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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Does eccentric exercise reduce pain and improve strength in physically active adults with symptomatic lower extremity tendinosis: a systematic review

NJ Wasielewski and KM Kotsko.

Review published: 2007.

CRD summary

This review concluded that eccentric exercise is an effective form of treatment for lower extremity tendinosis, but there is little evidence to suggest that it is superior to other forms of therapeutic exercise. The included studies were small and the authors’ conclusions appear over optimistic. The included studies are not sufficient to draw reliable conclusions about effectiveness or safety.

Authors' objectives

To assess the effectiveness of eccentric exercise for the treatment of lower extremity tendinosis.

Searching

Trials in English were identified through a computerised bibliographic search of PubMed (1980 to 2006), CINAHL (1982 to 2006), Web of Science (1995 to 2006), SPORTDiscus (1980 to 2006), PEDro and the Cochrane CENTRAL Register; the search terms were reported.

Study selection

Study designs of evaluations included in the review

Randomised controlled trials (RCTs) were eligible for inclusion.

Specific interventions included in the review

Studies of eccentric exercise protocols used to treat lower extremity tendinosis were eligible for inclusion. The most common treatment protocols involved 3 sets of 15 repetitions performed twice daily; variations ranged upward to 12 sets and 100 repetitions. Velocity of the movement, allowing pain during exercise, and load varied among the studies. Some studies used concomitant treatments alongside eccentric exercise. The control treatments included concentric/eccentric exercise, night splints, ultrasound, massage, stretching and no treatment.

Participants included in the review

Studies in adults with a clinical diagnosis of tendinosis were eligible for inclusion. In the included studies, the location of the tendinosis was the patellar or the Achilles.

Outcomes assessed in the review

Studies that reported pain or strength outcomes were eligible for inclusion. Pain outcomes included the Victorian Institute of Sport Assessment, visual analogue scales and other unspecified pain measures, while strength was most often measured at the knee and ankle.

How were decisions on the relevance of primary studies made?

Two reviewers independently assessed abstracts for inclusion. All potentially eligible trials were retrieved in full text and independently reviewed in more detail. Any disagreements were resolved by consensus.

Assessment of study quality

Quality was assessed using the PEDro criteria, a 10-point scale in which 8 points refer to internal validity, while 2 points ensure that the statistical results are interpretable by the reader. Two reviewers independently assessed each study and any disagreements were resolved by consensus.

Data extraction

The data extraction was carried out in duplicate with consensus resolution of discrepancies. For pain and strength outcomes, the relative risk and 95% confidence intervals (CIs) were calculated for dichotomous data and the effect size (Hedges g) and 95% CIs for continuous data.

Methods of synthesis

How were the studies combined?

A narrative synthesis was provided. The results were grouped by control group therapy.

How were differences between studies investigated?

Differences in some study characteristics were summarised in a table or reported in the text.

Results of the review

Eleven RCTs (n=289) were included in the review.

The methodological quality of the included trials was relatively good, with trials scoring between 4 and 7 points of a possible 10 on the PEDro scale. The authors explained that the intervention of eccentric exercise does not allow for blinding of the patient or therapist, thus reducing the 10-point quality score to a maximum of 8 points.

There were no significant differences between the groups when eccentric exercise was compared with no treatment (1 RCT of patellar tendinosis), alternative eccentric exercise (1 RCT of patellar tendinosis), stretching (1 RCT of patellar tendinosis and 1 RCT of Achilles tendinosis) and night splints (1 RCT of Achilles tendinosis).

Eccentric versus concentric exercise.

Three trials compared eccentric exercise with concentric exercise for the treatment of Achilles tendinosis. There were no differences in pain scores between the treatment groups in any of the trials at any of the individual follow-up times. However, one study showed that when pain scores were averaged across all follow-up times, the eccentric exercise group exhibited significantly less pain.

There were no differences in strength between the groups. However, interim results (week 6 of a 12-week protocol) for one study showed significantly higher vertical jump scores in the concentric exercise group compared with the eccentric exercise group.

Two further RCTs investigated patellar tendinosis. One study showed no difference between groups for any outcome, while the other showed a large treatment effect for pain for eccentric exercise.

Eccentric exercise versus non-thermal ultrasound versus frictional massage.

One trial of patellar tendinosis showed significant improvements in pain scores in the eccentric exercise group.

Authors' conclusions

Current research indicates that eccentric exercise is an effective form of treatment for lower extremity tendinosis. However, there is little evidence to suggest that it is superior to other forms of therapeutic exercise.

CRD commentary

The review addressed a clear question with clearly defined inclusion criteria. A number of relevant electronic databases were searched and the search terms were reported. There is no indication that the authors sought unpublished trials, and the restriction to English language publications may indicate that not all relevant data were included. The potential influence of publication bias was not considered in the report. The authors attempted to minimise bias and errors during the review process by carrying out the study selection, quality assessment and data extraction in duplicate. The authors’ decision not to pool studies in a meta-analysis was justified given the range of eccentric exercise protocols and differences in outcome measures. In light of the small number of studies, some with very small sample sizes (many with fewer than 20 participants), the authors’ conclusion that eccentric exercise is an effective form of treatment appears over optimistic. The studies included are not sufficient to draw reliable conclusions about effectiveness or safety.

Implications of the review for practice and research

Practice: The authors stated that clinicians should follow the eccentric exercise protocol of Alfredson et al. (see Other Publications of Related Interest) and have patients rest for 4 to 6 weeks for optimal reduction of tendinosis symptoms.

Research: The authors stated that studies should be undertaken in order to confirm or refute this review and emphasised that, because of the nature of the trials, multicentre studies may be necessary to recruit sufficient patients. The authors also made recommendations for avoiding methodological bias, such as the use of concealed allocation, intention-to-treat analysis, assessor blinding, and valid and reliable outcome measures.

Funding

Not stated.

Bibliographic details

Wasielewski N J, Kotsko K M. Does eccentric exercise reduce pain and improve strength in physically active adults with symptomatic lower extremity tendinosis: a systematic review. Journal of Athletic Training 2007; 42(3): 409-421. [PMC free article: PMC1978463] [PubMed: 18059998]

Other publications of related interest

Alfredson H, Pietila T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998;26:360–6.

Indexing Status

Subject indexing assigned by NLM

MeSH

Adult; Clinical Protocols; Exercise Therapy /methods; Humans; Lower Extremity; Massage /methods; Motor Activity; Muscle Strength; Muscle Stretching Exercises; Pain /etiology /ultrasonography; Pain Management; Randomized Controlled Trials as Topic; Tendinopathy /complications /physiopathology /therapy /ultrasonography; Treatment Outcome

AccessionNumber

12007003630

Database entry date

01/09/2008

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 18059998

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