No Difference in Clinical Effects When Comparing Alfredson Eccentric and Silbernagel Combined Concentric-Eccentric Loading in Achilles Tendinopathy: A Randomized Controlled Trial.

BACKGROUND: Alfredson isolated eccentric loading and Silbernagel concentric-eccentric loading have both shown beneficial effects on clinical symptoms in midportion Achilles tendinopathy (AT), but they have never been compared directly. PURPOSE: To test for differences in clinical effects at 1-year follow-up between Alfredson and Silbernagel loading in midportion AT. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: A total of 40 recreational athletes were allocated to the Alfredson group (AG) or the Silbernagel group (SG). The primary outcome was the difference in the Victorian Institute of Sports Assessment-Achilles (VISA-A) at 1-year follow-up. Secondary outcomes were the visual analog scale for pain during activities of daily living (VAS-ADL) and sports activities (VAS-sports), the EuroQol 5 Dimensions instrument (EQ-5D), and global perceived effect score. Measurements were performed at baseline and 12-week, 26-week, and 1-year follow-up. Analysis was performed using a linear mixed-regression model with intervention (AG vs SG), time (12 weeks, 26 weeks, and 1 year postoperatively), and intervention-by-time interaction. RESULTS: The VISA-A score improved for both AG and SG, from 60.7 ± 17.1 at baseline to 89.4 ± 13.0 at 1-year follow-up and from 59.8 ± 22.2 to 83.2 ± 22.4, respectively (P < .001 for both). Because the interaction term did not significantly improve the model, we reported a treatment effect without interaction term, indicating a constant difference at each follow-up. The linear mixed model with correction for baseline VISA-A and confounders revealed a nonsignificant treatment effect (2.4 [95% CI, -8.5 to 13.3]; P = .656). In addition, after adjustment for the respective baseline values and confounders, nonsignificant treatment effects were found for the VAS-ADL (-2.0 [95% CI, -11.3 to 7.3]; P = .665) and VAS-sports (1.3 [95% CI, -12.8 to 15.3], P = .858). The EQ-5D subscales improved in both groups. After 1 year, significantly more SG participants considered themselves improved (77.3% [SG] vs 50.0% [AG]; P = .04). CONCLUSION: No differences in clinical effects were found between Alfredson and Silbernagel loading at up to 1-year follow-up. Both programs significantly improved clinical symptoms, and given their high adherence rates, offering either of them as a home-based program with limited supervision appears to be an effective treatment strategy for midportion AT. REGISTRATION: NTR5638 (Netherlands Trial Register number).

Cross-cultural adaptation and measurement properties of the Dutch knee self efficacy scale (K-SES).

BACKGROUND: Self-efficacy is related to outcome after anterior cruciate ligament (ACL) tears. The Knee Self Efficacy Scale (K-SES) available in Swedish and English, was developed to measure self-efficacy in present (K-SESpresent) and future (K-SESfuture) functioning. The objective of this study was to determine measurement properties of the K-SES in Dutch patients. METHODS: The K-SES was translated and structural validity, internal consistency, test-retest reliability, and measurement error were assessed in three patient samples: one group completed the questionnaire and additional measures pre-surgery (N = 200), and one group post-surgery (N = 58). The third group (post-surgery) completed the K-SES twice (N = 50). RESULTS: Exploratory factor analysis distinguished two underlying important factors: K-SESpresent and K-SESfuture. However, the distinction was not confirmed in Confirmatory Factor Analysis (CFA). Internal consistency for both subscales was excellent (Cronbach's alpha > .80). Test-retest reliability absolute agreement was 0.95. A-priori formulated hypotheses on the relation between Knee Self Efficacy Scale Dutch (K-SES-D) and related constructs were confirmed. Moderate to high correlations (r > 0.50) were reported with Knee Injury and Osteoarthritis Outcome Score (KOOS) before reconstruction. High negative correlation was found with fear of movement and pain catastrophizing (r < - 0.60), and low correlation (r < 0.50) with locus of control and measures of distress. CONCLUSION: Acceptability, internal consistency and test-retest reliability of the K-SES-D subscales are satisfactory. Construct validity of both subscales was confirmed by exploratory factor analysis and hypothesis testing. However, construct validity was not confirmed in CFA. Further research is needed to test responsiveness.

Intrarater reliability of the Humac NORM isokinetic dynamometer for strength measurements of the knee and shoulder muscles.

OBJECTIVE: To determine the intrarater reliability of the Humac NORM isokinetic dynamometer for concentric and eccentric strength tests of knee and shoulder muscles. RESULTS: 54 participants (50% female, average age 20.9 ± 3.1 years) performed concentric and eccentric strength measures of the knee extensors and flexors, and the shoulder internal and external rotators on two different Humac NORM isokinetic dynamometers, which were situated at two different centers. The knee extensors and flexors were tested concentrically at 60° and 180°/s, and eccentrically at 60° s. Concentric strength of the shoulder internal and external rotators, and eccentric strength of the external rotators were measured at 60° and 120°/s. We calculated intraclass correlation coefficients (ICCs), standard error of measurement, standard error of measurement expressed as a %, and the smallest detectable change to determine reliability and measurement error. ICCs for the knee tests ranged from 0.74 to 0.89, whereas ICC values for the shoulder tests ranged from 0.72 to 0.94. Measurement error was highest for the concentric test of the knee extensors and lowest for the concentric test of shoulder external rotators.

Shoulder Dynamic Control Ratio and Rotation Range of Motion in Female Junior Elite Handball Players and Controls.

OBJECTIVE: To compare glenohumeral range of motion and shoulder rotator muscle strength in healthy female junior elite handball players and controls. DESIGN: Cross-sectional case-control study. SETTING: Sports medical center. PARTICIPANTS: Forty elite female handball players and 30 controls active in nonoverhead sports participated in this study. MAIN OUTCOME MEASURES: Passive external rotator (ER), internal rotator (IR), and total range of motion (TROM) of the dominant and nondominant arm were examined with a goniometer. An isokinetic dynamometer was used to evaluate concentric and eccentric rotator muscle strength at 60 and 120 degrees/s with dynamic control ratio (DCR = ERecc:IRcon) as the main outcome parameter. RESULTS: Except for the ER range of motion in the nondominant arm, no significant differences were found between groups for IR, ER of the dominant arm, and the TROM. Within the handball group, the side-to-side difference for IR of the dominant arm was -1.4 degrees. The ER and the TROM of the dominant arm were significantly larger, 6.3 and 4.9 degrees, respectively. For both groups, the DCR values were above 1 and no significant differences were found between the dominant and nondominant arm. The DCR values in the handball group were significantly lower than in the control group. CONCLUSIONS: Based on the adopted definitions for muscle imbalance, glenohumeral internal range of motion deficit and TROM deficit our elite female handball players seem not at risk for shoulder injuries. Prospective studies are needed to support the belief that a DCR below 1 places the shoulder at risk for injury.

Return to Sport in Athletes with Midportion Achilles Tendinopathy: A Qualitative Systematic Review Regarding Definitions and Criteria.

BACKGROUND: Midportion Achilles tendinopathy (AT) can cause long-term absence from sports participation, and shows high recurrence rates. It is important that the decision to return to sport (RTS) is made carefully, based on sharply delimited criteria. Lack of a well-defined definition and criteria hampers the decision to RTS among athletes with AT, and impedes comparison of RTS rates between different studies. OBJECTIVE: The aim of this study was to systematically review the literature for definitions of, and criteria for, RTS in AT research. STUDY DESIGN: Qualitative systematic review. METHODS: The PubMed, EMBASE, Cochrane, CINAHL, PEDro, and Scopus electronic databases were searched for articles that reported on the effect of a physiotherapeutic intervention for midportion AT. Article selection was independently performed by two researchers. Qualitative content analysis was used to analyze the included studies and extract definitions of, and criteria for, RTS. RESULTS: Thirty-five studies were included in the content analysis, showing large variety in both the definitions and criteria. Thirty-two studies reported a definition of RTS, but only 19 studies described the criteria for RTS. The content analysis revealed that 'reaching pre-injury activity/sports level, with the ability to perform training and matches without limitations', 'absence of pain', and 'recovery' were the main content categories used to define RTS. Regarding the criteria for RTS, eight different content categories were defined: (1) 'level of pain'; (2) 'level of functional recovery'; (3) 'recovery of muscle strength'; (4) 'recovery of range of motion'; (5) 'level of endurance of the involved limb'; (6) 'medical advice'; (7) 'psychosocial factors'; and (8) 'anatomical/physiological properties of the musculotendinous complex'. Many criteria were not clearly operationalized and lacked specific information. CONCLUSIONS: This systematic review shows that RTS may be defined according to the pre-injury level of sports (including both training and matches), but also with terms related to the absence of pain and recovery. Multiple criteria for RTS were found, which were all related to level of pain, level of functional recovery, muscular strength, range of motion, endurance, medical advice, psychosocial factors, or anatomical/physiological properties of the Achilles tendon. For most of the criteria we identified, no clear operationalization was given, which limits their validity and practical usability. Further research on how RTS after midportion AT should be defined, and which criteria should be used, is warranted. PROSPERO REGISTRATION NUMBER: CRD42017062518.

Alfredson versus Silbernagel exercise therapy in chronic midportion Achilles tendinopathy: study protocol for a randomized controlled trial.

BACKGROUND: Midportion Achilles tendinopathy (AT) is a common overuse injury, usually requiring several months of rehabilitation. Exercise therapy of the ankle plantar flexors (i.e. tendon loading) is considered crucial during conservative rehabilitation. Alfredson's isolated eccentric and Silbernagel's combined concentric-eccentric exercise programs have both shown beneficial results, but it is unknown whether any of these programs is superior for use in clinical practice. Therefore, the primary objective of this study is to compare the effectiveness of both programs on clinical symptoms. Secondary objectives are to compare the effectiveness of both programs on quality of life and functional outcome measures, to investigate the prognostic value of baseline characteristics, to investigate differences in cost-effectiveness. METHODS/DESIGN: Eighty-six recreational athletes (21-60 years of age) with unilateral chronic midportion AT (i.e. ≥ 3 months) will be included in this multicenter assessor blinded randomized controlled trial. They will be randomly allocated to either a group performing the Alfredson isolated eccentric training program (n = 43), or a group performing the Silbernagel combined concentric-eccentric program (n = 43). In the Alfredson group, participants will perform eccentric heel-drops on their injured side, twice daily for 12 weeks, whereas in the Silbernagel group, participants perform various concentric-eccentric heel-raise exercises, once daily for 12 weeks. Primary outcome measure will be the Victorian Institute of Sport Assessment - Achilles (VISA-A) questionnaire. Secondary outcomes will be a visual analogue scale (VAS) for pain during daily activities and sports, duration of morning stiffness, global perceived effect, the 12-item Short Form Health Survey and the Euroqol instrument, and functional performance measured with the heel-raise test and the countermovement jump. Additionally, alongside the RCT, a cost-effectiveness analysis will be performed. Assessments will be performed at baseline and after 12, 26, and 52 weeks. DISCUSSION: This study is the first to directly compare the Alfredson and the Silbernagel exercise program in a randomized trial. The results can further enlarge the evidence base for choosing the most appropriate exercise program for patients with midportion AT. TRIAL REGISTRATION: Dutch Trial register: NTR5638 . Date of registration: 7 January 2016.

Measuring individual hierarchy of anxiety invoking sports related activities: development and validation of the Photographic Series of Sports Activities for Anterior Cruciate Ligament Reconstruction (PHOSA-ACLR).

BACKGROUND: Fear of harm (FoH) after Anterior Cruciate Ligament Reconstruction (ACLR) should be addressed in physical therapy as it hampers return to sports. However, there are no instruments assessing FoH specific for ACLR. The objective of this study is to describe the development and measurement properties of the Photograph Series of Sports Activities for ACLR (PHOSA-ACLR) measuring ACL injury related FoH. METHODS: Based on literature and opinion of physical therapists with extensive experience in ACLR treatment, photographs depicting FoH inducing situations in ACL injury were considered for inclusion in the instrument. For each photograph the patients is asked to report perceived harmfulness. The set of photographs was completed by two samples of patients with ACLR: 1 cross-sectional sample (n = 55), and 1 test-retest reliability sample (n = 58). Internal consistency and structural validity were assessed in 109 patients. In 58 patients criterion validity was assessed by calculating pearson correlations with the Tampa Scale of Kinesiophobia (TSK). Correlations with self-reported knee function (KOOS and Lysholm score), and Knee Self-efficacy Scale (K-SES) were computed for hypothesis testing. Test-retest reliability was determined in a group of 55 patients, assessed twice with 1 week between assessments. RESULTS: Twelve photographs depicting sports related movements that are likely to invoke FoH after ACLR were selected. Two items were deleted because of lack of discrimination. The remaining 10 items were included in the PHOSA-ACLR, and the scale showed excellent internal consistency (Cronbach's Alpha is .95). Items reflected one dimension, and was strongly correlated with TSK (r = .59). A priori formulated hypotheses are confirmed and test-retest correlation was excellent (ICC = .86). CONCLUSION: The PHOSA-ACLR showed acceptable measurement properties. The PHOSA-ACLR gives specific information about fear invoking sports situations that are not measured by other kinesophobia measures. Therefore, the PHOSA-ACLR might be a valuable additional tool in rehabilitation of ACLR patients. Additional research is needed to determine responsiveness to change.

Eccentric versus conventional exercise therapy in patients with rotator cuff tendinopathy: a randomized, single blinded, clinical trial.

PURPOSE: To investigate the effectiveness of isolated eccentric versus conventional exercise therapy in patients with rotator cuff tendinopathy. METHODS: Thirty-six patients with rotator cuff tendinopathy, diagnosed by an orthopaedic surgeon, were included and randomly allocated to an isolated eccentric exercise (EE) group (n = 20, mean age = 50.2 ± 10.8 years) or a conventional exercise (CG) group (n = 16, mean age = 48.6 ± 12.3 years). Both groups fulfilled a 12-week daily home-based exercise programme and received a total amount of nine treatment sessions. The Constant Murley score was used to evaluate both objective (e.g. range of motion and strength) and subjective measures (e.g. pain and activities of daily living). A visual analogue scale (VAS) was used to evaluate pain during daily activities. As secondary outcomes, shoulder range of motion and isometric abduction strength in 45° in the scapular plane were evaluated. All measurements were taken at baseline, at 6, 12 and 26 weeks. RESULTS: After 26 weeks, both groups showed a significant increase in the Constant Murley score and a significant decrease in VAS scores. No difference was found between the groups, for any of the evaluated outcome measures. CONCLUSION: A 12-week-isolated eccentric training programme of the rotator cuff is beneficial for shoulder function and pain after 26 weeks in patients with rotator cuff tendinopathy. However, it is no more beneficial than a conventional exercise programme for the rotator cuff and scapular muscles. Based on the results, clinicians should take into account that performing two eccentric exercises twice a day is as effective as performing six concentric/eccentric exercises once a day in patients with rotator cuff tendinopathy.

Consensus on Exercise Reporting Template (CERT): Modified Delphi Study.

BACKGROUND: Exercise interventions are often incompletely described in reports of clinical trials, hampering evaluation of results and replication and implementation into practice. OBJECTIVE: The aim of this study was to develop a standardized method for reporting exercise programs in clinical trials: the Consensus on Exercise Reporting Template (CERT). DESIGN AND METHODS: Using the EQUATOR Network's methodological framework, 137 exercise experts were invited to participate in a Delphi consensus study. A list of 41 items was identified from a meta-epidemiologic study of 73 systematic reviews of exercise. For each item, participants indicated agreement on an 11-point rating scale. Consensus for item inclusion was defined a priori as greater than 70% agreement of respondents rating an item 7 or above. Three sequential rounds of anonymous online questionnaires and a Delphi workshop were used. RESULTS: There were 57 (response rate=42%), 54 (response rate=95%), and 49 (response rate=91%) respondents to rounds 1 through 3, respectively, from 11 countries and a range of disciplines. In round 1, 2 items were excluded; 24 items reached consensus for inclusion (8 items accepted in original format), and 16 items were revised in response to participant suggestions. Of 14 items in round 2, 3 were excluded, 11 reached consensus for inclusion (4 items accepted in original format), and 7 were reworded. Sixteen items were included in round 3, and all items reached greater than 70% consensus for inclusion. LIMITATIONS: The views of included Delphi panelists may differ from those of experts who declined participation and may not fully represent the views of all exercise experts. CONCLUSIONS: The CERT, a 16-item checklist developed by an international panel of exercise experts, is designed to improve the reporting of exercise programs in all evaluative study designs and contains 7 categories: materials, provider, delivery, location, dosage, tailoring, and compliance. The CERT will encourage transparency, improve trial interpretation and replication, and facilitate implementation of effective exercise interventions into practice.

Reproducibility of a battery of commonly used clinical tests to evaluate lumbopelvic motor control.

OBJECTIVE: To determine reproducibility of a battery of clinical tests for evaluating lumbopelvic motor control (LMC). DESIGN: Test-retest design. PARTICIPANTS: Fifty healthy subjects. OUTCOME MEASURES: Two raters independently examined performance on 12 clinical tests for evaluating LMC. All tests were scored on a seven-point scale, based on qualitative and quantitative performance. Subjects were measured twice, with a two week interval between examinations. Intra- and inter-rater reproducibility of each test were determined using intraclass correlation coefficients (ICCs), standard error of measurement, smallest detectable change (SDC) and limits of agreement. RESULTS: Reliability of the tests ranged from poor to excellent. Intra-rater ICCs ranged from 0.00 to 0.82, whereas inter-rater ICCs varied from 0.00 to 0.96. SDC values were smallest for supine leg raising, bent knee fall out, prone bridge and unilateral prone bridge (<2 points). CONCLUSION: This study shows limited reproducibility of a battery of 12 clinical tests for the evaluation of LMC in a healthy population. Supine leg raising, bent knee fall out, prone bridge, and unilateral prone bridge showed the smallest measurement errors. The other 8 tests were found to have large measurement errors. Based on these results, dichotomization of the rating method might be considered in order to improve reproducibility values.