardized protocols do not adhere to scientific resistance training principles, consider individual factors, or take the importance of individualized training into account. Resistance training programs in case of tendinopathy are currently not achieving the required intensity and dosage, leading to high recurrence rates. Therefore, better methods for individualizing and progressing resistance training are required to improve outcomes. One potential method is autoregulation, which allows individuals to progress training at their own rate, taking individual factors into account. Despite the finding of their effectiveness in increasing the strength of healthy athletes, autoregulation methods have not been investigated in case of tendinopathy. The purpose of this narrative review was 3-fold: firstly, to give an overview and a critical analysis of the individual factors involved in tendinopathy and current resistance training protocols and their limitations. Secondly, to give an overview of the history, methods, and application of autoregulation strategies both in sports performance and physiotherapy. Finally, a theoretical adaptation of a current tendinopathy resistance training protocol using autoregulation methods is presented, providing an example of how the method could be implemented in clinical practice or future research.

The implementation of resistance training principles in exercise interventions for lower limb tendinopathy: A systematic review

OBJECTIVES

The primary purpose of this systematic review is to examine the literature on resistance training interventions for lower limb tendinopathy to evaluate the proportion of interventions that implemented key resistance training principles (specificity, progression, overload, individualisation) and reported relevant prescription components (frequency, intensity, sets, repetitions) and reported intervention adherence.

METHODS

Two reviewers performed a systematic review after screening titles and abstracts based on eligibility criteria. Identified papers were obtained in full text, with data extracted regarding the implementation of resistance training principles. Included articles were evaluated by the Cochrane risk of bias tool, with a scoring tool out of 10 used for implementation and reporting of the 5 key principles. Scientific databases were searched in November 2020 and included Medline, CINAHL, AMED, and Sportsdiscus.

RESULTS

52 randomised controlled trials investigating resistance training in five different lower limb tendinopathies were included. Although most studies considered the principles of progression (92%) and individualisation (88%), only 19 studies (37%) appropriately described how this progression in resistance was achieved, and only 18 studies (35%) reported specific instruction on how individualisation was applied. Adherence was considered in 27 studies (52%), with only 17 studies (33%) reporting the levels of adherence. In the scoring criteria, only 5 studies (10%) achieved a total maximum score of 10, with 17 studies (33%) achieving a maximum score of 8 for implementing and reporting the principles of specificity, overload, progression and individualisation.

CONCLUSION

There is meaningful variability and methodological concerns regarding the application and reporting of resistance training principles, particularly progression and individualisation, along with intervention adherence throughout studies. Collectively, these findings have important implications for the prescription of current resistance training interventions, including the design and implementation of future interventions for populations with lower limb tendinopathies.

Should Exercises be Painful or not? Effects on Clinical and Experimental Pain in Individuals with Shoulder Pain

Exercise can reduce pain, however the effect of painful versus non-painful exercises is uncertain. The primary aim of this randomized crossover study was to compare the effect of painful versus nonpainful isometric shoulder exercises on pain intensity after exercise in individuals with rotator cuff-related shoulder pain. Secondary exploratory aims were to describe the effects on pressure pain thresholds (PPTs), conditioned pain modulation (CPM) and muscle strength. On separate days, 35 individuals performed painful isometric shoulder exercises (external rotation; 20% above pain threshold), nonpainful isometric shoulder exercises (external rotation; 20% below pain threshold), and a rest condition, in randomised order. Shoulder pain intensity, PPTs, CPM, and external rotation strength were assessed before, immediately after and 45 minutes after conditions. No significant differences were observed between painful and nonpainful exercises. Visual analogue scale scores increased immediately after both painful and non-painful exercises compared with rest (P = .047, partial ƞ² = .07), but were similar to preexercise levels after 45 minutes. No changes in PPTs, CPM, or muscle strength after exercises compared with rest were observed. Painful and non-painful isometric exercises caused a moderate but short-lasting increase in shoulder pain in individuals with RCRSP. Isometric exercises had no effect on pain sensitivity and shoulder muscle strength or CPM. Perspective: This study evaluated for the first time in individuals with rotator cuff-related shoulder pain the effects of painful versus non-painful isometric exercises on different pain-related outcome measures. Both painful and non-painful isometric exercises caused a moderate but relatively short-lasting increase in shoulder pain in individuals with rotator cuff-related shoulder pain. Trial registration number: (ClinicalTrials.gov) NCT03675399.

Immediate Effects of two Isometric Calf Muscle Exercises on Mid-portion Achilles Tendon Pain

The objectives of this randomized, cross-over pilot study were to determine whether isometric plantarflexion exercises resulted in an immediate change in Achilles tendon pain during a loading task, and whether this differed in knee extension or flexion. Eleven participants with mid-portion Achilles tendinopathy were recruited from NHS community physiotherapy services and local running clubs. Participants were then randomized to complete an isometric calf muscle exercise with the knee fully extended or flexed to 80°. Participants switched to the alternate exercise after a minimum seven-day period. Achilles tendon pain during a specific, functional load test was measured on a 11-point numeric pain rating scale (NPRS) pre- and post-intervention. There was a small, immediate, mean reduction in pain following isometric plantar flexion performed in both knee extension (1.6, 95%CI 0.83 to 2.45, p=0.001) and knee flexion (1.3, 95%CI 0.31 to 2.19, p=0.015). There were no significant differences between the two positions. A non-significant, potentially clinically relevant finding was a 20% larger reduction in symptoms in knee extension versus flexion (p=0.110). In conclusion, isometric plantarflexion holds gave an approximately 50% immediate reduction in Achilles tendon pain with a functional load test. There were no significant differences between the two positions and both were well tolerated.

Does isometric exercise result in exercise induced hypoalgesia in people with local musculoskeletal pain? A systematic review

OBJECTIVE

The aim of this review was to investigate if exercise induced hypoalgesia (EIH) occurs following isometric muscle contraction in people with local musculoskeletal symptoms.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, EMBASE, CINAHL & SportDiscus electronic databases were searched (inception to April 2020).

ELIGIBILITY CRITERIA

Two authors independently evaluated eligibility. Randomised controlled and crossover (repeated measures) trials that measured the effects of isometric exercise in participants with localised musculoskeletal pain during, and up to 2 hours after isometric exercise were included. Other inclusion criteria included comparison to another intervention, or comparison to healthy controls. Primary outcomes were experimentally induced pain thresholds and secondary outcomes included measures of pain sensitivity from clinical testing.

RESULTS

13 studies with data from 346 participants were included for narrative synthesis. EIH was reported in some upper and lower limb studies but there were no consistent data to show isometric exercises were superior to comparison interventions.

CONCLUSION

There was no consistent evidence for EIH following isometric exercise in people with musculoskeletal pain. These findings are different to those reported in asymptomatic populations (where EIH is consistently demonstrated) as well as conditions associated with widespread symptoms such as fibromyalgia (where isometric exercise may induce hyperalgesia). Although well tolerated when prescribed, isometric exercise did not induce EIH consistently for people seeking care for local musculoskeletal symptoms. The variance in the dose, location of contraction and intensity of protocols included in this review may explain the inconsistent findings. Further work is required to better understand endogenous analgesia in musculoskeletal pain conditions.

Altered Central Pain Processing in Patients With Chronic Plantar Heel Pain: A Critically Appraised Topic

Clinical Scenario: Plantar heel pain is a common condition frequently associated with persistent symptoms and functional limitations affecting both the athletic and nonathletic populations. Common interventions target impairments at the foot and ankle and local drivers of symptoms. If symptoms are predominantly perpetuated by alterations in central pain processing, addressing peripheral impairments alone may not be sufficient. Clinical Question: Do individuals with chronic plantar heel pain demonstrate signs potentially associated with altered central pain processing? Summary of Key Findings: After searching 6 electronic databases (PubMed, CINAHL, Scopus, SportDiscus, Cochrane, and PEDro) and filtering titles based on predetermined inclusion and exclusion criteria, 4 case-control studies were included. All studies scored highly on the Newcastle-Ottawa Scale for quality assessment. Using pressure pain thresholds, each study found decreased pressure pain hypersensitivity locally and at a remote site compared to control groups, suggesting the presence, to some extent, of altered nociceptive pain processing. Clinical Bottom Line: In the studies reviewed, reported results suggest a possible presence of centrally mediated symptoms in persons with plantar heel pain. However, despite findings from these studies, limitations in appropriate matching based on body mass index and measures used suggest additional investigation is warranted. Strength of Recommendation: According to the Oxford Centre for Evidence-Based Medicine, there is evidence level C to suggest chronic plantar heel pain is associated with alterations in central pain processing.

Randomised, cross-over trial on the effect of isotonic and isometric exercise on pain and strength in proximal hamstring tendinopathy: trial protocol

Background

Proximal hamstring tendinopathy (PHT) is a condition that occurs at all ages and levels of sporting participation. Presenting as localised lower buttock pain with tasks such as squatting and sitting, it can cause disability with sport, work and other activities of daily living. Recent research has investigated the effect of isometric exercise on pain and strength with a range of tendinopathies but there are no published studies on PHT. This protocol paper details a study investigating the effectiveness of isometric compared with isotonic exercise on pain and strength in people with PHT.

Methods/Design

The study is a prospective, cross-over randomised controlled trial (RCT). Twenty participants with PHT, recruited from the local community and sporting clubs will be recruited for the study. Participants will receive one session of isotonic hamstring strength exercises and one session of isometric hamstring exercise, with random allocation to the order of intervention.

Primary outcomes will be hamstring strength measured with a dynamometer and pain with a functional task, assessed immediately following and 45 min after intervention. A secondary outcome will be pain with sitting assessed 24 hours after intervention.

The effect of isotonic versus isometric exercise on hamstring pain and strength will be determined using a repeated measures linear mixed model. Further analyses will determine the proportion of patients with clinically important pain and strength improvements, using relative risks, χ² testing and number needed to treat.

Discussion

This RCT protocol will investigate the effect of isometric compared with isotonic exercise for PHT.

Tendinopathy

Tendinopathy describes a complex multifaceted pathology of the tendon, characterized by pain, decline in function and reduced exercise tolerance. The most common overuse tendinopathies involve the rotator cuff tendon, medial and lateral elbow epicondyles, patellar tendon, gluteal tendons and the Achilles tendon. The prominent histological and molecular features of tendinopathy include disorganization of collagen fibres, an increase in the microvasculature and sensory nerve innervation, dysregulated extracellular matrix homeostasis, increased immune cells and inflammatory mediators, and enhanced cellular apoptosis. Although diagnosis is mostly achieved based on clinical symptoms, in some cases, additional pain-provoking tests and imaging might be necessary. Management consists of different exercise and loading programmes, therapeutic modalities and surgical interventions; however, their effectiveness remains ambiguous. Future research should focus on elucidating the key functional pathways implicated in clinical disease and on improved rehabilitation protocols.

Stretching and relaxing the plantar fascia may change plantar fascia thickness but not pressure pain thresholds: a cross-sectional study of patients with plantar fasciopathy

Background

Despite the established relevance of ultrasonography and assessment of pressure pain thresholds in patients with plantar fasciopathy, patient and probe positioning has been mostly ignored and are not necessarily reported in research. The primary aim of this study was to compare plantar fascia thickness in stretched and relaxed positions in patients with plantar fasciopathy. The secondary aim was to compare plantar heel pressure pain thresholds in these positions.

Methods

In this cross-sectional study, we measured the plantar fascia thickness with ultrasonography, and localised pressure pain thresholds using pressure algometry of 20 patients with plantar fasciopathy. These were assessed bilaterally, with the plantar fascia in both a stretched and relaxed position. In the stretched position, toes were maximally dorsiflexed, while in the relaxed position participants’ feet were hanging freely over the end of the table.

Results

The plantar fascia of the most symptomatic foot was significantly thicker when stretched compared with the relaxed position (sagittal: mean difference 0.2 mm, 95%CI: 0.1–0.4, P = 0.013; frontal: mean difference − 0.27, 95%CI: − 0.49 to − 0.06, P = 0.014). The plantar fascia was significantly thinner in the frontal plane compared with the sagittal plane in both positions (stretched: mean difference − 0.2 mm, 95%CI: − 0.42 to − 0.03, P = 0.025; relaxed: mean difference − 0.3 mm, 95%CI:-0.49 to − 0.08, P = 0.008). There was no difference between pressure pain thresholds in stretched or relaxed positions in either foot (P > 0.4).

Conclusions

The plantar fascia was significantly thicker in a stretched compared with a relaxed position and in the sagittal compared with the frontal plane, but differences were smaller than the standard deviation. Pressure pain thresholds were not different between the positions. These results highlight the importance of how ultrasonography is performed and reported in research to allow for replication.

Trial registration

The study was pre-registered September 25th, 2017 on ClinicalTrials.gov (NCT03291665).

Exercise-induced hypoalgesia after acute and regular exercise: experimental and clinical manifestations and possible mechanisms in individuals with and without pain

This review describes methodology used in the assessment of the manifestations of exercise-induced hypoalgesia in humans and previous findings in individuals with and without pain. Possible mechanisms and future directions are discussed.

Exercise and physical activity is recommended treatment for a wide range of chronic pain conditions. In addition to several well-documented effects on physical and mental health, 8 to 12 weeks of exercise therapy can induce clinically relevant reductions in pain. However, exercise can also induce hypoalgesia after as little as 1 session, which is commonly referred to as exercise-induced hypoalgesia (EIH). In this review, we give a brief introduction to the methodology used in the assessment of EIH in humans followed by an overview of the findings from previous experimental studies investigating the pain response after acute and regular exercise in pain-free individuals and in individuals with different chronic pain conditions. Finally, we discuss potential mechanisms underlying the change in pain after exercise in pain-free individuals and in individuals with different chronic pain conditions, and how this may have implications for clinical exercise prescription as well as for future studies on EIH.

Landing biomechanics are not immediately altered by a single-dose patellar tendon isometric exercise protocol in male athletes with patellar tendinopathy: A single-blinded randomized cross-over trial

OBJECTIVES

To a) determine the acute effects of a single-dose patellar tendon isometric exercise protocol on involved limb landing biomechanics in individuals with patellar tendinopathy and asymptomatic patellar tendon pathology, and b) determine if individuals with patellar tendinopathy demonstrated changes in pain following a single-dose patellar tendon isometric exercise protocol.

DESIGN

Single-blinded randomized cross-over trial.

SETTING

Laboratory; PARTICIPANTS: 28 young male athletes with symptomatic (n = 13, age: 19.62 ± 1.61) and asymptomatic (n = 15, age: 21.13 ± 1.88) patellar tendinopathy.

MAIN OUTCOME MEASURES

Participants completed a single-dose patellar tendon isometric exercise protocol and a sham-TENS protocol, randomized and separated by 7-10 days. Pain-levels during a single-limb decline squat (SLDS) and three-dimensional biomechanics were collected during a double-limb jump-landing task before and after each intervention protocol. A mixed-model repeated measures ANOVA was conducted to compare change scores for all dependent variables.

RESULTS

There were no group × intervention interactions for change in pain (F_{(1, 26)} = 0.555, p = 0.463). There was one significant group × intervention interaction for vertical ground reaction force (VGRF) (F_{(1, 26)} = 5.33, p = 0.029). However, post-hoc testing with Bonferroni correction demonstrated no statistical significance for group (SYM: t = -1.679, p = 0.119; ASYM: t = -1.7, p = 0.107) or intervention condition (isometric: t = -2.58, p = 0.016; sham-TENS: 0.72, p = 0.460). There were no further significant group × intervention interactions (p > 0.05).

CONCLUSIONS

A single-dose patellar tendon isometric exercise protocol did not have acute effects on landing biomechanics or pain levels in male athletes with patellar tendinopathy or asymptomatic patellar tendon pathology.

Effectiveness of isometric exercise in the management of tendinopathy: a systematic review and meta-analysis of randomised trials

Objective

To systematically review and critically appraise the literature on the effectiveness of isometric exercise in comparison with other treatment strategies or no treatment in tendinopathy.

Design

A systematic review and meta-analysis of randomised controlled trials.

Data sources

Electronic searches of Medline, Cumulative Index to Nursing and Allied Health Literature, EMBASE and Cochrane were undertaken from inception to May 2020.

Methods

Overall quality of each study was determined based on a combined assessment of internal validity, external validity and precision. For each outcome measure, level of evidence was rated based on the system by van Tulder et al.

Results

Ten studies were identified and included in the review, including participants with patellar (n=4), rotator cuff (n=2), lateral elbow (n=2), Achilles (n=1) and gluteal (n=1) tendinopathies. Three were of good and seven were of poor overall quality. Based on limited evidence (level 3), isometric exercise was not superior to isotonic exercise for chronic tendinopathy either immediately following treatment or in the short term (≤12 weeks) for any of the investigated outcome measures. Additionally, for acute rotator cuff tendinopathy, isometric exercise appears to be no more effective than ice therapy in the short term (limited evidence; level 3).

Summary

Isometric exercise does not appear to be superior to isotonic exercise in the management of chronic tendinopathy. The response to isometric exercise is variable both within and across tendinopathy populations. Isometric exercise can be used as part of a progressive loading programme as it may be beneficial for selected individuals.

PROSPERO registration number

CRD42019147179.

Strength and Power Training in Rehabilitation: Underpinning Principles and Practical Strategies to Return Athletes to High Performance

Injuries have a detrimental impact on team and individual athletic performance. Deficits in maximal strength, rate of force development (RFD), and reactive strength are commonly reported following several musculoskeletal injuries. This article first examines the available literature to identify common deficits in fundamental physical qualities following injury, specifically strength, rate of force development and reactive strength. Secondly, evidence-based strategies to target a resolution of these residual deficits will be discussed to reduce the risk of future injury. Examples to enhance practical application and training programmes have also been provided to show how these can be addressed.

Isometric exercises do not provide immediate pain relief in Achilles tendinopathy: A quasi-randomized clinical trial

Background

Isometric exercises may provide an immediate analgesic effect in patients with lower‐limb tendinopathy and have been proposed as initial treatment and for immediate pain relief. Current evidence is conflicting, and previous studies were small.

Objective

To study whether isometric exercises result in an immediate analgesic effect in patients with chronic midportion Achilles tendinopathy.

Methods

Patients with clinically diagnosed chronic midportion Achilles tendinopathy were quasi‐randomized to one of four arms: isometric calf‐muscle exercises (tiptoes), isometric calf‐muscle exercises (dorsiflexed ankle position), isotonic calf‐muscle exercises, or rest. The primary outcome was pain measured on a visual analogue scale (VAS) score (0‐100) during a functional task (10 unilateral hops) both before and after the intervention. Between‐group differences were analyzed using a generalized estimation equations model.

Results

We included 91 patients. There was no significant reduction in pain on the 10 hop test after performing any of the four interventions: isometric (tiptoes) group 0.2, 95%CI −11.2 to 11.5; isometric (dorsiflexed) group −1.9, 95%CI −13.6 to 9.7; isotonic group 1.4, 95%CI −8.3 to 11.1; and rest group 7.2, 95%CI −2.4 to 16.7. There were also no between‐group differences after the interventions.

Conclusion

The isometric exercises investigated in this study did not result in immediate analgesic benefit in patients with chronic midportion Achilles tendinopathy. We do not recommend isometric exercises if the aim is providing immediate pain relief. Future research should focus on the use of isometric or isotonic exercise therapy as initial treatment as all exercise protocols used in this study were well‐tolerated.

Lived experience and attitudes of people with plantar heel pain: a qualitative exploration

Background

Plantar heel pain is a common source of pain and disability. Evidence-based treatment decisions for people with plantar heel pain should be guided by the best available evidence, expert clinical reasoning, and consider the needs of the patient. Education is a key component of care for any patient and needs to be tailored to the patient and their condition. However, no previous work has identified, far less evaluated, the approaches and content required for optimal education for people with plantar heel pain. The aim of this study was to gather the patients’ perspective regarding their lived experience, attitudes and educational needs in order to inform the content and provision of meaningful education delivery approaches.

Methods

Using a qualitative descriptive design, semi-structured interviews were conducted with participants with a clinical diagnosis of plantar heel pain. A topic guide was utilised that focused on the experience of living with plantar heel pain and attitudes regarding treatment and educational needs. Interviews were audio recorded, transcribed verbatim and analysed using the Framework approach. Each transcription, and the initial findings, were reported back to participants to invite respondent validation.

Results

Eighteen people with plantar heel pain were interviewed. Descriptive analysis revealed eight themes including perceptions of plantar heel pain, impact on self, dealing with plantar heel pain, source of information, patient needs, patient unmet needs, advice to others and interest in online education. Participants revealed doubt about the cause, treatment and prognosis of plantar heel pain. They also expressed a desire to have their pain eliminated and education individually tailored to their condition and needs. Respondent validation revealed that the transcripts were accurate, and participants were able to recognise their own experiences in the synthesised themes.

Conclusion

Plantar heel pain has a negative impact on health-related quality of life. Participants wanted their pain eliminated and reported that their expectations and needs were frequently unmet. Health professionals have an important role to be responsive to the needs of the patient to improve their knowledge and influence pain and behaviour. Our study informs the content needed to help educate people with plantar heel pain.

Corticosteroid injection plus exercise versus exercise, beyond advice and a heel cup for patients with plantar fasciopathy: protocol for a randomised clinical superiority trial (the FIX-Heel trial)

Background

Plantar fasciopathy has a lifetime prevalence of 10%. Patients experience sharp pain under the heel, often for several months or years. Multiple treatments are available, but no single treatment appears superior to the others. A corticosteroid injection offers short-term pain relief but is no better than placebo in the longer term (> 8 weeks). Heavy-slow resistance training has shown potentially positive effects on long-term outcomes (> 3 months), and combining exercises with an injection may prove to be superior to exercises alone. However, the effect of heavy-slow resistance training compared with a simpler approach of patient advice (e.g., load management) and insoles is currently unknown. This trial compares the efficacy of patient advice with patient advice plus heavy-slow resistance training and with patient advice plus heavy-slow resistance training plus a corticosteroid injection in improving the Foot Health Status Questionnaire pain score after 12 weeks in patients with plantar fasciopathy.

Methods

In this randomised superiority trial, we will recruit 180 patients with ultrasound-confirmed plantar fasciopathy and randomly allocate them to one of three groups: (1) patient advice and an insole (n = 60); (2) patient advice, an insole, and self-dosed heavy-slow resistance training consisting of heel raises (n = 60); or (3) patient advice, an insole, heavy-slow resistance training, and an ultrasound-guided corticosteroid injection (n = 60). All participants will be followed for 1 year, with the 12-week follow-up considered the primary endpoint. The primary outcome is the Foot Health Status questionnaire pain domain score. Secondary outcomes include the remaining three domains of the Foot Health Status Questionnaire, a 7-point Global Rating of Change, the Pain Self-Efficacy Questionnaire, physical activity level, health-related quality of life measured by the EQ-5D-5L, and Patient Acceptable Symptom State, which is the point at which participants feel no further need for treatment. Additionally, a health economic evaluation of the treatments will be carried out.

Discussion

This trial will test if adding heavy-slow resistance training to fundamental patient advice and an insole improves outcomes and if a corticosteroid injection adds even further to that effect in patients with plantar fasciopathy.

Trial registration

ClinicalTrials.gov, NCT03804008. Prospectively registered on January 15, 2019.

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.

Heavy-slow resistance training in addition to an ultrasound-guided corticosteroid injection for individuals with plantar fasciopathy: a feasibility study

INTRODUCTION

Plantar fasciopathy, characterised by plantar heel pain, affects one in ten in a lifetime. Heavy-slow resistance training (HSR) is an emerging treatment, but it often takes considerable time before the effect starts to manifest. Combining HSR with a corticosteroid injection (known for its short-term pain relief) could potentially improve outcomes in both short and long term. As this combination is yet to be investigated, we aimed to evaluate the feasibility of combining HSR with a corticosteroid injection for individuals with plantar fasciopathy before investigating the efficacy in a clinical trial.

MATERIALS AND METHODS

We recruited 20 participants with plantar fasciopathy for this prospectively registered feasibility study (ClinicalTrials.gov: NCT03535896). Participants received an ultrasound-guided injection and performed heel raises on a step every second day for 8 weeks. To assess participant acceptability of the combined interventions and exercise compliance, we used a 7-point Likert scale dichotomised to "unacceptable" (categories 1-2) or "acceptable" (categories 3-7) and training diaries. Greater than or equal to 10/20 had to rate the combination "acceptable", ≥ 15/20 had to perform ≥ 20 training sessions, and ≥ 15/20 had to start exercising ≤ 7 days after injection to confirm feasibility.

RESULTS

Eighteen out of 20 rated the combination acceptable. Five training diaries could not be retrieved. Ten out of 15 participants performed ≥ 20 training sessions, and 15/15 started exercising ≤ 7 days after injection.

CONCLUSIONS

Based on participant acceptability and time to exercise start, combining HSR with corticosteroid injection is feasible and the efficacy should be investigated in a future trial. Due to loss of 5/20 training diaries, firm conclusions regarding exercise compliance could not be drawn.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03535896.

Self-dosed and pre-determined progressive heavy-slow resistance training have similar effects in people with plantar fasciopathy: a randomised trial

QUESTION

For people with plantar fasciopathy, is a 12-week self-dosed heavy-slow resistance training program more beneficial than a 12-week pre-determined heavy-slow resistance training program?

DESIGN

A randomised trial with concealed allocation, partial blinding, and intention-to-treat analysis.

PARTICIPANTS

Seventy people with plantar fasciopathy confirmed on ultrasonography.

INTERVENTION

Both groups performed a repeated heel raise exercise in standing for 12 weeks. Participants in the experimental group were self-dosed (ie, they performed as many sets as possible with as heavy a load as possible, but no heavier than 8 repetition maximum). The exercise regimen for the control group was pre-determined (ie, it followed a standardised progressive protocol).

OUTCOME MEASURES

The primary outcome was the Foot Health Status Questionnaire pain domain. Secondary outcomes included: a 7-point Likert scale of Global Rating of Change dichotomised to 'improved' or 'not improved'; Patient Acceptable Symptom State defined as when participants felt no further need for treatment; and number of training sessions performed.

RESULTS

There was no significant between-group difference in the improvement of Foot Health Status Questionnaire pain after 12 weeks (adjusted MD -6.9 points, 95% CI -15.5 to 1.7). According to the Global Rating of Change, 24 of 33 in the experimental group and 20 of 32 in the control group were improved (RR = 1.16, 95% CI 0.83 to 1.64). Only four participants achieved Patient Acceptable Symptom State: three of 35 in the experimental group and one of 35 in the control group. No significant between-group difference was found in the number of training sessions that were performed (MD -2 sessions, 95% CI -8 to 3).

CONCLUSION

Self-dosed and pre-determined heavy-slow resistance exercise programs are associated with similar effects on plantar fasciopathy pain and other outcomes over 12 weeks. Advising people with plantar fasciopathy to self-dose their slow-heavy resistance training regimen did not substantially increase the achieved dose compared with a pre-determined regimen. These regimens are not sufficient to achieve acceptable symptom state in the majority of people with plantar fasciopathy.

REGISTRATION

ClinicalTrials.govNCT03304353.

Prevalence and incidence rate of lower-extremity tendinopathies in a Danish general practice: a registry-based study

Background

Tendinopathies of the lower extremity (e.g. Achilles, patellar, and plantar heel pain) are common in both general and sporting populations. However, the prevalence and incidence in Danish general practice is unknown. The aim was to determine the prevalence and incidence rate of lower-extremity tendinopathies in a Danish general practice.

Methods

In this registry-based study, we extracted data from the electronic patient files of all patients in a single Danish general practice. The practice included 8836 patients. We searched ICPC-2 codes to identify patients with either of the following lower-extremity tendinopathies: plantar heel pain; Achilles tendinopathy; patellar tendinopathy; greater trochanteric pain syndrome or adductor tendinopathy. We defined an incident and prevalent case as a patient with a consultation because of tendinopathy in 2016 only. A prevalent, but not incident case was a patient with consultations in both 2015 and 2016. Incidence and prevalence were expressed as the number of patients with a tendinopathy per 1000 registered patients.

Results

The prevalence and incidence rate were 16.6 and 7.9 per 1000 registered patients, respectively. Plantar heel pain was the most prevalent tendinopathy and accounted for 39% of lower-extremity tendinopathies. Patients with tendinopathies were significantly older than all registered patients (46.0 years (95%CI: 43.3;48.7) versus 38.8 years (95%CI: 38.4;39.3), respectively).

Conclusions

Lower-extremity tendinopathies, especially plantar heel pain, had a high prevalence and incidence rate in a Danish general practice. In a typical general practice with 5000 patients, general practitioners should expect to see more than 80 patients with a lower-extremity tendinopathy every year.