26/09/16. Tendon hierarchy. Eccentric exercise for tendon rehabilita2on (?) Collagen synthesis and tendon metabolism in vivo

Transcription

1 Eccentric exercise for tendon rehabilita2on (?) Tendon hierarchy S. Peter Magnusson ECM PG & GAG Ins+tute of Sports Medicine Copenhagen & Musculoskeletal Rehabilita+on Research Unit Bispebjerg Hospital, Copenhagen, Denmark Faculty of Health & Medical Science, University of Copenhagen, Denmark Magnusson et al, Nature Reviews Rheum 2010 Collagen synthesis and tendon metabolism in vivo 13% MVC Lack of 2ssue renewal in human adult Achilles tendon PICP (ug/l) Langberg et al, 1999, 2001 Core Achilles tendon +ssue, n= 28 (+ 4 muscle samples) Birth year range: Time of death: year C level measured with accelerator mass spectrometry (AMS) Bojsen-Moller et al, J Appl Physiol 2006 Kadler. Biochem J 1996 Heinemeier et al. FASEB J,

2 Do tendons adapt/grow in response to loading? Region specific adapta2on to months and years of high load on patellar tendon 4-6% Stress (N/m 2, MPa) CSA (mm 2 ) 20-28% Strain (%) Kongsgaard et al, ACTA Physiol 2007 Couppé et al, JAP 2008 Tendon hypertrophy/adapta2ons in response to loading? Achilles & patellar tendon load Patella Achilles Heinemeier et al, FASEB 2013 Finni et al 2000 Komi

3 Intratendinuous force transmission: Is there a weak link? What is an overuse injury? Tendinopathy Region specific? Microtear? Lian et al, AJSM 2005 Management of tendinopathy? Effect of NSAID on Achilles tendinopathy region in response to acute exercise Corticosteroid injections Eccentric training Sclerosing therapy PRP NSAID Surgery Ultrasound therapy Shockwave therapy Oxygen therapy Stretching Cryotherapy.... Gold standard? NSAID (600 mg x 3/day/1 week) Treadmill running x 1h Biopsy 2h aeer Pingel et al, EJAP

4 Effect of corticosteroids? Surgery as a Treatment for Patellar Tendinopathy Eccentric exercises +/- surgery Surgery: open tenotomy (+ exercise, incl ecc) (Kongsgaard et al, SJMSS 2009) (Smidt et al, Lancet 2002) Ecc, 12 weeks, twice daily, 3 x 15 reps Bahr et al. JBJS 2006 How to treat tendinopathy? NSAID Cor+costeroid injec+ons Sclerosing therapy PRP NSAID Surgery Loading based rehab Eccentrics Ultrasound therapy Shockwave therapy Oxygen therapy Stretching Cryotherapy.... Eccentric Exercise in Chronic Tendini2s Stretch-shortening Eccentric-concentric The pa+ent, from a standing posi+on, flexes the knees and drops to a squawng posi2on abruptly, then recoils to the standing posi2on The progression of the exercise protocol with aba+ng symptoms is then to increase the speed of the movement, and thereaeer an external load is added for addi+onal progression Stanish et al, Clin Orthop,

5 Heavy-Load Eccentric Calf Muscle Training For the Treatment of Chronic Achilles Tendinosis Superior short-term results with eccentric calf muscle training compared to concentric training in pa2ents with chronic Achilles tendinosis Eccentric training 1.0 BW Contrac2on mode or load magnitude? Concentric training Isolated eccentric Gold Standard Our treatment model with heavy-load eccentric calf muscle training has a very good short-term effect on athletes in their early for+es 1+ BW 1+ BW Controls; the pa+ents in this group were res+ng and were not on any training regimen. Alfredson et al, AJSM, BW Mafi et al, Knee Surg, 2001 Corticosteroid injections, eccentric decline squats and heavy slow resistance training in patellar tendinopathy Corticosteroid injections, eccentric decline squats and heavy slow resistance training in patellar tendinopathy Thursday Morning RCT 12 weeks Mee2ng of: 8/11-07 CORT 2 peritendinous cor+costeroid injec+ons 4 wks between each injec+on ECC Twice per day. 3 x 15 unilat eccentric squats on decline board. Load progressively increased HSR 3 +mes per week Leg-press, squat, hack-squat 3 x 6-15 RM SLOW movements (6 sec) Kongsgaard et al, SJMSS 2009 Kongsgaard et al, SJMSS

6 Collagen content and cross-link density Corticosteroid injections, eccentric decline squats and heavy slow resistance training in patellar tendinopathy Treatment sa+sfac+on 6 month follow up Eyre et al 2008 Collagen (mg/mg) Pentosidine (nmol/coll) CORT group ECC group HSR group Δ (%) Δ (%) Δ (%) -16 ± 9-1 ± ± 27 $ +14 ± ± ± 13 $ HP/LP ratio -11 ± ± ± 13 $ Sa+sfied Not sa+sfied Kongsgaard et al, SJMSS 2009 Kongsgaard et al, SJMSS 2009 Heavy slow resistance versus eccentric training as treatment of Achilles tendinopathy. liale clinical or mechanis2c evidence for isola2ng the eccentric component,. Eccentric program 2x daily Heavy slow resistance 3 / wk whether eccentric exercise is more effec2ve than other forms of therapeu2c exercise.. remains ques2onable. Beyer et al, AJSM

7 Intramuscular collagen expression response to contrac2on to similar force level Tendon collagen expression response to contrac2on to dissimilar force level 4 sessions Garma et al, J Appl Physiol days of s+mula+on Heinemeier et al, J Physiol 2007 Tendon and muscle hypertrophy independent of resistance exercise contrac2on mode Open concentric Closed - eccentric Eccentric load 120% of concentric Farrup et al, SJMSS,

8 Tendon mechanical proper2es Couppe et al, JOSPT 2015 Plas2city of human Achilles tendon mechanical and morphological proper2es in response to cyclic strain 90 % MVC 55 % MVC Force (N) 1 s loading, 1 s unloading Deforma+on (m) Ut tensio sic vis, As the extension so the force Robert Hooke, De potenna resntuva, 1679 Arampatzis et al, J Biomech, 2010 Plas2city of human Achilles tendon mechanical and morphological proper2es in response to cyclic strain 90 % MVC 55 % MVC Adapta2onal responses of the human Achilles tendon by modula2on of the applied cyclic strain magnitude 90 % MVC 55 % MVC 1 s loading, 1 s unloading 3 s loading, 3 s unloading Fewer reps, same volume as 1s Arampatzis et al, J Biomech, 2010 Arampatzis et al, J Exp Biol,

9 Adapta2onal responses of the human Achilles tendon by modula2on of the applied cyclic strain magnitude 90 % MVC 55 % MVC Eccentric or Concentric Exercises for the Treatment of Tendinopathies? Couppe et al, JOSPT s loading, 3 s unloading The focus on eccentric exercise has overshadowed other aspects of tendinopathy rehabilita+on, and acknowledgement of the limited evidence may prompt a broader approach, including the use of heavy load and low speed, which has some support from both basic science and clinical trials. Arampatzis et al,j Exp Biol, 2007 It is what we think we know that keeps us from learning Claude Bernard 9