Policies on doctors’ declaration of interests in medical organisations : a thematic analysis

ObjectivesThere has been growing concern about doctors? conflicts of interests (COIs) but it is unclear what processes and tools exist to enable the consistent declaration and management of such interests. This study mapped existing policies across a variety of organisations and settings to better understand the degree of variation and identify opportunities for improvement.DesignThematic analysis.Setting and ParticipantsWe studied the COI policies of 31 UK and international organisations which set or influence professional standards or engage doctors in healthcare commissioning and provision settings.Main outcome measures:Organisational policy similarities and differences.ResultsMost policies (29/31) referred to the need for individuals to apply judgement when deciding whether an interest is a conflict, with just over half (18/31) advocating a low threshold. Policies differed on the perception of frequency of COI, the timings of declarations, the type of interests that needed to be declared, and how COI and policy breaches should be managed. Just 14/31 policies stated a duty to report concerns in relation to COI. Only 18/31 policies advised COI would be published, while three stated that any disclosures would remain confidential.ConclusionsThe analysis of organisational policies revealed wide variation in what interests should be declared, when and how. This variation suggests that the current system may not be adequate to maintain a high level of professional integrity in all settings and that there is a need for better standardisation that reduces the risk of errors while addressing the needs of doctors, organisations and the public.Publisher PDFPeer reviewe

Feasibility and acceptability of exercise interventions for adults with tendinopathy: a mixed methods review.

This is a protocol for a review that aims to explore the feasibility and acceptability of any exercise intervention for the treatment of any tendinopathy. The first specific review question is: What is the current knowledge about the feasibility of delivering exercise interventions for tendinopathy from the perspective of those delivering and receiving interventions? Specifically: a) How feasible is the delivery of exercise therapy for tendinopathy in terms of rates (e.g. of adherence, attendance, fidelity); and b) What are patients' and healthcare professionals' perceptions of the feasibility of exercise therapy for tendinopathy? The second specific review question is: What is the current knowledge about acceptability of receiving exercise therapy for tendinopathy from the perspective of people with tendinopathy? Specifically: a) How acceptable is exercise therapy in terms of tolerability; and b) What are patients' and healthcare professionals' perceptions of the acceptability of exercise therapy for tendinopathy

The effectiveness of exercise interventions for tendinopathy.

This is a protocol for a study that aimed to determine: 1) which exercise interventions are most effective across all tendinopathies; 2) does the type/location of the tendinopathy, or other specific covariates, affect which are the most effective exercise therapies. The protocol was intended to guide a scoping review, and was then meant to be updated for the effectiveness review

Effect of resistance exercise dose components for tendinopathy management: a systematic review with meta-analysis.

The objective of this study was to investigate potential moderating effects of resistance exercise dose components - including intensity, volume and frequency - for the management of common tendinopathies. The study was conducted through a systematic review with meta-analysis and meta-regressions, using sources that included (but were not limited to) MEDLINE, CINAHL, SPORTDiscus, ClinicalTrials.gov and the ISRCTN Registry. Selection criteria were based on randomised and non-randomised controlled trials investigating resistance exercise as the dominant treatment class, reporting sufficient information regarding two or more components of exercise dose. A total of 110 studies were included in meta-analyses (148 treatment arms (TAs), 3953 participants), reporting on five tendinopathy locations (rotator cuff: 48 TAs; Achilles: 43 TAs; lateral elbow: 29 TAs; patellar: 24 TAs; gluteal: 4 TAs). Meta-regressions provided consistent evidence of greater pooled mean effect sizes for higher intensity therapies comprising additional external resistance compared to body mass only (large effect size domains: βBodyMass:External = 0.50 [95% CrI: 0.15 to 0.84; p = 0.998]; small effect size domains βBodyMass:External = 0.04 [95% CrI: -0.21 to 0.31; p = 0.619]) when combined across tendinopathy locations or analysed separately. Greater pooled mean effect sizes were also identified for the lowest frequency (less than daily) compared with mid (daily) and high frequencies (more than once per day) for both effect size domains, when combined or analysed separately (p ≥ 0.976). Evidence for associations between training volume and pooled mean effect sizes was minimal and inconsistent. The study found that resistance exercise dose is poorly reported within tendinopathy management literature. However, this large meta-analysis identified some consistent patterns indicating greater efficacy on average with therapies prescribing higher intensities (through inclusion of additional loads) and lower frequencies, potentially creating stronger stimuli and facilitating adequate recovery

Are patients satisfied? A systematic review and meta-analysis of patient ratings in exercise therapy for the management of tendinopathy.

Outcomes measuring patient rating of overall condition, including patient satisfaction, are associated with improved general health and higher quality of life. However, this outcome domain is under-explored in the management of tendinopathy. The purpose of this systematic review and meta-analysis was to synthesise intervention data investigating patient satisfaction and perceived improvement or deterioration following engagement in exercise therapy for the management of tendinopathy. A search of randomised controlled trials investigating exercise therapy interventions across all tendinopathies was conducted, extracting data assessing patient rating of overall condition. Outcomes were split into those measuring satisfaction (binary) and those measuring global rating of change (GROC). Bayesian hierarchical models were used to meta-analyse proportions and mean effect size (percentage of maximum) for the two outcome categories. From a total of 124 exercise therapy studies, 34 (Achilles: 41%, rotator cuff: 32%, patellar: 15%, elbow: 9% and gluteal: 3%) provided sufficient information to be meta-analysed. The data were obtained across 48 treatment arms and 1246 participants. The pooled estimate for proportion of satisfaction was 0.63 [95% CrI: 0.53 to 0.73], and the pooled estimate for percentage of maximum GROC was 53 [95% CrI: 38 to 69%]. Evidence was also obtained that the proportion of patients reporting positive satisfaction and perception of change increased with longer durations relative to treatment onset. The study concluded that patient satisfaction is not commonly reported in tendinopathy research and, in those studies where it is reported, satisfaction and GROC appear similar and are ranked moderately high, demonstrating that patients generally perceive exercise therapy for tendinopathy management positively. Further research including greater consistency in measurement tools is required to explore, and where possible identify patient and exercise moderating factors that can be used to improve person-centred care

Which treatment classes and combinations are more effective for the management of common tendinopathies? A systematic review and network meta-analysis.

The aim of this research was to quantify the comparative effectiveness of treatment classes used for the management of the most common tendinopathies. The project studied network meta-analyses comparing combinations of exercise, non-exercise, and non-active treatments across a range of tendinopathy locations and outcome domains. The review covered randomised and quasi-randomised controlled trials including an exercise arm and persons with a tendinopathy diagnosis at any location, and of any severity or duration. Outcome measures included outcomes assessing disability, function, pain, shoulder range of motion, physical function capacity, or quality of life. Through network meta-analyses, broad (exercise/non-exercise/combined/non-active) and more specific (exercise/biomechanics/injection/electrotherapy/manual-therapy/non-active/surgery) treatment class models were fitted with hierarchical Bayesian models. Results were interpreted using pooled standardised mean difference effect sizes and ranking through Surface Under the Cumulative Ranking curves (SUCRA). Treatment hierarchies were assessed using the GRADE minimally contextualised framework. Two-hundred studies comprising 458 treatments arms were identified. Many comparisons were within the same class reducing data available to assess comparative effectiveness. Data from 85 studies generating 140 pairwise comparisons consistently identified the superiority of combining exercise and non-exercise treatment classes (SUCRA: 0.70 to 0.88). Central estimates indicated that combining exercise and non-exercise treatments increased effect sizes by ~0.1 to 0.3 compared with exercise alone. Analysis of more specific treatment classes identified with low/very low certainty the superiority of combining exercise with either biomechanical (e.g. taping, bracing or splinting; SUCRA: 0.73) or injection therapies (SUCRA: 0.72). The study concluded that clinicians should consider combining exercise and non-exercise therapies as a starting point for tendinopathy management. The most effective treatment combinations include exercise with the use of biomechanical or injection therapies

What are small, medium and large effect sizes for exercise treatments of tendinopathy? A systematic review and meta-analysis.

The objective of this study was to quantify and describe effect size distributions from exercise therapies across a range of tendinopathies and outcome domains, to inform future research and clinical practice through conducting a systematic review with meta-analysis. The review and meta-analysis explored moderating effects and context specific small, medium, and large thresholds. The study looked specifically at randomised and quasi-randomised controlled trials involving any persons with a diagnosis of rotator cuff, lateral elbow, patellar, Achilles or gluteal tendinopathy of any severity or duration. The study was conducted using common databases, six trial registries and six grey literature databases, which were searched on 18/01/21 (PROSPERO: CRD42020168187). Standardised mean difference (SMDpre) effect sizes were used with Bayesian hierarchical meta-analysis models to calculate the 0.25- (small), 0.5- (medium) and 0.75-quantiles (large), and to compare pooled means across potential moderators. Risk of bias was assessed with Cochrane's Risk of Bias tool. Data were obtained from 114 studies comprising 171 treatments and 4104 participants. SMDpre effect sizes were similar across tendinopathies but varied across outcome domains. Greater threshold values were obtained for self-reported measures of pain (small = 0.5; medium = 0.9; large = 1.4), disability (small = 0.6; medium = 1.0; large = 1.5) and function (small = 0.6; medium = 1.1; large = 1.8); and lower threshold values obtained for quality of life (small = -0.2; medium = 0.3; large = 0.7), and objective measures of physical function (small = 0.2; medium = 0.4; large = 0.7). Potential moderating effects of assessment duration, exercise supervision and symptom duration were also identified, with greater pooled mean effect sizes estimated for longer assessment durations, supervised therapies and studies comprising patients with shorter symptom durations. The study found that the effect size of exercise on tendinopathy is dependent on the type of outcome measure assessed. Threshold values presented here can be used to guide interpretation and assist with further research better establishing minimal important change

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness.

Tendons are cords of strong, flexible tissue that attach muscles to bones, allowing joints to move. Tendinopathy is a common condition that can affect any tendon in the body, causing pain and limiting function. Exercise is often used to treat tendinopathy. We examined over 500 research papers on exercise for tendinopathy. The most common tendons to be studied were the calf (Achilles), knee (patellar), elbow, and shoulder. Strengthening exercise was studied most often, especially in lower limb tendinopathy. Other types of exercise such as stretching, balance and aerobic activity were less common, but were used to some extent in the upper and lower limbs. We found that exercise therapy is safe and beneficial for the tendinopathies that have been studied to date. Exercise may be most beneficial when combined with another intervention such as injection or electrotherapy. Strengthening exercise may be most beneficial for lower limb tendinopathies. However, more research is needed on the type of strengthening and the dosage, such as how many exercises and how much resistance to use. Shoulder tendinopathies may benefit from exercise that targets joint flexibility and position more than strengthening. We also found that people who receive exercise therapy for tendinopathy are generally satisfied with the effect it has on their symptoms. Finally, we found that an individualised, person-centred approach to delivering exercise therapy is valued by people with tendinopathy. They also believe that the patient-healthcare provider relationship is important for promoting the confidence and motivation people need to continue with exercise programmes, especially when they complete them independently. Although we examined a lot of papers, many of the studies were low quality. This means there is still a need for high-quality studies to tell us how effective specific types of exercise are for specific tendinopathies. There is also a need for more studies on patients' and professionals' experiences of receiving or providing exercise for tendinopathy.This project is registered as www.osf.io/a8ewy/ (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)

Policies on doctors' declaration of interests in medical organisations: a thematic analysis

Objectives There has been growing concern about doctors’ conflicts of interest (COI) but it is unclear what processes and tools exist to enable the consistent declaration and management of such interests. This study mapped existing policies across a variety of organisations and settings, to better understand the degree of variation and identify opportunities for improvement. Design We studied the COI policies of 31 UK and international organisations which set or influence professional standards or engage doctors in healthcare commissioning and provision settings. Thematic and content analyses identified policy similarities and differences. Results Most policies (29/31) referred to the need for individuals to apply judgement when deciding whether an interest is a conflict, with just over half (18/31) advocating a low threshold. Policies differed on the perception of frequency of COI, the timings of declarations, the type of interests that needed to be declared and how COI and policy breaches should be managed. Just 14/31 policies stated a duty to report concerns in relation to COI. Only 18/31 policies advised COI would be published, while three stated that any disclosures would remain confidential. Conclusions The analysis of organisational policies revealed wide variation in what interests should be declared, when and how. This variation suggests that the current system may not be adequate to maintain a high level of professional integrity in all settings and that there is a need for better standardisation that reduces the risk of errors whilst addressing the needs of doctors, organisations and the public

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

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. Plain language summary Tendons are cords of strong, flexible tissue that attach muscles to bones, allowing joints to move. Tendinopathy is a common condition that can affect any tendon in the body, causing pain and limiting function. Exercise is often used to treat tendinopathy. We examined over 500 research papers on exercise for tendinopathy. The most common tendons to be studied were the calf (Achilles), knee (patellar), elbow and shoulder. Strengthening exercise was studied most often, especially in lower-limb tendinopathy. Other types of exercise such as stretching, balance and aerobic activity were less common, but were used to some extent in the upper and lower limbs. We found that exercise therapy is safe and beneficial for the tendinopathies that have been studied to date. Exercise may be most beneficial when combined with another intervention such as injection or electro-therapy. Strengthening exercise may be most beneficial for lower-limb tendinopathies. However, more research is needed on the type of strengthening and the dosage, such as how many exercises and how much resistance to use. Shoulder tendinopathies may benefit from exercise that targets joint flexibility and position more than strengthening. We also found that people who receive exercise therapy for tendinopathy are generally satisfied with the effect it has on their symptoms. Finally, we found that an individualised, person-centred approach to delivering exercise therapy is valued by people with tendinopathy. They also believe that the patient-healthcare provider relationship is important for promoting the confidence and motivation people need to continue with exercise programmes, especially when they complete them independently. Although we examined a lot of papers, many of the studies were low quality. This means there is still a need for high-quality studies to tell us how effective specific types of exercise are for specific tendinopathies. There is also a need for more studies on patients’ and professionals’ experiences of receiving or providing exercise for tendinopathy. Scientific summary Background Tendinopathy refers to a spectrum of changes in damaged or diseased tendons leading to pain and functional impairment, often chronic or recurrent in nature. Tendinopathy can affect any muscle-tendon unit in the body but is most reported in the Achilles, patellar, lateral elbow, rotator cuff and hip tendons. Tendinopathy is common, affects all age-groups and, although often associated with athletic populations, it is also prevalent in non-athletic and sedentary populations. Tendinopathy is primarily managed conservatively using exercise therapy that may consist of one or more types of exercise including resistance, flexibility, proprioception, balance and whole-body exercise. A substantive number of studies and systematic reviews have been conducted on various aspects of exercise for tendinopathy. These mostly comprise efficacy studies, with a growing trend towards qualitative studies of lived experience. Previous systematic reviews have typically focussed on individual tendinopathies and included small numbers of homogeneous studies. Driven by the need for clear evidence-based guidance to inform clinical practice in this field, the current mixed-methods evidence synthesis project was designed to comprehensively map the research conducted to date, and to take an inclusive approach to synthesising the evidence on efficacy, feasibility and acceptability of exercise for tendinopathy, to make recommendations for practice and research. Review questions The specific review questions were as follows: (1) What exercise interventions have been reported in the literature and for which tendinopathies? (2) What outcomes have been reported in studies investigating exercise interventions for tendinopathies? (3) Which exercise interventions are most effective across all tendinopathies? (4) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? And (5) how feasible and acceptable are exercise interventions for tendinopathies? Methods We conducted an initial scoping review to address questions 1 and 2, followed by an efficacy workstream consisting of three systematic reviews with meta-analyses to address questions 3 and 4, and a convergent segregated mixed-method systematic review to address question 5. All reviews are reported according to the PRISMA 2020 statement and relevant extensions. Scoping review: Using Joanna Briggs Institute (JBI) methodology and an a priori protocol made publicly available on Open Science Framework (OSF) and published in JBI Evidence Synthesis, we searched for studies and systematic reviews on any exercise therapy for any tendinopathy experienced by people of any age or sex. Inclusion was limited to studies published in any language from 1998 onwards and conducted in countries with very high human development (as defined by the United Nations Development Programme). In April 2020 we searched MEDLINE, CINAHL, AMED and SPORTDiscus via EBSCOhost, EMBase via Ovid, the Cochrane library (controlled trials, systematic reviews), JBI Evidence Synthesis, PEDRo and Epistemonikos. We also searched six trial registries, five grey literature databases and Google Scholar. Search results were deduplicated in Proquest® RefWorks. They were then imported to Covidence systematic review software (Melbourne, Australia) where title/abstract followed by full-text screening was conducted by two reviewers independently, with conflicts resolved by a third reviewer. Data were extracted from included studies using a bespoke data-extraction tool developed by the review team using Microsoft Excel®. Efficacy reviews: Using effectiveness review methodology and a priori protocols registered on PROSPERO (overarching methodology) and OSF (review-specific methods), three efficacy reviews were conducted. Efficacy review 1 quantified efficacy through calculation of a range of effect sizes from exercise-only interventions. In efficacy review 2, pairwise effect sizes were calculated to quantify comparative efficacy between different exercise therapies based on their dominant therapy class (e.g. resistance, flexibility, proprioception) and their dominant therapy type (e.g. eccentric-only, static stretching, joint position sense). In efficacy review 3, pairwise effect sizes were calculated between exercise-only therapies, non-exercise therapies (e.g. surgery, injection, manual therapy (MT)) and combined therapies to quantify comparative efficacy across a range of therapy classes frequently used in the management of tendinopathy. Studies were identified from the scoping review search, a search update (19 January 2021) and reference and citation searching of systematic reviews included in the scoping review. Screening was conducted as described above. Risk of bias and data extraction were completed by two independent reviewers. The Grading of Recommendations, Assessment, Development and Evaluations framework was used to assess the strength of evidence. Mixed-method review: Using JBI methodology and an a priori protocol (PROSPERO) we searched for quantitative, qualitative and mixed-methods studies exploring any aspect of feasibility or acceptability of exercise for tendinopathy from patients’ or providers’ perspectives. Studies were identified from the scoping review and effectiveness update searches, and a further search (29 March 2021) to locate additional studies. Screening was conducted as described above and methodological quality was assessed by two reviewers independently using JBI critical appraisal tools, with conflicts at each stage resolved by discussion or a third reviewer. Data were extracted from quantitative studies using a bespoke data-extraction tool developed by the review team in Microsoft Excel®. Data were extracted from qualitative studies using the data-extraction tool in JBI SUMARI software. Data extraction for both data types was conducted by two reviewers independently with conflicts resolved by discussion or a third reviewer. A convergent segregated approach to data synthesis was applied, where each data type was synthesised independently, followed by integration of findings from the quantitative and qualitative syntheses using comparative analysis. Data synthesis was an iterative process involving four reviewers. Results Scoping review: The search identified 13,729 unique studies. Following screening, 555 studies were included in the review, 119 of which were systematic reviews. A range of exercise interventions were reported across multiple tendinopathies, with Achilles, lateral elbow, patellar and rotator cuff-related shoulder pain (RCRSP) the most studied. Strengthening exercise was most frequently reported (84%), with eccentric exercise the most common mode for Achilles (89%), patellar (85%) and lateral elbow tendinopathies (44%). Flexibility exercise was more commonly reported in the upper (≈60%) than lower limb (≈25%). Exercise therapies for RCRSP showed the greatest range with respect to mode of exercise. Reporting of exercise interventions was highly variable such that few were identified as being replicable. A range of health domains and outcome measurement tools were reported, with lack of consensus a key finding in this review. Disability was the most common primary health domain for RCRSP (65%), Achilles (68%) and patellar tendinopathies (75%), and physical function capacity was most common for lateral elbow tendinopathy (49%). Impairment-based outcome measures were dominant across tendinopathies, with psychosocial outcomes rarely reported. Few true effectiveness studies were identified, with most studies being conducted under controlled circumstances. Therefore, efficacy, rather than effectiveness, was explored in the contingent reviews. Efficacy reviews: 204 studies comprising 467 treatment arms (TAs) and 12,081 participants were identified that met the inclusion criteria to be included in at least one of the reviews (review 1: 125 studies/188 TAs; review 2: 55 studies; review 3: 201 studies). In the context of low and often very low strength of evidence, the efficacy reviews concluded that exercise therapy is safe and efficacious, and that patients are generally satisfied with the outcome and perceive their improvements to be substantive. RCRSP may benefit from exercise interventions that focus on flexibility and proprioception more than strengthening. Resistance training that combines both concentric and eccentric exercise may be most beneficial given the intensities and frequencies commonly adopted in practice. Combining exercise with a non-exercise adjunct such as electro-therapy, injection or taping may be most beneficial and could be considered in the early phase of management. Mixed-method review: 96 reports from 94 studies were included in the review (85 quantitative, 11 qualitative). Quantitative findings: For feasibility, measures of adherence, attendance and fidelity were reported in 75, 13 and 3 studies respectively. Self-reported exercise adherence was good (at least 70%) and attendance to supervised exercise sessions excellent (90%). Different approaches to measuring fidelity were used in the three studies, with a range of findings reported. Acceptability was reported in 17 studies as tolerability (n = 15), satisfaction with exercise (n = 2), willingness to do the exercise (n = 2), helpfulness (n = 1) and how easy it was to fit into daily activities (n = 1), with some studies including more than one measure. The findings provide evidence that exercise for tendinopathy is acceptable, but heterogeneity in defining, measuring and reporting the various dimensions of acceptability combined with the limited number of studies reporting acceptability limits our ability to draw firm conclusions. Qualitative findings: 68 findings from 11 studies generated two synthesised findings: (1) patients and healthcare professionals report a range of highly personalised experiences and opinions of exercise therapies along with several barriers and facilitators to adhering to exercise; therefore, a person-centred, individualised approach should be used when delivering such interventions to people with tendinopathy; and (2) patients and healthcare professionals place value on appropriate and timely patient education facilitated by an effective ‘therapeutic alliance’ between patient and physiotherapist, to promote motivation and confidence in the exercise therapy being undertaken. Integration of quantitative and qualitative findings: The qualitative findings largely supported and explained the quantitative findings. For example, qualitative findings explain the factors that can influence adherence, including barriers, facilitators, beliefs, previous experiences and the ‘therapeutic alliance’. They provide explanation for supervised exercise being adhered to more than unsupervised, due to levels of confidence. They also help to explain the range of tolerability reported: beliefs about the pain–exercise relationship, the individualised response to pain, and the impact of symptomatic response all moderate an individual’s tolerability of therapeutic exercise. Environmental factors including group-based exercise and remote supervision via telehealth had been explored in the qualitative but not quantitative studies. Strengths and limitations Strengths: All tendinopathies and all forms of exercise were included in this evidence synthesis, allowing a large amount of data to be included. The modelling approaches featured in both the efficacy and mixed-methods reviews attempted to synthesise these data, identifying general results and where possible exploring heterogeneity to generate novel and clinically relevant findings. In addition, the inclusive approach with regard to tendinopathies, participants, therapies and outcomes enabled the review to synthesise diverse sets of information from both the providers’ and patients’ perspectives to provide the most comprehensive summary of the field to date. We excluded few studies based on language of publication, as we used both automated and personal translation where possible. Limitations: Restricting inclusion to studies conducted in countries with very high human development, by applying the Human Development Index, may have excluded some potentially relevant studies but does make the findings more relevant to the UK context. Several limitations in the available body of evidence were identified through conducting this project and include low-quality evidence, lack of agreed definitions (e.g. adherence), lack of standardised measurements (e.g. feasibility, acceptability), lack of consensus on outcome domains and measurement tools, poor reporting of exercise interventions and patient factors, and a lack of qualitative research. Conclusions and recommendations In conclusion, this comprehensive, robust, inclusive mixed-methods evidence synthesis has provided an extensive map of the contemporary research on exercise for tendinopathy, evaluated the efficacy and comparative efficacy of exercise across the common tendinopathies and identified what is known about the feasibility and acceptability of exercise therapy for the management of tendinopathy from patients’ and providers’ perspectives. The following recommendations can be made. Practice recommendations: Outcome domains are important to consider when evaluating the outcome of specific exercise interventions, with subjective measures likely to result in larger relative improvements compared to objective outcomes. Gathering information on patient satisfaction, including reasons for (dis)satisfaction, would be useful to inform practice. Resistance training should be prescribed at an appropriate intensity and frequency to increase muscle strength and subsequent positive adaptations to tendons. Use of flexibility and proprioceptive exercise should be considered for RCRSP rather than using resistance exercise in isolation; flexibility regimes may also be considered for Achilles tendinopathy. A focus on eccentric resistance exercise above all other treatments does not appear warranted. Given the loading protocols commonly used, it is likely that standard resistance exercise practices that combine concentric and eccentric exercise will be superior to eccentric-only and easier to implement in practice. Exercise could be combined with other non-exercise adjuncts earlier in the rehabilitative process. An individualised, person-centred approach should be taken when delivering exercise therapy to people with tendinopathy. Research recommendations: There is still a need for high-quality adequately powered research in the following areas: dose parameters and their interactions with patient characteristics; cost-effectiveness, which may also investigate models that include multiple modalities earlier in the therapeutic process; true effectiveness studies such as pragmatic trials to better quantify the effectiveness of current and developing therapeutic models