Systematische Literaturanalyse über exzentrisches Training bei chronischer Mid-portion-Achillestendinopathie: Gibt es einen Standard?

 

 Buy Article Permissions and Reprints

Zusammenfassung

Hintergrund: Obwohl exzentrisches Kräftigungstraining der Achillessehne bei chronischer Mid-portion-Tendinopathie mittlerweile durch die wissenschaftliche Datenlage als konservative Therapieoption anerkannt ist, fehlen bislang Empfehlungen hinsichtlich Trainingsdosierung, Trainingsdauer sowie standardisierte Trainingsprotokolle. Fragestellungen: Hat exzentrisches Training in der Therapie chronischer Achillestendinopathie einen überlegenen Effekt gegenüber anderen konservativen Therapieoptionen? Können aufgrund der Datenlage reliable Empfehlungen hinsichtlich Dosierung und Zeitdauer des Trainings ausgesprochen werden? Studiendesign: Systematische Literaturanalyse der gegenwärtigen Datenlage exzentrischen Trainings zur Therapie chronischer Achillestendinopathie entsprechend den PRISMA-Leitlinien für Metaanalysen. Datenquelle: National Library of Medicine (NLM) ab Jahrgang 1950 – 2010. Auswahlkriterien: Randomisiert kontrollierte, prospektive Studien. Studienteilnehmer und Follow-up: 8 randomisiert kontrollierte Studien schlossen 416 Individuen ein. Die mediane Anzahl Probanden pro Studie belief sich auf 42 mit einer Spannweite von 17 – 116 Probanden. Der mediane Follow-up-Zeitraum belief sich auf 12 Wochen mit einer Spannweite von 12 bis 54 Wochen. Resultate: 124 Paper entsprachen den initialen Suchkriterien in der NLM. Nach Durchsicht von Titel, Abstracta sowie der Volltexte verblieben 8 randomisiert-kontrollierte Studien. Alle 8 eingeschlossenen Studien der Jahre 1992 – 2008 zeigten einen positiven Effekt auf chronische Achillestendinopathien bei ähnlichen Trainingsprotokollen des exzentrischen Kräftigungstrainings. Limitationen: Eine gepoolte statistische Auswertung der eingeschlossenen Studien war bei unterschiedlichem Studiendesign sowie bei mangelhaft dokumentierter Compliance nicht möglich. Schlussfolgerung: Trotz unterschiedlicher Trainingscompliance scheinen offensichtlich durch exzentrisches Kräftigungstraining ähnlich positive Ergebnisse in der konservativen Therapie der chronischen Mid-portion-Achillestendinopathie erreicht zu werden. Eine klare Empfehlung hinsichtlich Dosis und Trainingsdauer kann aufgrund der heterogenen Studienlage sowie Outcome-Parameter (Ordinalskala, VAS, FAOS, AOFAS, VISA-A) noch immer nicht abgegeben werden.

Abstract

Background: Throughout the recent decade, eccentric training has become a widely accepted therapy option in the conservative treatment of chronic Achilles tendinopathy. Nevertheless, current recommendations are missing regarding dosage and duration of eccentric training as well as standardized training protocols. Objectives: Is eccentric training as a conservative treatment in chronic Achilles tendinopathy of beneficial effect versus other conservative treatments? According to the current scientific data, is it possible to recommend dosages and duration of training time of eccentric training? Study design: Systematic review of the current scientific literature on eccentric training as a conservative treatment in chronic Achilles tendinopathy according to the PRISMA-guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Data source: National library of Medicine (NLM) between the years 1950 and 2010. Study eligibility criteria: Prospective randomised controlled trials (RCT). Participants: 8 RCTs included 416 subjects with a median number of 42 subjects and a range of 17 to 116 subjects per trial. Median follow-up duration was 12 weeks with a range from 12 to 54 weeks. Results: 124 papers met the eligibility criteria in the NLM, whereas only eight randomised controlled trials were included in this review after screening titles, abstracts and full texts. All included trials demonstrated an improvement in pain after performing equivalent training protocols of eccentric training in chronic Achilles tendinopathy. Limitations: A pooled statistical evaluation of the included trials could not be performed due to different study designs as well as limited documentation of subjects’ compliance. Conclusion: In spite of different compliance, effects of eccentric training in conservative treatment of chronic mid-portion-Achilles tendinopathy are promising. Because of the heterogeneous outcome variables (ordinal scale, VAS, FAOS, AOFAS, VISA-A) and the methodological limitations of the trials, no definite recommendation can be published concerning dosage and duration of eccentric training in chronic Achilles tendinopathy.

Literatur

• 1 Sayana M K, Maffulli N. Eccentric calf muscle training in non-athletic patients with Achilles tendinopathy.  J Sci Med Sport. 2007;  10 (1) 52-58 Epub 2006 Jul 7. PMID: 16 828 343
  Google Scholar
• 2 Alfredson H. Chronic midportion Achilles tendinopathy: an update on research and treatment.  Clin Sports Med. 2003;  22 (4) 727-741 Review. PMID: 14 560 544
  Google Scholar
• 3 McLauchlan G J, Handoll H H. Interventions for treating acute and chronic Achilles tendinitis.  Cochrane Database Syst Rev. 2001;  2 CD000232 Review. PMID: 11 405 956
  Google Scholar
• 4 Alfredson H, Lorentzon R. Chronic Achilles tendinosis: recommendations for treatment and prevention.  Sports Med. 2000;  29 (2) 135-146 PMID: 10 701 715
  Google Scholar
• 5 Alfredson H, Lorentzon R. Intratendinous glutamate levels and eccentric training in chronic Achilles tendinosis: a prospective study using microdialysis technique.  Knee Surg Sports Traumatol Arthrosc. 2003;  11 (3) 196-199 Epub 2003 Apr 24. PMID: 12 712 235
  Google Scholar
• 6 Almekinders L C, Temple J D. Etiology, diagnosis, and treatment of tendonitis: an analysis of the literature.  Med Sci Sports Exerc. 1998;  30 (8) 1183-1190 . Review. PMID: 9 710 855
  Google Scholar
• 7 Alfredson H, Cook J. A treatment algorithm for managing Achilles tendinopathy: new treatment options.  Br J Sports Med. 2007;  41 (4) 211-216 Epub 2007 Feb 20. Review. PMID: 17 311 806
  Google Scholar
• 8 Rees J D, Wilson A M, Wolman R L. Current concepts in the management of tendon disorders.  Rheumatology. 2006;  45 (5) 508-521 Epub 2006 Feb 20. PMID: 16 490 749
  Google Scholar
• 9 Shalabi A, Kristoffersen-Wiberg M, Aspelin P et al. Immediate Achilles tendon response after strength training evaluated by MRI.  Med Sci Sports Exerc. 2004;  36 (11) 1841-1846 PMID: 15 514 495
  Google Scholar
• 10 Mafi N, Lorentzon R, Alfredson H. Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis.  Knee Surg Sports Traumatol Arthrosc. 2001;  9 (1) 42-47 PMID: 11 269 583
  Google Scholar
• 11 Fahlström M, Jonsson P, Lorentzon R et al. Chronic Achilles tendon pain treated with eccentric calf-muscle training.  Knee Surg Sports Traumatol Arthrosc. 2003;  11 (5) 327-333 . Epub 2003 Aug 26. PMID: 12 942 235
  Google Scholar
• 12 Roos E M, Engström M, Lagerquist A et al. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy – a randomized trial with 1-year follow-up.  cand J Med Sci Sports. 2004;  14 (5) 286-295 . PMID: 15 387 802
  Google Scholar
• 13 Brown R, Orchard J, Kinchington M et al. Aprotinin in the management of Achilles tendinopathy: a randomised controlled trial.  Br J Sports Med. 2006;  40 (3) 275-279 . PMID: 16 505 089
  Google Scholar
• 14 Vos R J, Weir de A, Visser R J et al. The additional value of a night splint to eccentric exercises in chronic midportion Achilles tendinopathy: a randomised controlled trial.  Br J Sports Med. 2007;  41 (7) e5 Epub 2006 Dec 18. PMID: 17 178 774
  Google Scholar
• 15 Nørregaard J, Larsen C C, Bieler T et al. Eccentric exercise in treatment of Achilles tendinopathy.  Scand J Med Sci Sports. 2007;  17 (2) 133-138 PMID: 17 394 474
  Google Scholar
• 16 Petersen W, Welp R, Rosenbaum D. Chronic Achilles tendinopathy: a prospective randomized study comparing the therapeutic effect of eccentric training, the AirHeel brace, and a combination of both.  Am J Sports Med. 2007;  35 (10) 1659-1667 . Epub 2007 Jun 14. PMID: 17 569 792
  Google Scholar
• 17 Rompe J D, Nafe B, Furia J P et al. Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial.  Am J Sports Med. 2007;  35 (3) 374-383 Epub 2007 Jan 23. Erratum in: Am J Sports Med 2007; 35 (7): 1216. PMID: 17 244 902
  Google Scholar
• 18 Knobloch K, Kraemer R, Jagodzinski M et al. Eccentric training decreases paratendon capillary blood flow and preserves paratendon oxygen saturation in chronic achilles tendinopathy.  J Orthop Sports Phys Ther. 2007;  37 (5) 269-276 PMID: 17 549 956
  Google Scholar
• 19 Moher D, Cook D J, Eastwood S et al. Improving the quality of reporting of meta-analysis of randomized controlled trials: The QUOROM statement.  Lancet. 1999;  354 1896-1900 PMID: 10 584 742
  Google Scholar
• 20 Moher D, Liberati A, Tetzlaff J et al. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement.  Int J Surg. 2010;  8(5) 336-341. Epub 2010 Feb 18. PMID: 20 171 303
  Google Scholar
• 21 Woodley B L, Newsham-West R J, Baxter G D. Chronic tendinopathy: effectiveness of eccentric exercise.  Br J Sports Med. 2007;  41 (4) 188-198 discussion 199. Epub 2006 Oct 24. Review. PMID: 17 062 655
  Google Scholar
• 22 Meyer A, Tumilty S, Baxter G D. Eccentric exercise protocols for chronic non-insertional Achilles tendinopathy: how much is enough?.  Scand J Med Sci Sports. 2009;  19 (5) 609-615 Epub 2009 Jul 6. Review. PMID: 19 602 185
  Google Scholar
• 23 Robinson J M, Cook J L, 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;  35 335-341 PMID: 11 579 069
  Google Scholar
• 24 Niesen-Vertommen S L, Taunto J E, Clement D B et al. The effect of eccentric versus concentric exercise in the management of Achilles tendonitis.  Clin J Sport Med. 1992;  2(2) 109-113
  Google Scholar
• 25 Silbernagel K G, Thomeé R, Thomeé P et al. Eccentric overload training for patients with chronic Achilles tendon pain – a randomised controlled study with reliability testing of the evaluation methods.  Scand J Med Sci Sports. 2001;  11 (4) 197-206 PMID: 11 476 424
  Google Scholar
• 26 Knobloch K, Schreibmueller L, Longo U G et al. Eccentric exercises for the management of tendinopathy of the main body of the Achilles tendon with or without the AirHeel Brace. A randomized controlled trial. A: effects on pain and microcirculation.  Disabil Rehabil. 2008;  30 (20 – 22) 1685-1691 PMID: 18 720 121
  Google Scholar
• 27 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 (3) 360-366 PMID: 9 617 396
  Google Scholar
• 28 Jonsson P, Alfredson H, Sunding K et al. New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: results of a pilot study.  Br J Sports Med. 2008;  42 (9) 746-749 Epub 2008 Jan 9. PMID: 18 184 750
  Google Scholar
• 29 Stanish W D, Rubinovich R M et al. Eccentric exercise in chronic tendinitis.  lin Orthop Relat Res. 1986;  208 65-68 PMID: 3 720 143
  Google Scholar
• 30 Jüni P, Holenstein F, Sterne J et al. Direction and impact of language bias in meta-analyses of controlled trials: empirical study.  Int J Epidemiol. 2002;  31 (1) 115-123 PMID: 11 914 306
  Google Scholar
• 31 Dickersin K. The existence of publication bias and risk factors for its occurrence.  JAMA. 1990;  263 (10) 1385-1389 PMID: 2 406 472
  Google Scholar

1 Robert Krämer und Johan Lorenzen sind gleichberechtigte Erstautoren.

Dr. Robert Krämer

Plastische, Hand- und Wiederherstellungschirurgie, Medizinische Hochschule Hannover

Carl-Neuberg-Straße 1

30625 Hannover

Email: kraemer.robert@mh-hannover.de