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Physical Therapy

Physical Therapy. Treating Tendinopathies. Renee McKenzie, DPT. Modalities and Treatments. Stretching Ultrasound Iontophoresis Phonophoresis Low-level Laser Eccentric exercise Instrument-Assisted Manuals ASTYM Graston. Ultrasound, Iontophoresis, Phonophoresis.

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Physical Therapy

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  1. Physical Therapy Treating Tendinopathies Renee McKenzie, DPT

  2. Modalities and Treatments • Stretching • Ultrasound • Iontophoresis • Phonophoresis • Low-level Laser • Eccentric exercise • Instrument-Assisted Manuals • ASTYM • Graston

  3. Ultrasound, Iontophoresis, Phonophoresis • Evidence supporting the use of ultrasound, iontophoresis or phonophoresis in combination with other treatments, or as the sole treatment, is lacking

  4. Low-Level Laser • 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

  5. Eccentric Strengthening • 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

  6. Eccentric Strengthening

  7. Eccentric Strengthening Studies that included Eccentric Training as an intervention for Lateral Elbow Tendinopathy Table 1

  8. Instrument-Assisted Manuals • ASTYM • Graston

  9. ASTYM • 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

  10. ASTYM Outcome Reports Table 2

  11. Graston Technique • 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

  12. Graston Technique Outcome Data Table 3

  13. Things To Consider • 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

  14. References 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. 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 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 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

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