Effect of a common exercise programme with an individualised progression criterion based on the measurement of neuromuscular capacity versus current best practice for lower limb tendinopathies (MaLaGa trial): a protocol for a randomised clinical trial

Adrian Escriche-Escuder, Antonio I Cuesta-Vargas, Jose Casaña, Adrian Escriche-Escuder, Antonio I Cuesta-Vargas, Jose Casaña

Abstract

Introduction: High-load resistance training has shown positive effects in pain and function in lower limb tendinopathies. However, some authors suggest that current exercise programmes produce an increase in tolerance to load and exercise in general but without fixing some existing issues in tendinopathy. This may indicate the need to include training aspects not currently taken into account in the current programmes. The main objective of this study will be to compare the effect of a common exercise protocol for the three predominant lower limb tendinopathies (Achilles, patellar and gluteal), based on an individualised control of the dose and training of specific aspects of the neuromuscular system versus the current best practice for each location.

Methods and analysis: This study will be conducted among people with mid-portion Achilles, patellar or gluteal tendinopathy. The participants allocated to the experimental group will perform a 14-week innovative common therapeutic exercise programme. Participants allocated to the control group will carry out a 14-week exercise programme based on the best current practice for each of the studied locations. The Victorian Institute of Sports Assessment questionnaire will be considered the primary outcome. Pain, central sensitisation, fear avoidance behaviour, quality of life, treatment satisfaction, lower-limb strength and function, and high-density electromyography profile will be evaluated as secondary outcomes. Outcomes will be assessed at baseline, 7 weeks, after the intervention (week 14), 26 weeks and 52 weeks.

Ethics and dissemination: The study has been approved by the Portal de Ética de la Investigación Biomédica de Andalucía Ethics Committee (1221-N-19). All participants will be informed about the purpose and content of the study and written informed consent will be completed. The results of this study will be published in a peer-reviewed journal and will be disseminated electronically and in print.

Trial registration number: NCT03853122; Pre-results.

Keywords: foot & ankle; hip; knee; rehabilitation medicine; sports medicine.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Flow chart of the study.

References

    1. Cook JL, Purdam C. Is compressive load a factor in the development of tendinopathy? Br J Sports Med 2012;46:163–8. 10.1136/bjsports-2011-090414
    1. Cardoso TB, Pizzari T, Kinsella R, et al. . Current trends in tendinopathy management. Best Pract Res Clin Rheumatol 2019;33:122–40. 10.1016/j.berh.2019.02.001
    1. Mallows AJ, Debenham J, Littlewood C. Are psychological variables a feature in tendinopathy: a systematic review. Physiotherapy 2016;102:e154–5. 10.1016/j.physio.2016.10.180
    1. Docking SI, Cook J. How do tendons adapt? Going beyond tissue responses to understand positive adaptation and pathology development: a narrative review. J Musculoskelet Neuronal Interact 2019;19:300–10.
    1. Kongsgaard M, Kovanen V, Aagaard P, et al. . Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports 2009;19:790–802. 10.1111/j.1600-0838.2009.00949.x
    1. Kubo K, Ikebukuro T, Yata H, et al. . Time course of changes in muscle and tendon properties during strength training and detraining. J Strength Cond Res 2010;24:322–31. 10.1519/JSC.0b013e3181c865e2
    1. Rio E, Kidgell D, Moseley GL, et al. . Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. Br J Sports Med 2016;50:209–15. 10.1136/bjsports-2015-095215
    1. Rio E, Kidgell D, Purdam C, et al. . Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med 2015;49:1277–83. 10.1136/bjsports-2014-094386
    1. Rio E, van Ark M, Docking S, et al. . Isometric contractions are more analgesic than isotonic contractions for patellar tendon pain: an In-Season randomized clinical trial. Clin J Sport Med 2017;27:253–9. 10.1097/JSM.0000000000000364
    1. Holden S, Lyng K, Graven-Nielsen T, et al. . Isometric exercise and pain in patellar tendinopathy: a randomized crossover trial. J Sci Med Sport 2020;23:208–14. 10.1016/j.jsams.2019.09.015
    1. Crombie KM, Brellenthin AG, Hillard CJ, et al. . Endocannabinoid and opioid system interactions in exercise-induced hypoalgesia. Pain Med 2018;19:118–23. 10.1093/pm/pnx058
    1. Malliaras P, Barton CJ, Reeves ND, et al. . Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med 2013;43:267–86. 10.1007/s40279-013-0019-z
    1. Lim HY, Wong SH. Effects of isometric, eccentric, or heavy slow resistance exercises on pain and function in individuals with patellar tendinopathy: a systematic review. Physiother Res Int 2018;23:e1721. 10.1002/pri.1721
    1. Alfredson H, Pietilä T, Jonsson P, et al. . Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998;26:360–6. 10.1177/03635465980260030301
    1. Habets B, van Cingel REH. Eccentric exercise training in chronic mid-portion Achilles tendinopathy: a systematic review on different protocols. Scand J Med Sci Sports 2015;25:3–15. 10.1111/sms.12208
    1. Beyer R, Kongsgaard M, Hougs Kjær B, et al. . Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy: a randomized controlled trial. Am J Sports Med 2015;43:1704–11. 10.1177/0363546515584760
    1. Mellor R, Bennell K, Grimaldi A, et al. . Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. BMJ 2018;361:k1662. 10.1136/bmj.k1662
    1. Malliaras P. Understanding mechanisms to improve exercise interventions in tendinopathy. Phys Ther Sport 2017;27:50–1. 10.1016/j.ptsp.2016.12.006
    1. Escriche-Escuder A, Casaña J, Cuesta-Vargas AI. Load progression criteria in exercise programmes in lower limb tendinopathy: a systematic review. BMJ Open 2020;10:e041433. 10.1136/bmjopen-2020-041433
    1. Altman DG. Better reporting of randomised controlled trials: the CONSORT statement. BMJ 1996;313:570–1. 10.1136/bmj.313.7057.570
    1. Habets B, van Cingel REH, Backx FJG, et al. . Alfredson versus Silbernagel exercise therapy in chronic midportion Achilles tendinopathy: study protocol for a randomized controlled trial. BMC Musculoskelet Disord 2017;18:296. 10.1186/s12891-017-1656-4
    1. Docking SI, Ooi CC, Connell D. Tendinopathy: is imaging telling us the entire story? J Orthop Sports Phys Ther 2015;45:842–52. 10.2519/jospt.2015.5880
    1. Khan KM, Forster BB, Robinson J, et al. . Are ultrasound and magnetic resonance imaging of value in assessment of Achilles tendon disorders? A two year prospective study. Br J Sports Med 2003;37:149–53. 10.1136/bjsm.37.2.149
    1. Scott A, Squier K, Alfredson H, et al. . Icon 2019: international scientific tendinopathy symposium consensus: clinical terminology. Br J Sports Med 2020;54:bjsports-2019-100885. 10.1136/bjsports-2019-100885
    1. Pearson SJ, Stadler S, Menz H, et al. . Immediate and short-term effects of short- and long-duration isometric contractions in patellar tendinopathy. Clin J Sport Med 2020;30:335–40. 10.1097/JSM.0000000000000625
    1. van Ark M, Cook JL, Docking SI, et al. . Do isometric and isotonic exercise programs reduce pain in athletes with patellar tendinopathy in-season? a randomised clinical trial. J Sci Med Sport 2016;19:702–6. 10.1016/j.jsams.2015.11.006
    1. Malliaras P, Cook J, Purdam C, et al. . Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations. J Orthop Sports Phys Ther 2015;45:887–98. 10.2519/jospt.2015.5987
    1. Mascaró A, Cos Miquel Àngel, Morral A, et al. . Load management in tendinopathy: clinical progression for Achilles and patellar tendinopathy. Apunts Medicina de l’Esport 2018;53:19–27. 10.1016/j.apunts.2017.11.005
    1. Tran QT, Docherty D. Dynamic training volume: a construct of both time under tension and volume load. J Sports Sci Med 2006;5:707–13.
    1. Corradi EFF, Lanza MB, Lacerda LT, et al. . Acute physiological responses with varying load or time under tension during a squat exercise: a randomized cross-over design. J Sci Med Sport 2021;24:171–6. 10.1016/j.jsams.2020.07.015
    1. Pareja-Blanco F, Alcazar J, Sánchez-Valdepeñas J, et al. . Velocity loss as a critical variable determining the adaptations to strength training. Med Sci Sports Exerc 2020;52:1752–62. 10.1249/MSS.0000000000002295
    1. Schoenfeld BJ, Grgic J, Ogborn D, et al. . Strength and hypertrophy adaptations between low- vs. high-load resistance training: a systematic review and meta-analysis. J Strength Cond Res 2017;31:3508–23. 10.1519/JSC.0000000000002200
    1. Jenkins NDM, Miramonti AA, Hill EC, et al. . Greater neural adaptations following high- vs. low-load resistance training. Front Physiol 2017;8:331. 10.3389/fphys.2017.00331
    1. Zatsiorsky VM, Kraemer WJ. Science and practice of strength training. 2nd edn. Champaign IL: Human Kinetics, 2006.
    1. Häkkinen K, Keskinen KL. Muscle cross-sectional area and voluntary force production characteristics in elite strength- and endurance-trained athletes and sprinters. Eur J Appl Physiol Occup Physiol 1989;59:215–20. 10.1007/BF02386190
    1. Kountouris A, Cook J. Rehabilitation of Achilles and patellar tendinopathies. Best Pract Res Clin Rheumatol 2007;21:295–316. 10.1016/j.berh.2006.12.003
    1. Sancho I, Morrissey D, Willy RW, et al. . Education and exercise supplemented by a pain-guided hopping intervention for male recreational runners with midportion Achilles tendinopathy: a single cohort feasibility study. Phys Ther Sport 2019;40:107–16. 10.1016/j.ptsp.2019.08.007
    1. Purdam CR, Jonsson P, Alfredson H, et al. . A pilot study of the eccentric decline squat in the management of painful chronic patellar tendinopathy. Br J Sports Med 2004;38:395–7. 10.1136/bjsm.2003.000053
    1. Visentini PJ, Khan KM, Cook JL, et al. . The VISA score: an index of severity of symptoms in patients with jumper’s knee (patellar tendinosis). Victorian Institute of sport tendon Study Group. J Sci Med Sport 1998;1:22–8. 10.1016/s1440-2440(98)80005-4
    1. Robinson JM, Cook JL, Purdam C, et al. . The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. Br J Sports Med 2001;35:335–41. 10.1136/bjsm.35.5.335
    1. Fearon AM, Ganderton C, Scarvell JM, et al. . Development and validation of a VISA tendinopathy questionnaire for greater trochanteric pain syndrome, the VISA-G. Man Ther 2015;20:805–13. 10.1016/j.math.2015.03.009
    1. Hernández-Sánchez S, Poveda-Pagán EJ, Alakhdar-Mohmara Y, et al. . Cross-cultural adaptation of the Victorian Institute of sport assessment-achilles (VISA-A) questionnaire for Spanish athletes with achilles tendinopathy. J Orthop Sports Phys Ther 2018;48:111–20. 10.2519/jospt.2018.7402
    1. Hernandez-Sanchez S, Hidalgo MD, Gomez A. Cross-cultural adaptation of VISA-P score for patellar tendinopathy in Spanish population. J Orthop Sports Phys Ther 2011;41:581–91. 10.2519/jospt.2011.3613
    1. Price DD, McGrath PA, Rafii A, et al. . The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain 1983;17:45–56. 10.1016/0304-3959(83)90126-4
    1. Carlsson AM. Assessment of chronic pain I. Aspects of the reliability and validity of the visual analogue scale. Pain 1983;16:87–101. 10.1016/0304-3959(83)90088-X
    1. van Wilgen P, van der Noord R, Zwerver J. Feasibility and reliability of pain pressure threshold measurements in patellar tendinopathy. J Sci Med Sport 2011;14:477–81. 10.1016/j.jsams.2011.05.004
    1. Tompra N, van Dieën JH, Coppieters MW. Central pain processing is altered in people with Achilles tendinopathy. Br J Sports Med 2016;50:1004–7. 10.1136/bjsports-2015-095476
    1. Sayed-Noor AS, Englund E, Wretenberg P, et al. . Pressure-pain threshold algometric measurement in patients with greater trochanteric pain after total hip arthroplasty. Clin J Pain 2008;24:232–6. 10.1097/AJP.0b013e3181602159
    1. Linton SJ, Boersma K. Early identification of patients at risk of developing a persistent back problem: the predictive validity of the Orebro musculoskeletal pain questionnaire. Clin J Pain 2003;19:80–6. 10.1097/00002508-200303000-00002
    1. Cuesta-Vargas AI, González-Sánchez M. Spanish version of the screening Örebro musculoskeletal pain questionnaire: a cross-cultural adaptation and validation. Health Qual Life Outcomes 2014;12:157. 10.1186/s12955-014-0157-5
    1. Mayer TG, Neblett R, Cohen H, et al. . The development and psychometric validation of the central sensitization inventory. Pain Pract 2012;12:276–85. 10.1111/j.1533-2500.2011.00493.x
    1. Cuesta-Vargas AI, Roldan-Jimenez C, Neblett R, et al. . Cross-cultural adaptation and validity of the Spanish central sensitization inventory. Springerplus 2016;5:1837. 10.1186/s40064-016-3515-4
    1. Neblett R, Mayer TG, Hartzell MM, et al. . The fear-avoidance components scale (FACS): development and psychometric evaluation of a new measure of pain-related fear avoidance. Pain Pract 2016;16:435–50. 10.1111/papr.12333
    1. Rabin R, de Charro F. EQ-5D: a measure of health status from the EuroQol group. Ann Med 2001;33:337–43. 10.3109/07853890109002087
    1. Hernandez G, Garin O, Pardo Y, et al. . Validity of the EQ-5D-5L and reference norms for the Spanish population. Qual Life Res 2018;27:2337–48. 10.1007/s11136-018-1877-5
    1. Craig CL, Marshall AL, Sjöström M, et al. . International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc 2003;35:1381–95. 10.1249/01.MSS.0000078924.61453.FB
    1. Voutilainen A, Pitkäaho T, Kvist T, et al. . How to ask about patient satisfaction? The visual analogue scale is less vulnerable to confounding factors and ceiling effect than a symmetric Likert scale. J Adv Nurs 2016;72:946–57. 10.1111/jan.12875
    1. Gabel CP, Melloh M, Burkett B, et al. . Lower limb functional index: development and clinimetric properties. Phys Ther 2012;92:98–110. 10.2522/ptj.20100199
    1. Cuesta-Vargas AI, Gabel CP, Bennett P. Cross cultural adaptation and validation of a Spanish version of the lower limb functional index. Health Qual Life Outcomes 2014;12:75. 10.1186/1477-7525-12-75
    1. Rodriguez-Moya A, González-Sánchez M, Cuesta-Vargas AI. Efecto del vendaje neuromuscular a corto plazo en La fuerza en La extensión de rodilla. Fisioterapia 2011;33:256–61. 10.1016/j.ft.2011.07.007
    1. Muff G, Dufour S, Meyer A, et al. . Comparative assessment of knee extensor and flexor muscle strength measured using a hand-held vs. isokinetic dynamometer. J Phys Ther Sci 2016;28:2445–51. 10.1589/jpts.28.2445
    1. Enoka RM. Physiological validation of the decomposition of surface EMG signals. J Electromyogr Kinesiol 2019;46:70–83. 10.1016/j.jelekin.2019.03.010
    1. Negro F, Muceli S, Castronovo AM, et al. . Multi-channel intramuscular and surface EMG decomposition by convolutive blind source separation. J Neural Eng 2016;13:026027. 10.1088/1741-2560/13/2/026027
    1. Martinez-Valdes E, Laine CM, Falla D, et al. . High-density surface electromyography provides reliable estimates of motor unit behavior. Clin Neurophysiol 2016;127:2534–41. 10.1016/j.clinph.2015.10.065
    1. Martinez-Valdes E, Falla D, Negro F, et al. . Differential motor unit changes after endurance or high-intensity interval training. Med Sci Sports Exerc 2017;49:1126–36. 10.1249/MSS.0000000000001209

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