Renee McKenzie, DPT

Stretching Ultrasound Iontophoresis Phonophoresis Low-level Laser Eccentric exercise Instrument-Assisted Manuals

- ASTYM- Graston

Evidence supporting the use of ultrasound, iontophoresis or phonophoresis in combination with other treatments, or as the sole treatment, is lacking

Level of effectiveness may be dependent on dosage- A review of 13 randomized placebo-control trials (730

patients) for the treatment of lateral elbow tendinopathy1

Significant improvement seen with tendon application 904nm and possibly 632nm

Tendon application of 820nm and 1064nm; unable to establish effectiveness

- A review of 25 controlled clinical trials 12 showed positive effects and 13 were inconclusive or

showed no effect2

The review failed to state what dosages were used, only that the 12 studies with improvement followed current dosage recommendations

Though results are promising, further research is needed to determine the level of effectiveness- A review of 11 RCTs (443 tendons) assessing the

effectiveness of eccentric exercise concluded that “there is a lack of high quality evidence to support the ‐effectiveness of eccentric exercise in comparison with other treatments for relieving pain and improving function or satisfaction in patients with tendinopathies.”3

Eccentric exercise remains a favorable approach. - They are simple to perform and provide a cost effective,

safe and efficient way to treat tendinosis.4 - Despite the lack of evidence, eccentric exercise has the

strongest evidence of efficacy.5

Author, year Groups No. of participants Length of study/follow-up (weeks)

Satisfactory and back to pre-injury activity

Fahlström, Martin et al., 20036

Chronic Achilles tendinosis mid-portion

78 (101 tendons) 12 89%

Chronic insertional Achilles tendon pain

30 (31 tendons) 12 32%

Maffulli, Nicola et al., 20087

Tendinopathy of the Achilles tendon

45 (45 tendons) 12 60%

Studies that included Eccentric Training as an intervention for Lateral Elbow Tendinopathy

Table 1

Author, Year

Design Groups (sample size) Training protocol, location

Length of study, follow-up (weeks)

Outcomes Differencea at longest follow-up

Svernlov, 2001

Randomized pilot study

1. Stretching (n=15) 2. Eccentricb training, stretching (n=15)

3 sets of 5 slowly twice daily

12, 52 VAS (pain), subjective change, MG

Yes (subjective)

Martinez-Silvestrini, 2005

RCT (stratified for gender)

1. Stretching (n=28) 2.Concentricb training, stretching (n=26) 3.Eccentricb training, stretching (n=27)

3 sets of 10 slowly once daily

6, 0 VAS (pain, PFG, patient satisfaction, function

No

Croisier, 2006

NRCTc 1. Physiotherapyd (A) (n=46) 2.Eccentrice training, physiotherapyd (A) (n=46)

3 sets of 15 slowly 3 times weekly

9, 0 VAS (pain), isokinetic strength, disability

Yes (all outcomes)

Stasinopoulos, 2006

NRCT 1. Cyriaxf (n=25) 2. PPNL (n=25) 3. Eccentricb training (n=25)

3 sets of 10 slowly 3 times weekly

4, 28 VAS (pain, function), PFG

Yes (all outcomes)

Note. RCT, randomized controlled trial; NRCT, non-randomized controlled trial; VAS, visual analogue scale; MG, maximal grip; PFG, pain free grip strength; PPNL, Polarized polychromatic non-coherent light. amore favorable outcome in eccentric group compared with other group(s);bwrist extensors;cmatched for age, gender, activity;dice, transcutaneous electrical stimulation, friction massage, wrist extensor stretching;ewrist extensors, elbow supinators;fdeep friction massage, Mill’s manipulation.

ASTYM Graston

Developed in the mid 90’s Set of three acrylic instruments Who can be certified

- Physical Therapist- Physical Therapist Assistant- Occupational Therapist- Certified Athletic Trainer

Table 2

Outcome ReportsAll Diagnostic Categories Total Cases Avg # of

ASTYM Tx Improved Same Worse

Shoulder Girdle Biceps tendinopathy 41 8 82.9% 14.6% 2.4% Impingement/tendinopathy of rotator cuff 123 8 91.9% 5.7% 2.4% Elbow/Forearm Lateral epicondylosis 1125 10 90.7% 9.0% 0.4% Lateral epicondylosis + carpal tunnel syndrome 48 9 89.6% 10.4% 0.0% Lateral epicondylosis + medial epicondylosis 123 10 86.2% 13.0% 0.8% Medial epicondylosis 168 9 93.5% 4.8% 1.8% Other tendinopathy of forearm (sprain/strain forearm) 99 8 92.9% 7.1% 0.0%

Knee Patellar tendinopathy 110 7 87.3% 12.7% 0.0% Shin, Ankle & Foot Achilles tendinopathy 316 9 94.6% 5.1% 0.3% Plantar fasciopathy-heel pain 958 9 91.9% 7.6% 0.5% Shin splints-tendinopathy of tibialis anterior, tibialis posterior, peroneal tendinopathy 93 9 95.7% 4.3% 0.0%

Developed in the mid 90’s Set of six stainless steel instruments Who can be certified

- Physical Therapist/Physiotherapist- Occupational Therapist- Chiropractor- Certified Athletic Trainer- Medical Physician- Dentist- Osteopath- Podiatrist- Selected Canadian Registered Massage Therapists

Table 3

Outcome DataInjury Average

# of TreatmentsComplete100%

Excellent90%+

Good80%+

Fair70%+

Unchangedless than 70% Success Rate

Achilles Tendinitis 8 4 73 15 0 8 92 Ankle Sprain 8 6 52 24 6 12 82 Plantar Fasciitis 7 2 44 24 11 19 70

Patella Femoral Syndrome 11 5 42 24 24 5 71

Cervical Pain 11 4 49 29 13 5 82 Low Back Pain 11 8 44 35 6 7 87 Fibromyalgia 10 6 31 44 6 13 81 Hip Pain 9 8 30 50 4 8 88 Hamstring Strain 8 12 58 12 12 6 82 ITB Tendinitis 7 0 64 18 9 9 82 Lat Epicondylitis 10 15 44 31 4 6 90 Med Epicondylitis 8 13 27 20 7 33 60 Rotator Cuff Tendinitis 9 14 40 38 3 5 92 Adhesive Capsulitis 15 0 18 55 18 9 73 Carpal Tunnel Syndrome 8 5 60 21 9 5 86 Wrist Tendinitis 7 13 46 33 4 4 92 Scar Pain 9 0 46 8 38 8 54 * = Median # of treatments Success Rate: Percentage of Resolution equates to attaining the patient/clinician goals of 1) increase in function 2) decrease in pain.

Due to the lack of high-quality evidence, the ideal physical therapy treatment/modalities for tendinopathies remains unclear

Eccentric exercise currently has the strongest evidence of efficacy

Newer approaches such as ASTYM and Graston are producing results worth noting

1: Bjordal, JM, RA Lopes-Martins, J Joensen, C Couppe, AE Ljunggren, A Stergioulas, and MI Johnson. "A systematic review with procedural assessments and meta analysis of low level laser therapy in lateral elbow tendinopathy (tennis elbow)." ‐BMC Musculoskeletal Disorders. (2008) 9:75

2: Tumilty, s, J Munn, S McDonough, DA Hurley, JR Basford, and GD Baxter. "Low level laser treatment of tendinopathy: a systematic review with meta-analysis.." Photomedicine And Laser Surgery . 28.1 (2010): 3-16.

4:Van Usen, C, and B Pumberger. "Effectiveness of eccentric exercises in the management of chronic Achilles tendinosis." J ALLIED HEALTH SCI PRACT. 5.2 (2007): 1-14

3: Chronic tendinopathy: effectiveness of eccentric exercise [Database of Abstracts of Reviews of Effects DARE-12007005641]. In: The Cochrane Library, Issue 3, 2011. Chichester, John Wiley & Sons Ltd. Abstract of: Chronic tendinopathy: effectiveness of eccentric exercise. Woodley, B L; Newsham West, R J; Baxter, G D. British Journal of Sports ‐Medicine 2007:41(4): 188-199

5: Kaeding, Christopher, and Thomas M Best. "Tendinosis: Pathophysiology and Nonoperative Treatment." Sports Health: A Multidisciplinary Approach . 1.4 (2009): 284-9

6: Fahlström, Martin, Per Jonsson, Ronny Lorentzon, and Håkan Alfredson. "Chronic Achilles tendon pain treated with eccentric calf-muscle training.." Knee Surgery, Sports Traumatology, Arthroscopy. 11. (2003): 327–333.

7: Maffulli, Nicola, Gayle Walley, Murali K. Sayana, Umile Giuseppe Longo, and Vincenzo Denaro. "Eccentric calf muscle training in athletic patients with Achilles." Disability and Rehabilitation. (2008

Table 1: Malliaras, Peter, Nicola Maffulli, and Giorgio Garau. "Eccentric training programmes in the management of lateral elbow." Disability and Rehabilitation. (2008)

Table 2: "http://www.astym.com/asp/marketing.aspx." http://www.astym.com. N.p., n.d. Web. 30 Nov2011.

Table 3: "http://www.astym.com/professionals/process.asp." . N.p., n.d. Web. 30 Nov 2011