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Cooper K, Alexander L, Brandie D, Brown VT, Greig L, Harrison I, MacLean C, Mitchell L, Morrissey D, Moss RA, Parkinson E, Pavlova AV, Shim J, Swinton PA. Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness. Health Technol Assess 2023; 27:1-389. [PMID: 37929629 PMCID: PMC10641714 DOI: 10.3310/tfws2748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
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.
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Affiliation(s)
- Kay Cooper
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Lyndsay Alexander
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - David Brandie
- Sportscotland Institute of Sport, Airthrey Road, Stirling, UK
| | | | - Leon Greig
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Isabelle Harrison
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Colin MacLean
- Library Services, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Laura Mitchell
- NHS Grampian, Physiotherapy Department, Ellon Health Centre, Schoolhill, Ellon, Aberdeenshire, UK
| | - Dylan Morrissey
- William Harvey Research Institute, School of Medicine and Dentistry, Queen Mary University of London, Mile End Hospital, Bancroft Road, London, UK
| | - Rachel Ann Moss
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Eva Parkinson
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | | | - Joanna Shim
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Paul Alan Swinton
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
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Li C, Wang J, Yang W, Yu K, Hong J, Ji X, Yao M, Li S, Lu J, Chen Y, Yan S, Wu H, Ma C, Yu X, Jiang G, Liu A. 3D-printed hydrogel particles containing PRP laden with TDSCs promote tendon repair in a rat model of tendinopathy. J Nanobiotechnology 2023; 21:177. [PMID: 37268942 DOI: 10.1186/s12951-023-01892-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 04/11/2023] [Indexed: 06/04/2023] Open
Abstract
Long-term chronic inflammation after Achilles tendon injury is critical for tendinopathy. Platelet-rich plasma (PRP) injection, which is a common method for treating tendinopathy, has positive effects on tendon repair. In addition, tendon-derived stem cells (TDSCs), which are stem cells located in tendons, play a major role in maintaining tissue homeostasis and postinjury repair. In this study, injectable gelatine methacryloyl (GelMA) microparticles containing PRP laden with TDSCs (PRP-TDSC-GM) were prepared by a projection-based 3D bioprinting technique. Our results showed that PRP-TDSC-GM could promote tendon differentiation in TDSCs and reduce the inflammatory response by downregulating the PI3K-AKT pathway, thus promoting the structural and functional repair of tendons in vivo.
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Affiliation(s)
- Congsun Li
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China
| | - Jie Wang
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China
| | - Weinan Yang
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China
| | - Kang Yu
- State Key Laboratory of Fluid Power and Mechatronic Systems, School of Mechanical Engineering, Hangzhou, Zhejiang, PR China
| | - Jianqiao Hong
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China
| | - Xiaoxiao Ji
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
| | - Minjun Yao
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China
| | - Sihao Li
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China
| | - Jinwei Lu
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China
| | - Yazhou Chen
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China
| | - Shigui Yan
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China
| | - Haobo Wu
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China
| | - Chiyuan Ma
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China
| | - Xiaohua Yu
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China.
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China.
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China.
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China.
| | - Guangyao Jiang
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China.
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China.
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China.
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China.
| | - An Liu
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, PR China.
- Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, PR China.
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, PR China.
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou, PR China.
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Chimenti RL, Post AA, Rio EK, Moseley GL, Dao M, Mosby H, Hall M, de Cesar Netto C, Wilken JM, Danielson J, Bayman EO, Sluka KA. The effects of pain science education plus exercise on pain and function in chronic Achilles tendinopathy: a blinded, placebo-controlled, explanatory, randomized trial. Pain 2023; 164:e47-e65. [PMID: 36095045 PMCID: PMC10016230 DOI: 10.1097/j.pain.0000000000002720] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 06/14/2022] [Indexed: 01/09/2023]
Abstract
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.
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Affiliation(s)
- Ruth L. Chimenti
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, United States
| | - Andrew A. Post
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, United States
| | - Ebonie K. Rio
- Physiotherapy, School of Allied Health, La Trobe University, Bundoora, Australia
| | - G. Lorimer Moseley
- IIMPACT in Health, Allied Health & Human Performance, Physiotherapy, University of South Australia, Kaurna Country, Adelaide, Australia
| | - Megan Dao
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, United States
| | - Hadley Mosby
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, United States
| | - Mederic Hall
- University of Iowa Sports Medicine, University of Iowa, Iowa City, IA, United States
- Department of Orthopaedics & Rehabilitation, University of Iowa, Iowa City, IA, United States
| | - Cesar de Cesar Netto
- Department of Orthopaedics & Rehabilitation, University of Iowa, Iowa City, IA, United States
| | - Jason M. Wilken
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, United States
| | - Jessica Danielson
- Institute for Clinical and Translational Science, Clinical Research Support, University of Iowa Hospital and Clinica, Iowa City, IA, United States
| | - Emine O. Bayman
- Department of Biostatistics and Department of Anesthesia, University of Iowa, Iowa City, IA, United States
| | - Kathleen A. Sluka
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, United States
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4
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Edgar N, Clifford C, O'Neill S, Pedret C, Kirwan P, Millar NL. Biopsychosocial approach to tendinopathy. BMJ Open Sport Exerc Med 2022; 8:e001326. [PMID: 35990762 PMCID: PMC9345071 DOI: 10.1136/bmjsem-2022-001326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2022] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Nathan Edgar
- Institute of Infection, Immunity and Inflammation College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Christopher Clifford
- Institute of Infection, Immunity and Inflammation College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK,Department of Physiotherapy, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Seth O'Neill
- Department of Physiotherapy, School of Allied Health Professionals, University of Leicester, Leicester, UK
| | - Carles Pedret
- Sports Medicine and Imaging Department, Clinica Mapfre de Medicina del Tenis C/Muntaner, Barcelona, Spain
| | - Paul Kirwan
- Discipline of Physiotherapy, Trinity College Dublin School of Medicine, Dublin, Ireland
| | - Neal L Millar
- Institute of Infection, Immunity and Inflammation College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
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