Research Paper Effectiveness Of Eccentric Exercise And A .
Int. J. Med. Sci. 2018, Vol. 15IvyspringInternational Publisher1764International Journal of Medical Sciences2018; 15(14): 1764-1770. doi: 10.7150/ijms.28656Research PaperEffectiveness of Eccentric Exercise and a Vibration orCryotherapy Program in Enhancing Rectus AbdominisMuscle Thickness and Inter-Rectus Distance in Patientswith Chronic Mid-Portion Achilles Tendinopathy: ARandomized Clinical TrialCarlos Romero-Morales 1, Pedro Javier Martín-Llantino1, César Calvo-Lobo2 , Hector Beltran-Alacreu3,4,Daniel López-López5, Rubén Sánchez-Gómez1, David Rodríguez-Sanz11.2.3.4.5.Faculty of Sport, Universidad Europea, Villaviciosa de Odón, Madrid, Spain.Nursing and Physical Therapy Department, Faculty of Health Sciences, Institute of Biomedicine (IBIOMED), Universidad de León, Ponferrada, Spain.Departamento de Fisioterapia. Centro Superior de Estudios Universitarios La Salle. Universidad Autónoma de Madrid. Spain.Motion in Brains Research Group. Instituto de Neurociencias y Ciencias del Movimiento. Centro Superior de Estudios Universitarios La Salle. UniversidadAutónoma de Madrid.Department of Health Sciences; Research, Health and Podiatry Unit. Faculty of Nursing and Podiatry, Universidade da Coruña, Ferrol, Spain. Corresponding author: Cesar Calvo Lobo. PhD, MSc, PT. Nursing and Physical Therapy Department, Institute of Biomedicine (IBIOMED), Faculty of HealthSciences, University of León, Av. Astorga, s/n, 24401 Ponferrada, León, Spain. Email: cecalvo19@hotmail.com Ivyspring International Publisher. This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY-NC) /4.0/). See http://ivyspring.com/terms for full terms and conditions.Received: 2018.07.20; Accepted: 2018.10.18; Published: 2018.11.23AbstractPurpose: Abdominal muscles are key in maintaining body stability and balance and an improvement in thefunctioning of these muscles could influence the rehabilitation process in lower limb pathologies such asAchilles Tendinopathy (AT). The aim was to explore whether calf eccentric exercise (EE) with vibrationtraining was more effective at causing adaptation to the rectus anterior (RA) thickness and inter-rectusdistance (IRD) than calf EE with cryotherapy.Methods: The investigation was a single-blinded, randomized, controlled clinical trial (NCT03515148).Sixty-one individuals diagnosed with mid-portion AT were recruited and divided in two groups: group A(n 30) followed an EE with vibration program and group B (n 31) an EE program with cryotherapy, for12-weeks. RA muscle thickness and IRD were measured in maximal isometric contraction and at rest asan indication of superficial abdominal muscle activation.Results: IRD measures showed a significant (P 0.05) decrease at baseline, 4 and at 12-weeks in bothgroups, but no significant differences were observed between the intervention groups. RA thickness wassignificantly increased (P 0.05) in measures at baseline, 4 and 12-weeks showed a significant increase inmaximal isometric contraction and at rest in favor of the EE vibration program group.Conclusions: The present study showed a RA thickness increase in both groups in favor of the EE vibrationprogram with respect to cryotherapy added to EE in short and mid term in maximal isometriccontraction and at rest in subjects with chronic mid-portion AT. IRD was decreased in both groupswithout between-groups differences.Key words: eccentric exercise, rectus abdominis, tendinopathyIntroductionAchilles tendinopathy (AT) is a very commondisease in athletes as well as in the general population[1]. This condition is characterized by pain, thickeningand dysfunction of the Achilles tendon, which is oneof the largest and strongest tendons in the lower limband is highly susceptible to tendinopathy [2]. Thehttp://www.medsci.org
Int. J. Med. Sci. 2018, Vol. 15prevalence and incidence rates of AT were 2.35 and2.16 per 1000 person-years, respectively [3]. Thiscommon overuse injury is often difficult to treat,leading to a negative impact on sports participation aswell as overall health and quality of life, sports,quality of life and at work [4].Several studies have shown that AT leads to anincreased eversion range of motion (ROM) in the rearfoot, a shortened maximum lower leg abduction, adecreased ankle joint dorsiflexion velocity and adecreased knee flexion [5]. In addition, negativedifferences in ground reaction forces, dynamic plantarpressure and tibial external rotation have also beenreported in patients with AT [5]. Moreover, a highbody mass index (BMI) and disorders in blood flowand a sedentary lifestyle are also considered riskfactors [6]. The term “tendinopathy” has beenadopted following the latest advances in this areareplacing the term “tendinitis”, due to the absence ofprostaglandin-meditated inflammation [7,8]. Severalstudies suggest that oral non-steroidal antiinflammatory drugs (NSAIDs) could help reducingthe symptoms in individuals who suffer some type oftendinopathy [9]. However, intervention withNSAIDs may be related with gastrointestinal andcardio-vascular adverse effects [10]. Rather, loadinterventions, such as eccentric exercises (EE), areconsidered the first line treatment in AT rehabilitation[11]. EE have been shown to be effective in bothreducing pain and improving functionality in patientswith AT in several studies [12–14].Cryotherapy is presented as an alternativeintervention for patients with mid-portion AT andmay decrease pain and normalise the blood flow [15].Specifically, cryotherapy has demonstrated benefitsalone or when combined with other therapies, such ascompression in patients with AT [16].Several studies have shown the efficacy ofwhole-body vibration training (WBVT) in endurance,triceps surae muscle strength, lower limb muscleflexibility, motor control and decreasing pain insubjects with AT [17,18]. In addition, Horstman et al.[18] carried out a 12-weeks WBVT program in 58subjects with AT showing benefits in sonographicfeatures, such as tendon structure and path, and painintensity. Due to this, WBVT has been considered asan alternative intervention in AT patients.Despite that Achilles EE programs are orientedto work eccentrically the lower limb, abdominal wallmuscles are involved working in a coordinatedmanner for maintain the body stability and balance.Trunk muscles are partially comprised by transversusabdominis (TrA), external oblique (EO), internaloblique (IO) and rectus abdominis (RA), multifidus,pelvic floor muscles, erector spinae and quadratum1765lumborum, and they are morphologically different[19]. These muscles work synergistically transferringloads through the body, in both directions [20].Regarding the deep trunk muscles, the TrA,multifidus, IO and pelvic floor muscles may beconsidered as deep stabilizers which support spinestability [21] and whose automatic activation providesa belt-like tension to the trunk which may be definedas “Core” [22]. Moreover, Hodges and Richardson[23] reported that TrA and oblique muscles workwhenever there is a movement or an imbalance of thebody, regardless of the direction of these forces.Considering the superficial trunk muscles, the RA,erector spinae, EO and quadratus lumborum may beconsidered as “global stabilizers” which supportlarger trunk movements using a quick and powerfultorque [21]. Kim and Lee [24] reported that two lowerlimb muscle exercises, sit-up and leg raise showed anincrease of the activation of the abdominal wallmuscles, being the eccentric sit-up exercise the mostefficient. Despite the eccentric activations of the lowerlimb muscles have been widely reported in patientswith Achilles tendinopathy [11,25,26], as well as thelocal effects of cryotherapy [15,16] and vibration [18]on the Achilles tendon s symptoms and signs, there isa lack of knowledge regarding the global abdominalmuscles activation during EE in conjunction withcryotherapy or vibration in patients with AT. In theabdominal complex area, rehabilitative ultrasoundimaging (RUSI) has been widely used to evaluateabdominal wall muscles features, such as thickness,cross sectional area (CSA) and inter-rectus distance(IRD) [27–30]. Concretely, the RA thickness and IRDmay be considered as key RUSI measurements of theglobal stabilizers morphology [31] and may be relatedto alterations in the lower limb neuromuscular controlthat result in abdominal wall adaptations [32].The aim of the present study was to evaluate theRA muscle thickness and IRD in patients with chronicmid-portion AT who carried out an EE vibrationprogram compared to an EE program withcryotherapy. It was hypothesized that an interventionwith EE training in combination with vibration couldbe more beneficial for the abdominal muscleactivation with respect to its combination withcryotherapy in patients with chronic mid-portion AT.MethodsStudy DesignThe present study was a prospective,single-blinded, randomized, controlled clinical trial(registered at ClinicalTrials.gov as NCT03515148)evaluating individuals over a period of 12-weeksbetween January 2017 and January 2018, following thehttp://www.medsci.org
Int. J. Med. Sci. 2018, Vol. 15Consolidated Standards(CONSORT) guidelines.1766ofReportingTrialsParticipantsIn this study, 61 individuals diagnosed withmid-portion AT (age: 41.2 10 years) were recruitedand randomly divided in two groups (A and B):group A (n 30) received the EE program plusvibration and group B (n 31) the EE program pluscryotherapy (Figure 1). The enrollment of subjectswas performed by a specialized medical doctor withmore than 10 years of experience in sport medicine.The selection criteria defined eligible subjects as thosewho: were aged 18-65 years, had had symptoms in themid-portion of the Achilles tendon for at least 3months [33], had a visual analog scale (VAS) painscore of at least 3 out of 10 points, had not receivedany physical therapy. Exclusion criteria were asfollows: patients with any infection or systemicdisease [12], a lower limb injury within the last 12months, previous fracture [33] and negative experiences with one or more interventions in the past [34].Ethical statementThe study was authorized by the ethicscommittee of Hospital Universitario de la Princesa,Madrid, Spain (approval code: 2828A). The studyrespects the Declaration of Helsinki for humanexperimentation [35]. All the participants in the studysigned the informed consent form.Eccentric exercise intervention for bothgroupsBoth groups performed a 12-week EE programaccording to modified guidelines by Alfredson et al.[14]. The original protocol was composed of 90repetitions, twice a day and 7 days per week. In thepresent study, all participants performed 90 EErepetitions, by completing three sets of 15 repetitionsin two training situations (45 repetitions with the kneefully extended and 45 repetitions with the kneeslightly flexed). EE program was carried out in closedkinetic chain. The Template for InterventionDescription and Replication (TIDieR) checklist wascompleted to ensure both interventions werereproducible and listed as per our registered protocol[36]. In addition, a protocol deviation was carried outdue to week 4 follow-up was added even though notin the registered protocol. Participants compliance tothe protocol was self-reported in a written document.Eccentric exercise plus vibration program (A)Eccentric exercise plus vibration interventionwas developed on a Power Plate My3 (PerformanceHealth Systems, Northbrook, US) vibrationplatform following to the Alfredson et al. [14]EE protocol. The participants, who wereincluded in this group, performed the EEprogram and were simultaneously placed ina standing position on the Power Platesystem using a vibration frequency of 3 Hzand an amplitude of 4mm for approximately5 minutes (coinciding with the EEintervention duration) following the Hazellet al. [37] protocol.Eccentric exercise plus cryotherapyprogram (B)Before carrying out the EE program[14], the cryotherapy intervention wasperformed. Cryotherapy intervention wascarried out by seating the patients andimmersing their bare lower limb into a70-liter bucket containing 55cm-deep waterat 8 2 C for 17 minutes [38]. After theimmersion, the EE program was performedduring 5 minutes following the previousdescribed protocol [14].Outcome measuresFigure 1. CONSORT flow algorithm outlining the participant enrollment, allocation,follow-up, and attrition numbers for this study.The ultrasound imaging assessmentwas carried out using a LogiQ P7 ultrasoundsystem (GE Healthcare; UK) with a 4 to 13http://www.medsci.org
Int. J. Med. Sci. 2018, Vol. 15linear transducer (L6- 12- RS type; 38-mm footprint).Ultrasound assessments of the RA, ipsilateral to theAT, and IRD were carried out in the supine position,with the transducer aligned with the umbilicus for theRA examination (Figure 2A) and just under theumbilicus for the IRD measurement (Figure 2B) inaccordance with Whittaker et al. [27], who reportedexcellent interday and interexaminer reliability(intraclass correlation coefficients from 0.92 to 0.99)for these ultrasound measurements. Assessmentswere carried out prior to any intervention, and at 4and at 12 weeks post-intervention, both with calfmuscles at rest and in maximal isometric contraction.The mean of 3 repeated values was collected for eachmeasurement with the transducer at the same point atthe end of the expiration. Muscle thickness wasdescribed as the distance inside the caliper lines ofeach muscle (Figure 2A) and IRD was consider as thedistance between the RA muscles (Figure 2B) [27].ImageJ software (version 2.0) was used to analyze theimages offline.Statistical analysisStatistical package for social sciences, version23.0 software for Windows (IBM SPSS Statistics forWindows; NY: IBM Corp.) was employed for dataanalysis. An α error of 0.05 (95% confidence interval)and a desired power of 80% (β error of 0.2) were usedfor all the statistical tests. The Shapiro-Wilk test wasused for normality assumption. For the baselinecomparison, the Student t test was used, consideringthe homogeneity of variance following Levene s test.A two-way analysis of variance (ANOVA) forrepeated measures was employed to examine theintra-subject (pre and post) and inter-subject(treatment group) effects for the dependent variables.1767Post-hoc analyses were carried out by means ofBonferroni s correction. The level of significance wasset at P 0.05.ResultsSociodemographic data did not statisticallydiffer between the two groups (P 0.05) (Table 1) andall participants self-reported compliance to theprotocol across the 12 weeks follow-up. IRD measuresshowed a significant (P 0.05) decrease at 4 and at12-weeks in both groups (Table 2), but no significantdifferences (P 0.05) were observed between theintervention groups (Figure 3A). RA thickness wassignificantly increased (P 0.05) in measures at 4 and12-weeks showed a significant increase in maximalisometric contraction and at rest in favor of the EEvibration program group (Figure 3B).DiscussionTo our knowledge, this is the first study that hasevaluated RA thickness and IRD in patients withchronic mid-portion AT following an EE andvibration program compared to those following an EEprogram with cryotherapy.Inter-rectus distanceOur findings showed an IRD decrease in bothgroups at 4 and 12-weeks. A IRD narrowing has beenthe target of contemporary rehabilitation interventions [31]. In addition, Lee and Hodges [39] reportedthat these treatment approaches are “based on theassumption that restore RA alignment restore thefunction” and get a better appearance [40]. Likewise,IRD is the goal of many women after the pregnancy,assuming that the abdominal wall may be weak atpostpartum [41]. Several studies performed exercisesfocusing on the decrease of theIRD [31,42]. However, Lee andHodges [39] suggest that arehabilitation program should notbe focused only in IRD treatment.Moreover, a IRD reduction couldhave counterproductive consequences for esthetic, alignment andfunction [39].Based on our data, a lowerlimb EE program (with eithervibration or cryotherapy) aimed atAT patients may also potentiallybenefit individuals with disturbances in abdominal wall muscles(e.g. low back pain, postpartum)as an alternative to conventionalabdominal exercises, such abdomFigure 2. Ultrasound assessments. Abbreviations: IRD, inter-rectus distance; RA, rectus anterior.inal crunches or planks.http://www.medsci.org
Int. J. Med. Sci. 2018, Vol. 151768Rectus abdominis thicknessLower limb EE have previously been shown toincrease the activation of the abdominal wall musclesin healthy adults [24] and WBVT has also been shownto improve the motor units in muscles and extensionstrength of lower extremities [18], as well as muscleflexibility [43]. This is in agreement with our data,which show that RA thickness increases in bothgroups in favor of the EE vibration program. Anincrease in the thickness of the RA muscle, afundamental structure between pelvis and upperlimb, is beneficial in improving trunk stability,pressurizing the abdominal cavity and transferringloads from the lower limb to the upper limb.Current treatment of chronic mid-portionAchilles TendinopathyDespite NSAIDs may help marginally decreasing tendinopathy symptoms, these pharmacologicinterventions do not significant benefit patients withAT at long term [9], and may produce gastrointestinalor cardio-vascular adverse effects [10]. Exerciseinterventions have the advantage enhancing theAchilles tendon clinical symptoms [11,12]. Aprogressive muscle/tendon loading approach doesseem to be beneficial, although it is unclear whichprograms lead to better clinical outcomes [13], notablybecause factors such as age, pain and tendinopathysite all influence load management [44]. Cook et al.[45] reported that manual therapies, electrotherapyand taping techniques should not substitute exerciseprograms, but complement them.Table 1. Sociodemographic dataDataSexMen, (n, %)Women, (n, %)Age, yHeightWeightBMI, kg/m2Injury time, mean (SD)Cryotherapy5 16.1326 83.8742.1 9.21.72 0.073.63 9.3824.8 2.44.4 2.6EE Vibration Training P value0.6454 13.3326 86.6641.1 8.20.6451.75 0.00.69876.55 10.560.28525.2 2.50.4424.1 4.40.145Abbreviations: body mass index, BMITable 2. Inter-recti distance and rectus abdominis thicknessMeasure (mm) Cryotherapyn 31IRD RestBaseline18.41 6.74 weeks18.04 6.612weeks17.38 7.0IRD ContractionBaseline18.68 6.94 weeks17.79 6.812weeks17.32 7.5RA Thickness RestBaseline10.09 2.64 weeks10.61 2.212weeks10.85 2.1RA Thickness ContractionBaseline10.06 2.84 weeks10.58 2.412weeks10.91 2.1Eccentric ExerciseVibrationTraining n 30Intragroupp-valueintergroup p-value.001*.068.001*.38.001*.002*.001*.007*17.40 6.416.37 5.815.61 5.917.70 7.316.57 6.515.62 5.710.30 2.210.56 2.011.83 2.110.19 2.110.53 2.311.91 2.0Values are mean SD unless otherwise indicated. Abbreviations: inter-rectidistance, IRD; rectus anterior, RAFigure 3. Inter-recti distance and rectus abdominis thickness. Abbreviations: IRD, inter-rectus distance; RA, rectus anterior.http://www.medsci.org
Int. J. Med. Sci. 2018, Vol. 15Clinical considerationsWe indicate that a lower limb EE with WBVTprogram could be beneficial in patients withpathologies related to the abdominal wall muscles(e.g. low back pain, lumbopelvic pain and postpartumwomen), alongside more traditional approaches, suchas the TrA approach.17696.7.8.9.10.Limitations and futures studiesThe present study did not contain a suitablecontrol group and the main finding can only beextrapolated to individuals with chronic Achillesmid-portion tendinopathy. Despite the accuratedescription of the EE protocol, the time under tensionfor the exercise and each repetition was not recorded.Sonoelastography, electromyography and otherultrasound modalities were not used and could beuseful to provide more information about the musclean
increase of the activation of the abdominal wall muscles, being the eccentric sit-up exercise the most efficient. Despite the eccentric activations of the lower limb muscles have been widely reported in patients with Achilles tendinopa
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The U.S. Army Combined Arms Command is the proponent for this publication. Send comments or suggestions to the Deputy Commanding General for Training, Combined Arms Command, ATTN ATZL-CTT, Fort Leavenworth, KS 66027-7000. Unless this publication states otherwise, masculine nouns and pronouns refer to both men and women. 1 Chapter 1 The After-Action Review DEFINITION AND PURPOSE OF AFTER-ACTION .
