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Huang CK1, Hsiao K-L1, Chen P-Y1, Chen W-Y1, Shih Y-F1, Lee HC1
1National Yang-Ming University, Physical Therapy and Assistive Technology, Taipei City, Taiwan
Background: Achilles tendinopathy (AT) is a common condition among experienced and amateur athletes, and physical therapy or other conservative therapy are regarded as the first-line management for AT. Among of those interventions, eccentric exercises have been proved to be effective. In clinical practice, the treatment protocol usually combined eccentric exercise with other conservative therapy, such as extracorporeal shockwave therapy (ESWT), low-level laser therapy (LLLT), or the injection of platelet-rich plasma (PRP). However, previous systematic reviews provided preliminary evidence for combined interventions for AT, but the result lacked clinically significant outcome for pain and function.
Purpose: The aim of the study was to conduct a systematic review and meta-analysis of the effectiveness of eccentric exercises combined with ESWT, LLLT, or PRP for AT on pain scale and Victorian Institute of Sports Assessment-Achilles (VISA-A) scores.
Methods: A comprehensive strategy was used to search 5 electronic databases from inception to May 2018. Search terms included Achilles tendinopathy, extracorporeal shockwave therapy, low-level laser therapy, platelet-rich plasma and eccentric exercises (English and Chinese language full-text publications, human studies). Reference lists of eligible papers were hand-searched. Randomized controlled trials (RCTs) were included if they evaluated eccentric exercises combined with ESWT, LLLT, or PRP intervention for AT using at least one outcome of pain including the Visual Analogue Scale (VAS) or the Numerical Rating Scale (NRS), and/or VISA-A scores. Three independent reviewers screened 61 search results, identifying 10 suitable studies, and assessed methodological quality and risk of bias using the Physiotherapy Evidence Database (PEDro) score. Meta-analyses were based on fixed and random effects models respectively.
Results: Ten included articles showed high-quality with the PEDro score ranged from 6 to 10 (/10). Meta-analyses identified significant effects favoring eccentric exercises plus ESWT on VISA-A scores (mean difference [MD],13.5; 95% confidence interval [CI], 7.22 to 19.78; p 0.0001). However, the result did not favor the combination of eccentric exercises and LLLT or PRP on VAS (MD, -2.17, -1.42; 95% CI, -10.69 to 6.35, -27.18 to 24.34; p= 0.62, 0.91, respectively) and VISA-A scores (MD, 1.93, 0.31; 95% CI, -9.75 to 13.61, -1.81 to 2.43; p= 0.75, 0.77, respectively). The analysis of VAS on the effects of eccentric exercise plus ESWT was not available due to data insufficiency.
Conclusion(s): LLLT or PRP combined with eccentric exercises did not significantly improve the VISA-A scores or VAS in subjects with AT, but ESWT combined with eccentric exercises showed favoring effects on VAS. However, more randomized trials are needed to confirm these results, and the clinical effect on different portion of Achilles tendon and the cost effectiveness for different therapy should be evaluated in further research.
Implications: LLLT or PRP combined with eccentric exercise might not improve patient's VAS or VISA-A score comparing to eccentric exercise only for patients with AT. However, ESWT combined with eccentric exercise could have additional effects on improving VISA-A score than doing eccentric exercise alone.
Keywords: Achilles tendinopathy, eccentric exercise, conservative therapy
Funding acknowledgements: There are no funding sources supporting this work.
Purpose: The aim of the study was to conduct a systematic review and meta-analysis of the effectiveness of eccentric exercises combined with ESWT, LLLT, or PRP for AT on pain scale and Victorian Institute of Sports Assessment-Achilles (VISA-A) scores.
Methods: A comprehensive strategy was used to search 5 electronic databases from inception to May 2018. Search terms included Achilles tendinopathy, extracorporeal shockwave therapy, low-level laser therapy, platelet-rich plasma and eccentric exercises (English and Chinese language full-text publications, human studies). Reference lists of eligible papers were hand-searched. Randomized controlled trials (RCTs) were included if they evaluated eccentric exercises combined with ESWT, LLLT, or PRP intervention for AT using at least one outcome of pain including the Visual Analogue Scale (VAS) or the Numerical Rating Scale (NRS), and/or VISA-A scores. Three independent reviewers screened 61 search results, identifying 10 suitable studies, and assessed methodological quality and risk of bias using the Physiotherapy Evidence Database (PEDro) score. Meta-analyses were based on fixed and random effects models respectively.
Results: Ten included articles showed high-quality with the PEDro score ranged from 6 to 10 (/10). Meta-analyses identified significant effects favoring eccentric exercises plus ESWT on VISA-A scores (mean difference [MD],13.5; 95% confidence interval [CI], 7.22 to 19.78; p 0.0001). However, the result did not favor the combination of eccentric exercises and LLLT or PRP on VAS (MD, -2.17, -1.42; 95% CI, -10.69 to 6.35, -27.18 to 24.34; p= 0.62, 0.91, respectively) and VISA-A scores (MD, 1.93, 0.31; 95% CI, -9.75 to 13.61, -1.81 to 2.43; p= 0.75, 0.77, respectively). The analysis of VAS on the effects of eccentric exercise plus ESWT was not available due to data insufficiency.
Conclusion(s): LLLT or PRP combined with eccentric exercises did not significantly improve the VISA-A scores or VAS in subjects with AT, but ESWT combined with eccentric exercises showed favoring effects on VAS. However, more randomized trials are needed to confirm these results, and the clinical effect on different portion of Achilles tendon and the cost effectiveness for different therapy should be evaluated in further research.
Implications: LLLT or PRP combined with eccentric exercise might not improve patient's VAS or VISA-A score comparing to eccentric exercise only for patients with AT. However, ESWT combined with eccentric exercise could have additional effects on improving VISA-A score than doing eccentric exercise alone.
Keywords: Achilles tendinopathy, eccentric exercise, conservative therapy
Funding acknowledgements: There are no funding sources supporting this work.
Topic: Sport & sports injuries; Musculoskeletal: lower limb; Orthopaedics
Ethics approval required: No
Institution: Human Research Ethics Committee, National Yang-Ming University, Taiwan
Ethics committee: Hsuei-Chen Lee
Reason not required: This study was not a human trial research. Only using data from previous studies for systematic reviews and meta-analyses.
All authors, affiliations and abstracts have been published as submitted.
