Achilles Tendinopathy Toolkit: Section C - Summary of Evidence and Recommendations for Interventions: Difference between revisions
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==== Purpose, Scope and Disclaimer ==== | ==== Purpose, Scope and Disclaimer ==== | ||
The purpose of this document is to provide physical therapists with a summary of the evidence for interventions commonly used to manage mid‐substance Achilles tendinopathy. This decision‐making tool is evidence‐informed and where there is insufficient evidence, expert‐informed. It is not intended to replace the clinician’s clinical reasoning skills<br>and inter‐professional collaboration. ‘Acute’ refers primarily to the stage with the cardinal signs of heat, redness, pain, swelling and loss of function and a very recent onset of symptoms. | The purpose of this document is to provide physical therapists with a summary of the evidence for interventions commonly used to manage mid‐substance Achilles tendinopathy. This decision‐making tool is evidence‐informed and where there is insufficient evidence, expert‐informed. It is not intended to replace the clinician’s clinical reasoning skills<br>and inter‐professional collaboration. ‘Acute’ refers primarily to the stage with the cardinal signs of heat, redness, pain, swelling and loss of function and a very recent onset of symptoms. | ||
== Manual Therapy<br> == | == Manual Therapy<br> == | ||
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| There is a small amount of clinical evidence and more substantial expert level consensus to <u>support </u>the use of joint mobilizations in the chronic stage if assessment reveals joint restriction. | | There is a small amount of clinical evidence and more substantial expert level consensus to <u>support </u>the use of joint mobilizations in the chronic stage if assessment reveals joint restriction. | ||
|- | |- | ||
! scope="row" | '''Clinical implication | ! scope="row" | '''[[Achilles Tendinopathy Toolkit: Summary of Interventions#Explanation_of_clinical_implications|Clinical implication]]''' | ||
| <u>May consider</u> using manual therapy in the acute stage after undertaking a comprehensive biomechanical evaluation of the ‐ Joint mobs hip, knee, foot and ankle. | | <u>May consider</u> using manual therapy in the acute stage after undertaking a comprehensive biomechanical evaluation of the ‐ Joint mobs hip, knee, foot and ankle. | ||
| <u>May consider</u> using manual therapy in the chronic stage<br>after undertaking a comprehensive biomechanical<br>evaluation of the hip, knee, foot and ankle. | | <u>May consider</u> using manual therapy in the chronic stage<br>after undertaking a comprehensive biomechanical<br>evaluation of the hip, knee, foot and ankle. | ||
|- | |- | ||
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| There is a small amount of clinical evidence to <u>support the use of soft tissue techniques, such as frictions, in the chronic stage. | | There is a small amount of clinical evidence to <u>support the use of soft tissue techniques, such as frictions, in the chronic stage. | ||
|- | |- | ||
! scope="row" | '''Clinical implication | ! scope="row" | | ||
'''[[Achilles Tendinopathy Toolkit: Summary of Interventions#Explanation_of_clinical_implications|Clinical implication]]''' | |||
| <u>May consider</u> using manual therapy in the acute stage after undertaking a comprehensive biomechanical evaluation of the ‐ Joint mobs hip, knee, foot and ankle. | | <u>May consider</u> using manual therapy in the acute stage after undertaking a comprehensive biomechanical evaluation of the ‐ Joint mobs hip, knee, foot and ankle. | ||
| <u>May consider</u> a trial of soft tissue techniques, such as<br>frictions, in the chronic stage. | | <u>May consider</u> a trial of soft tissue techniques, such as<br>frictions, in the chronic stage. | ||
|} | |} | ||
* | * | ||
== Exercise == | == Exercise == | ||
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| There is a large amount of clinical evidence to<br><u>support</u> the use of exercise in the chronic stage but<br>the precise parameters to ensure effectiveness are<br>not clear. Eccentric exercise in particular is<br>supported although some protocols use both<br>concentric and eccentric exercise. Males appear to<br>benefit slightly more than females from eccentric<br>exercise. | | There is a large amount of clinical evidence to<br><u>support</u> the use of exercise in the chronic stage but<br>the precise parameters to ensure effectiveness are<br>not clear. Eccentric exercise in particular is<br>supported although some protocols use both<br>concentric and eccentric exercise. Males appear to<br>benefit slightly more than females from eccentric<br>exercise. | ||
|- | |- | ||
! scope="row" | Clinical implication | ! scope="row" | [[Achilles Tendinopathy Toolkit: Summary of Interventions#Explanation_of_clinical_implications|Clinical implication]] | ||
| <u>May consider</u> using stretching exercises in acute stage. No prescription parameters are provided. ACSM recommends 10-30 sec hold, 2‐4 repetitions. | | <u>May consider</u> using stretching exercises in acute stage. No prescription parameters are provided. ACSM recommends 10-30 sec hold, 2‐4 repetitions. | ||
| <u>Strongly consider </u>using eccentric exercise in the chronic stage using the following general parameters of a gradual progression to 3 sets of 15 repetitions, twice per day with the knee extended and with the knee flexed. | | <u>Strongly consider </u>using eccentric exercise in the chronic stage using the following general parameters of a gradual progression to 3 sets of 15 repetitions, twice per day with the knee extended and with the knee flexed. | ||
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|} | |} | ||
OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews. | |||
== Low level laser therapy (LLLT) == | |||
== Ultrasound (US) == | |||
CS ‐ Case studies; MA ‐ Meta‐analyses; OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews | |||
== Extracorporeal shock wave therapy (SWT) == | |||
CS ‐ Case studies; MA ‐ Meta‐analyses; OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews | |||
== Iontophoresis using dexamethasone == | |||
CS ‐ Case studies; MA ‐ Meta‐analyses; OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews | |||
== Taping == | |||
CS ‐ Case studies; MA ‐ Meta‐analyses; OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews | |||
== Orthotics == | |||
CS ‐ Case studies; MA ‐ Meta‐analyses; OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews | |||
== Night splints and braces == | |||
CS ‐ Case studies; MA ‐ Meta‐analyses; OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews | |||
== Heel raise inserts == | |||
CS ‐ Case studies; MA ‐ Meta‐analyses; OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews | |||
== Needling techniques == | |||
Acupuncture (trasitional Chinese medicine, anatomical, electrical) and intramuscular stimulation. | |||
CS ‐ Case studies; MA ‐ Meta‐analyses; OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews | |||
== Outcome measures == | |||
For any intervention selected by the clinician, it is strongly recommended that the clinician use one or more of the following outcome measures: | |||
=== A. Patient reported outcome measure === | |||
Such as: | |||
*A global measure of lower extremity function: e.g., The Lower Extremity Functional Scale (LEFS) ‐ not specific to Achilles tendinopathy | |||
**Available at:[[ http://www.physther.net/content/79/4/371/F1.large.jpg| http://www.physther.net/content/79/4/371/F1.large.jpg]] | |||
*Detailed questionnaire, specific to Achilles tendinopathy e.g. the VISA‐A questionnaire | |||
**Available at: [http://bjsm.bmj.com/content/suppl/2001/11/09/35.5.335.DC1/01055_Fig_1_data_supplement.pdf http://bjsm.bmj.com/content/suppl/2001/11/09/35.5.335.DC1/01055_Fig_1_data_supplement.pdf ] | |||
**Click on ‘view questionnaire’ | |||
=== B. Patient specific functional outcome measure such as: === | |||
*How much weight can be applied to the plantar flexed foot on a weighing scale before the onset of pain | |||
*The number of heel raises before the onset of pain | |||
*The number of heel drops before the onset of pain | |||
*The number of heel drops with a specific weight in a backpack before the onset of pain | |||
*How far can the client walk or run before the onset of pain | |||
== Explanation of clinical implications == | |||
*<u>Strongly consider: </u>High level/high quality evidence that this should be included in treatment. | |||
*<u>Consider: </u>Consistent lower level/lower quality or inconsistent evidence that this should be included in treatment. | |||
*<u>May consider: </u>No clinical evidence but expert opinion and/or plausible physiological rationale that this should be included in treatment. | |||
*<u>Consider NOT: </u>High level/high quality evidence that this should not be included in treatment.<br> | |||
== References == | == References == | ||
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References will automatically be added here, see [[Adding References|adding references tutorial]]. | References will automatically be added here, see [[Adding References|adding references tutorial]]. | ||
<references /> | <references /> | ||
== Acknowledgements == | |||
Developed by the BC Physical Therapy Tendinopathy Task Force: Dr. Joseph Anthony, Allison Ezzat, Diana Hughes, JR Justesen, Dr. Alex Scott, Michael Yates, Alison Hoens. | |||
A Physical Therapy Knowledge Broker project supported by: UBC Department of Physical Therapy, Physiotherapy Association of BC, Vancouver Coastal Research Institute and Providence Healthcare Research Institute. | |||
Revision as of 20:06, 21 July 2012
Achilles Tendinopathy (mid-substance):
Summary of the Evidence for Physical Therapy Interventions[edit | edit source]
Purpose, Scope and Disclaimer[edit | edit source]
The purpose of this document is to provide physical therapists with a summary of the evidence for interventions commonly used to manage mid‐substance Achilles tendinopathy. This decision‐making tool is evidence‐informed and where there is insufficient evidence, expert‐informed. It is not intended to replace the clinician’s clinical reasoning skills
and inter‐professional collaboration. ‘Acute’ refers primarily to the stage with the cardinal signs of heat, redness, pain, swelling and loss of function and a very recent onset of symptoms.
Manual Therapy
[edit | edit source]
|
Joint mobs | ||
|---|---|---|
| Stage of pathology | Acute | Chronic |
| Clinical research evidence | No | Yes |
| Published expert opinion | Yes | Yes |
| Take home message | There is no clinical evidence but there is expert level consensus to support | There is a small amount of clinical evidence and more substantial expert level consensus to support the use of joint mobilizations in the chronic stage if assessment reveals joint restriction. |
| Clinical implication | May consider using manual therapy in the acute stage after undertaking a comprehensive biomechanical evaluation of the ‐ Joint mobs hip, knee, foot and ankle. | May consider using manual therapy in the chronic stage after undertaking a comprehensive biomechanical evaluation of the hip, knee, foot and ankle. |
|
Soft-tissue techniques | ||
| Stage of pathology | Acute | Chronic |
| Clinical research evidence | No | Yes 1 SR 2 CS |
| Published expert opinion | No | Yes |
| Take home message | The clinical evidence neither supports nor refutes the use of frictions in the acute stage. |
There is a small amount of clinical evidence to <u>support the use of soft tissue techniques, such as frictions, in the chronic stage. |
| May consider using manual therapy in the acute stage after undertaking a comprehensive biomechanical evaluation of the ‐ Joint mobs hip, knee, foot and ankle. | May consider a trial of soft tissue techniques, such as frictions, in the chronic stage. | |
Exercise[edit | edit source]
| Stage of pathology | Acute | Chronic |
|---|---|---|
| Clinical research evidence | No | Yes 14 OS 6 SR 5 RCT |
| Published expert opinion | Yes | Yes |
| Take home message | There is a small amount of expert opinion to support the use of stretches in the acute stage. | There is a large amount of clinical evidence to support the use of exercise in the chronic stage but the precise parameters to ensure effectiveness are not clear. Eccentric exercise in particular is supported although some protocols use both concentric and eccentric exercise. Males appear to benefit slightly more than females from eccentric exercise. |
| Clinical implication | May consider using stretching exercises in acute stage. No prescription parameters are provided. ACSM recommends 10-30 sec hold, 2‐4 repetitions. | Strongly consider using eccentric exercise in the chronic stage using the following general parameters of a gradual progression to 3 sets of 15 repetitions, twice per day with the knee extended and with the knee flexed.
|
OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews.
Low level laser therapy (LLLT)[edit | edit source]
Ultrasound (US)[edit | edit source]
CS ‐ Case studies; MA ‐ Meta‐analyses; OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews
Extracorporeal shock wave therapy (SWT)[edit | edit source]
CS ‐ Case studies; MA ‐ Meta‐analyses; OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews
Iontophoresis using dexamethasone[edit | edit source]
CS ‐ Case studies; MA ‐ Meta‐analyses; OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews
Taping[edit | edit source]
CS ‐ Case studies; MA ‐ Meta‐analyses; OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews
Orthotics[edit | edit source]
CS ‐ Case studies; MA ‐ Meta‐analyses; OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews
Night splints and braces[edit | edit source]
CS ‐ Case studies; MA ‐ Meta‐analyses; OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews
Heel raise inserts[edit | edit source]
CS ‐ Case studies; MA ‐ Meta‐analyses; OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews
Needling techniques[edit | edit source]
Acupuncture (trasitional Chinese medicine, anatomical, electrical) and intramuscular stimulation.
CS ‐ Case studies; MA ‐ Meta‐analyses; OS ‐ Observational studies; RCT ‐ Randomized controlled trials; SR ‐ Systematic reviews
Outcome measures[edit | edit source]
For any intervention selected by the clinician, it is strongly recommended that the clinician use one or more of the following outcome measures:
A. Patient reported outcome measure[edit | edit source]
Such as:
- A global measure of lower extremity function: e.g., The Lower Extremity Functional Scale (LEFS) ‐ not specific to Achilles tendinopathy
- Available at:[[ http://www.physther.net/content/79/4/371/F1.large.jpg%7C http://www.physther.net/content/79/4/371/F1.large.jpg]]
- Detailed questionnaire, specific to Achilles tendinopathy e.g. the VISA‐A questionnaire
- Available at: http://bjsm.bmj.com/content/suppl/2001/11/09/35.5.335.DC1/01055_Fig_1_data_supplement.pdf
- Click on ‘view questionnaire’
B. Patient specific functional outcome measure such as:[edit | edit source]
- How much weight can be applied to the plantar flexed foot on a weighing scale before the onset of pain
- The number of heel raises before the onset of pain
- The number of heel drops before the onset of pain
- The number of heel drops with a specific weight in a backpack before the onset of pain
- How far can the client walk or run before the onset of pain
Explanation of clinical implications[edit | edit source]
- Strongly consider: High level/high quality evidence that this should be included in treatment.
- Consider: Consistent lower level/lower quality or inconsistent evidence that this should be included in treatment.
- May consider: No clinical evidence but expert opinion and/or plausible physiological rationale that this should be included in treatment.
- Consider NOT: High level/high quality evidence that this should not be included in treatment.
References[edit | edit source]
References will automatically be added here, see adding references tutorial.
Acknowledgements[edit | edit source]
Developed by the BC Physical Therapy Tendinopathy Task Force: Dr. Joseph Anthony, Allison Ezzat, Diana Hughes, JR Justesen, Dr. Alex Scott, Michael Yates, Alison Hoens.
A Physical Therapy Knowledge Broker project supported by: UBC Department of Physical Therapy, Physiotherapy Association of BC, Vancouver Coastal Research Institute and Providence Healthcare Research Institute.
