Considerations for multi-centre conditioned pain modulation (CPM) research; an investigation of the inter-rater reliability, level of agreement and confounders for the Achilles tendon and Triceps Surae

© The British Pain Society 2020. Objective: This study aimed to investigate the inter-rater reliability of the conditioned pain modulation (CPM) effect. Methods: The reliability between two examiners assessing the CPM effect via pressure pain thresholds and induced using the cold pressor test of 28 healthy volunteers at the mid-portion Achilles tendon (AT) and Triceps Surae musculotendinous junction was performed. Reliability was calculated using intraclass correlation coefficient (ICC). Confounders were assessed using multivariable generalised estimating equations (GEEs). Bias in the level of agreement was assumed if the confidence intervals (CIs) of the mean difference in Bland–Altman plots did not cross the line of equality. Results: The inter-rater reliability of the CPM effect was poor to moderate in the AT (ICC 95% CI = 0.00–0.66) and Triceps Surae (ICC 95% CI = 0.00–0.69). However, when accounting for confounders within the GEE, there were no differences between testers and Bland–Altman plots reported good agreement between testers. Habitual completion of running-related physical activity was a confounder for both the AT parallel-paradigm (p = 0.017) and sequential-paradigm (p = 0.029). Testing order was a confounder for the AT (p = 0.023) and Triceps Surae (p = 0.014) parallel-paradigm. Conclusion: This study suggests the CPM effect may be site specific (i.e. differences between the AT and Triceps Surae exist). In addition, differences in the reliability between examiners are likely due to the influence of confounders and not examiner technique and therefore appropriate analysis should be used in research investigating the CPM effect

Are you translating research into clinical practice? What to think about when it does not seem to be working

Introduction : The value of clinical research can be lost in translation and implementation. One often overlooked issue is whether clinicians can determine if their patient is similar to research participants and, ipso facto, whether the clinician treating that patient will have the same effects as what was reported in a research study. We present five questions and clinical tips for clinicians

JUMP-LANDING MECHANICS IN PATELLAR TENDINOPATHY IN ELITE JUNIOR BASKETBALL ATHLETES

The purpose of this study was to identify key modifiable jump-landing variables associated with patellar tendinopathy (PT). Thirty-six junior elite basketball players (18 men, 18 women) were recruited (8 PT, 11 controls, 17 excluded from statistical analysis). Three-dimensional (3D) landing technique during a stop-jump task and patellar tendon ultrasounds were recorded. A series of mixed-design factorial analyses of variance were used to determine any significant between-group differences. Athletes with PT utilised a lower ground reaction force (GRF) loading rate (LR) via increasing their time duration from initial foot-ground contact (IC) to peak vertical GRF (Fv). This strategy of a lower LR did not lead to those athletes with PT decreasing their peak GRF nor patellar tendon forces (FPT) in comparison to the controls

Are we asking the right questions to people with Achilles tendinopathy? The best questions to distinguish mild versus severe disability to improve your clinical management

Objective: Determine the capacity of individual items on the Tendinopathy Severity Assessment – Achilles (TENDINS-A), Foot and Ankle Outcome Score (FAOS), and Victorian Institute of Sports Assessment – Achilles (VISA-A) to differentiate patients with mild and severe tendon-related disability in order to provide clinicians the best questions when they are consulting patients with Achilles tendinopathy. Design: Cross-sectional. Participants: Seventy participants with Achilles tendinopathy (61.4% mid-portion only, 31.4% insertional only, 7.2% both). Outcome measures: The discrimination index was determined for each TENDINS-A, FAOS, and VISA-A item to determine if items could discriminate between mild and severe disability. A Guttman analysis for polytomous items was conducted. Results: All 62 tems from the TENDINS-A, FAOS, and VISA-A were ranked with the best items relating to pain with physical tendon loading, time for pain to settle following aggravating activities and time for the tendon to ‘warm-up’ following inactivity. Conclusions: Pain with loading the Achilles tendon, time for pain to settle following aggravating activity, as well as time taken for the tendon symptoms to subside after prolonged sitting or sleeping are the best questions indicative of the severity of disability in patients with Achilles tendinopathy. These questions can assist clinicians with assessing baseline severity and monitoring treatment response.</p

Are we asking the right questions to people with Achilles tendinopathy? The best questions to distinguish mild versus severe disability to improve your clinical management

Objective: Determine the capacity of individual items on the Tendinopathy Severity Assessment – Achilles (TENDINS-A), Foot and Ankle Outcome Score (FAOS), and Victorian Institute of Sports Assessment – Achilles (VISA-A) to differentiate patients with mild and severe tendon-related disability in order to provide clinicians the best questions when they are consulting patients with Achilles tendinopathy. Design: Cross-sectional. Participants: Seventy participants with Achilles tendinopathy (61.4% mid-portion only, 31.4% insertional only, 7.2% both). Outcome measures: The discrimination index was determined for each TENDINS-A, FAOS, and VISA-A item to determine if items could discriminate between mild and severe disability. A Guttman analysis for polytomous items was conducted. Results: All 62 tems from the TENDINS-A, FAOS, and VISA-A were ranked with the best items relating to pain with physical tendon loading, time for pain to settle following aggravating activities and time for the tendon to ‘warm-up’ following inactivity. Conclusions: Pain with loading the Achilles tendon, time for pain to settle following aggravating activity, as well as time taken for the tendon symptoms to subside after prolonged sitting or sleeping are the best questions indicative of the severity of disability in patients with Achilles tendinopathy. These questions can assist clinicians with assessing baseline severity and monitoring treatment response.</p

Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review

Tendinopathy can be resistant to treatment and often recurs, implying that current treatment approaches are suboptimal. Rehabilitation programmes that have been successful in terms of pain reduction and return to sport outcomes usually include strength training. Muscle activation can induce analgesia, improving self-efficacy associated with reducing one's own pain. Furthermore, strength training is beneficial for tendon matrix structure, muscle properties and limb biomechanics. However, current tendon rehabilitation may not adequately address the corticospinal control of the muscle, which may result in altered control of muscle recruitment and the consequent tendon load, and this may contribute to recalcitrance or symptom recurrence. Outcomes of interest include the effect of strength training on tendon pain, corticospinal excitability and short interval cortical inhibition. The aims of this concept paper are to: (1) review what is known about changes to the primary motor cortex and motor control in tendinopathy, (2) identify the parameters shown to induce neuroplasticity in strength training and (3) align these principles with tendon rehabilitation loading protocols to introduce a combination approach termed as tendon neuroplastic training. Strength training is a powerful modulator of the central nervous system. In particular, corticospinal inputs are essential for motor unit recruitment and activation; however, specific strength training parameters are important for neuroplasticity. Strength training that is externally paced and akin to a skilled movement task has been shown to not only reduce tendon pain, but modulate excitatory and inhibitory control of the muscle and therefore, potentially tendon load. An improved understanding of the methods that maximise the opportunity for neuroplasticity may be an important progression in how we prescribe exercise-based rehabilitation in tendinopathy for pain modulation and potentially restoration of the corticospinal control of the muscle-tendon complex

Assessment and monitoring of Achilles tendinopathy in clinical practice: A qualitative descriptive exploration of the barriers clinicians face

Our primary objective was to explore the barriers preventing clinicians from implementing what they think is ideal practice as it relates to using tools to aid diagnosis and monitor progress in mid-portion Achilles tendinopathy. Our secondary objectives were to describe the assessments employed by clinicians in their own practice to aid with (a) diagnosis and (b) monitoring progress in Achilles tendinopathy and explore the outcome measure domains clinicians believe to be the most and least important when managing patients with Achilles tendinopathy. We employed a qualitative descriptive study design. Thirteen participants (eight female, five male) from across Australia, consisting of two junior physiotherapists, five senior physiotherapists working in private practice, four senior physiotherapists working within elite sports organisations and two sport and exercise medicine doctors, were included and one-on-one interviews were performed. Audio was transcribed then entered into NVivo for coding and analysis. Four main themes were perceived as barriers to implementing ideal practice of assessment and monitoring in people with Achilles tendinopathy: financial constraints, time constraints, access to equipment and patient symptom severity. Assessments related to function, pain on loading, pain over a specified time frame and palpation are commonly used to assist diagnosis. Assessments related to disability, pain on loading, pain over a specified time frame and physical function capacity are used to monitor progress over time. Furthermore, pain on loading and pain over a specified time frame were considered the most important outcome measure domains for assisting diagnosis whereas pain on loading, patient rating of the condition and physical function capacity were the most important outcome measure domains for monitoring progress. A number of barriers exist that prevent clinicians from implementing what they view as ideal assessment and monitoring for Achilles tendinopathy. These barriers should be considered when developing new assessments and in clinical practice recommendations

Can we really say getting stronger makes your tendon feel better? No current evidence of a relationship between change in Achilles tendinopathy pain or disability and changes in Triceps Surae structure or function when completing rehabilitation: A systematic review

Objectives: Determine if improvements in pain and disability in patients with mid-portion Achilles tendinopathy relate to changes in muscle structure and function whilst completing exercise rehabilitation. Design: A systematic review exploring the relationship between changes in pain/disability and muscle structure/function over time, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Methods: Six online databases and the grey literature were searched from database inception to 16th December 2022 whereas clinical trial registries were searched from database inception to 11th February 2020. We included clinical studies where participants received exercise rehabilitation (± placebo interventions) for mid-portion Achilles tendinopathy if pain/disability and Triceps Surae structure/function were measured. We calculated Cohen\u27s d (95 % confidence intervals) for changes in muscle structure/function over time for individual studies. Data were not pooled due to heterogeneity. Study quality was assessed using a modified Newcastle–Ottawa Scale. Results: Seventeen studies were included for synthesis. No studies reported the relationship between muscle structure/function and pain/disability changes. Twelve studies reported muscle structure/function outcome measures at baseline and at least one follow-up time-point. Three studies reported improvements in force output after treatment; eight studies demonstrated no change in structure or function; one study did not provide a variation measure, precluding within group change over time calculation. All studies were low quality. Conclusions: No studies explored the relationship between changes in tendon pain and disability and changes in muscle structure and function. It is unclear whether current exercise-based rehabilitation protocols for mid-portion Achilles tendinopathy improve muscle structure or function. Systematic review registration: PROSPERO (registration number: CRD42020149970)

Does lower-limb osteoarthritis alter motor cortex descending drive and voluntary activation? A systematic review and meta-analysis

Purpose: The aim of the study was to quantify motor cortex descending drive and voluntary activation (VA) in people with lower-limb OA compared to controls. Methods: A systematic review and meta-analysis according to the PRISMA guidelines was carried out. Seven databases were searched until 30 December 2022. Studies assessing VA or responses to transcranial magnetic stimulation (TMS; i.e. motor evoked potential, intracortical facilitation, motor threshold, short-interval intracortical inhibition, and silent period) were included. Study quality was assessed using Joanna Briggs Institute criteria and evidence certainty using GRADE. The meta-analysis was performed using RevMan inverse variance, mixed-effect models. Results: Eighteen studies were included, all deemed low-quality. Quadriceps VA was impaired with knee OA compared to healthy controls (standardised mean difference (SMD)=0.84, 95% CI=−1.12–0.56, low certainty). VA of the more symptomatic limb was impaired (SMD=0.42, 95% CI=−0.75–0.09, moderate certainty) compared to the other limb in people with hip/knee OA. As only two studies assessed responses to TMS, very low-certainty evidence demonstrated no significant difference between knee OA and healthy controls for motor evoked potential, intracortical facilitation, resting motor threshold or short-interval intracortical inhibition. Conclusions: Low-certainty evidence suggests people with knee OA have substantial impairments in VA of their quadriceps muscle when compared to healthy controls. With moderate certainty we conclude that people with hip and knee OA had larger impairments in VA of the quadriceps in their more painful limb compared to their non-affected/other limb