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Trial registered on ANZCTR


Registration number
ACTRN12617000675325
Ethics application status
Approved
Date submitted
8/05/2017
Date registered
10/05/2017
Date last updated
26/07/2018
Type of registration
Prospectively registered

Titles & IDs
Public title
The relationship between changes in the neural mechanisms associated with pain and the improvement in clinical symptoms of Achilles tendon pain.
Scientific title
The correlation of changes in the neural mechanisms associated with pain and patient reported improvement in pain and function in mid-portion Achilles tendinopathy: A mechanistic cohort study
Secondary ID [1] 291878 0
None
Universal Trial Number (UTN)
U1111-1196-3375
Trial acronym
None
Linked study record
None

Health condition
Health condition(s) or problem(s) studied:
Mid-Portion Achilles Tendinopathy 303172 0
Condition category
Condition code
Musculoskeletal 302611 302611 0 0
Other muscular and skeletal disorders
Physical Medicine / Rehabilitation 302612 302612 0 0
Physiotherapy

Intervention/exposure
Study type
Interventional
Description of intervention(s) / exposure
Participants will now have the option to receive an exercise based intervention as opposed to it being a mandatory component of the trial. If the participant elects to complete exercise rehabilitation they will be provided either the following Isometric OR Eccentric exercise protocols to complete. They will also be free so receive other interventions, excluding surgical or injection modalities, such as massage and electrotherapy.

Isometric exercise
Isometric exercise will be prescribed as studies have shown positive effects on pain and function from this form of exercise in tendinopathy. Participants will be required to have a backpack with which weight could be added in order to progress the difficulty of the exercise. Participants will be required to download a free metronome application onto their smartphones. Participants will be given a template for recording their exercises and daily pain scores in order to monitor adherence and adverse effects. Participants were given a template for recording intervention rating of perceived exertion for each session. One exercise will be completed: Single leg straight knee heel raise off the floor. The exercise will only be completed on the affected leg. The intervention will be taught to participants by one of two post-graduate, masters qualified physiotherapists who have both completed doctoral research in the field of Achilles tendinopathy. The intervention is simple and has a short learning curve, with both physiotherapists providing the exercises after one session ensuring they are teaching an identical protocol. Participants will have two individually supervised sessions (1 x 30 minute session on day one and 1 x 30 minute session on day two) prior to being declared independent and able to continue the protocol without supervision. We will follow up the participants via email once every three weeks to ensure that they are completing the exercise regime and to identify if they are having any problems in completing the program monitor rating of perceived exertion scores. The participants exercises will then be offered optional supervised follow up sessions (1 x 30 minute session) at week 3 and 6 following inception of the protocol. Supervised sessions will occur inside a sports science laboratory on a university campus but all independent sessions can be completed at any location. The participants will complete a 12 week isometric exercise regime twice daily, 7 days a week. Six sets will be performed of each exercise and each set will contain 1 repetitions. The isometric phase of the exercise is to take 45 seconds per repetition. Participants will have a 60 second rest between sets. The contractions will be performed to a metronome, set at 60 beats per minute, to ensure participants are getting the correct time per contraction. Therefore each set will have 45 seconds of total time under tension. Participants will start with body weight only before progressing to a backpack. If the participant cannot perform the desired hold duration for each set they will be asked to hold as long as possible. Participants will complete a session rating of perceived exertion after every session of resistance training. When a participant’s rating of perceived exertion indicate the exercise session is less than a four on the 10 point scale they are then to progress the weight by adding 5kg increments into a backpack. An intervention diary is to be completed by participants to assess the adherence to the exercise program. This diary will be assessed once every three weeks by one of the instructing physiotherapists to ensure the patient is remaining adherent.

Eccentric Exercise
Eccentric exercise will be prescribed as studies have shown positive effects on pain and function from this form of exercise in tendinopathy. Participants will be required to have a backpack with which weight could be added in order to progress the difficulty of the exercise. Participants will be required to download a free metronome application onto their smartphones. Participants will be given a template for recording their exercises and daily pain scores in order to monitor adherence and adverse effects. Participants will be given a template for recording intervention rating of perceived exertion for each session. Two exercises will be completed: Single leg straight knee eccentric heel drop off a step and Single leg bent knee eccentric heel drop off a step. The exercises will only be completed on the affected leg. The intervention will be taught to participants by one of two post-graduate, masters qualified physiotherapists who have both completed doctoral research in the field of Achilles tendinopathy. The intervention is simple and has a short learning curve, with both physiotherapists providing the exercises after one session ensuring they are teaching an identical protocol. Participants will have two individually supervised sessions (1 x 30 minute session on day one and 1 x 30 minute session on day two) prior to being declared independent and able to continue the protocol without supervision. We will follow up the participants via email once every three weeks to ensure that they are completing the exercise regime and to identify if they are having any problems in completing the program monitor rating of perceived exertion scores. The participants exercises will then also be offered optional supervised follow up sessions (1 x 30 minute session) at week 3 and 6 following inception of the protocol. Supervised sessions will occur inside a sports science laboratory on a university campus but all independent sessions can be completed at any location. The participants will complete a 12 week eccentric exercise regime twice daily, 7 days a week. Three sets will be performed of each exercise and each set will contain 15 repetitions. The eccentric phase of the exercise is to take three seconds per repetition. Participants will have a 60 second rest between sets. The contractions will be performed to a metronome, set at 60 beats per minute, to ensure participants are getting the correct time per contraction. Therefore each set will have 45 seconds of total time under tension. Participants will start with body weight only before progressing to a backpack. If the participant cannot perform the desired amount of repetitions they will be asked to complete as many as possible. Participants will complete a session rating of perceived exertion after every session of resistance training. When a participant’s rating of perceived exertion indicate the exercise session is less than a four on the 10 point scale they are then to progress the weight by adding 5kg increments into a backpack. The weight added to the backpack will be monitored to ensure safety but no set maximum weight exists. An intervention diary is to be completed by participants to assess the adherence to the exercise program. This diary will be assessed once every three weeks by one of the instructing physiotherapists to ensure the patient is remaining adherent.
Intervention code [1] 297996 0
Rehabilitation
Comparator / control treatment
No comparator.
Control group
Uncontrolled

Outcomes
Primary outcome [1] 302028 0
Change in chronic Mid-Portion Achilles tendon pain and function using the VISA-A Scale
Timepoint [1] 302028 0
Weeks: 0, 3, 6, 9, 12
Secondary outcome [1] 334528 0
Change in chronic Mid-Portion Achilles tendon pain and function using the Patient Global Impression of Change
Timepoint [1] 334528 0
Weeks: 3, 6, 9, 12
Secondary outcome [2] 334529 0
Weight bearing ankle dorsiflexion range of motion using the knee to wall test (cm).
Timepoint [2] 334529 0
Weeks; 0, 12
Secondary outcome [3] 334531 0
Achilles tendon stiffness during single leg hopping using a force plate
Timepoint [3] 334531 0
Weeks: 0, 12
Secondary outcome [4] 334533 0
Achilles tendon structure using Ultrasound Tissue Characterization to classify tendon content into Echotypes 1, 2, 3 or 4.
Timepoint [4] 334533 0
Weeks: 0, 6 and 12
Secondary outcome [5] 334534 0
The type of exercise sessions (e.g. eccentric plantar flexion, soccer, Australian football, tennis) completed will be recorded using a physical activity diary.
Timepoint [5] 334534 0
This outcome measure will now be assessed in a training diary for the previous week.
Weeks: 0, 3, 6, 9, 12
Secondary outcome [6] 334535 0
Fear of movement will be assessed using the Tampa Scale of Kinesiophobia.
Timepoint [6] 334535 0
Weeks: 0, 3, 6, 12
Secondary outcome [7] 334537 0
Conditioned Pain Modulation Effect will be assessed as a proxy for endogenous analgesia with affected Achilles tendon and ipsilateral triceps surae musculotendinous junction pressure pain thresholds being taken before, one minute and 3 minutes after immersion of the participants hand (the hand on the unaffected side of the body) in ice water for two minutes.
Timepoint [7] 334537 0
Weeks: 0, 12
Secondary outcome [8] 334611 0
Achilles tendon pain during single leg hopping using an 11-point numerical rating scale.
Timepoint [8] 334611 0
Weeks; 0 and 12. The numerical rating scale of pain during single leg hopping will take place twice at each time point. Once before and once after ice water immersion for conditioned pain modulation.
Secondary outcome [9] 334612 0
Duration of exercise sessions will be recorded in minutes using a physical activity diary.
Timepoint [9] 334612 0
This outcome measure will now be assessed in a training diary for the previous week.
Weeks: 0, 3, 6, 9, 12
Secondary outcome [10] 334613 0
Intensity of exercise sessions, assessed using an 11-point Borg Rating of Perceived Exertion Scale, will be recorded using a physical activity diary.
Timepoint [10] 334613 0
This outcome measure will now be assessed in a training diary for the previous week.
Weeks: 0, 3, 6, 9, 12
Secondary outcome [11] 334664 0
Achilles tendon pain during exercise sessions, assessed using an 11-point Numerical Rating Scale, will be recorded using a physical activity diary.
Timepoint [11] 334664 0
This outcome measure will now be assessed in a training diary for the previous week.
Weeks: 0, 3, 6, 9, 12

Eligibility
Key inclusion criteria
Recreational or competitive runner
*Can have ceased running due to AT
*No limit on distance or running duration per week
Reported pain for greater than 3 months
Reported local Achilles Pain (<2 fingers width)
Reported local Achilles Stiffness
Reported impairment of functional activity
Ultrasound
*Local A-P Thickening of the mid-portion AT
*Hyperechoic area of the mid-tendon with colour Doppler signal within the area
Ability to given informed consent
Able to complete questionnaires
Able to begin Baseline Testing and Intervention within 2 weeks of recruitment
Minimum age
18 Years
Maximum age
60 Years
Gender
Both males and females
Can healthy volunteers participate?
No
Key exclusion criteria
VISA-A score of greater than 80/100
12 week wash out from other treatments
Corticosteroid injection within the past 12 months
Bilateral Achilles Tendinopathy
Insertional Achilles Tendinopathy
Previous Fracture lower limb within 12 months
Systemic Disease
*Diabetes
*Rheumatic Conditions
*Circulatory Disorders
*Neurological Disorders
Foot or Ankle Surgery in the previous 6 months
Regular intake of medication which may have an influence on outcome
*Statins
*Fluoroquinolones
Current of History of confounding lower limb or ankle injury
Current Radiculopathy
Contra-indications to Cold application
*Cold Uticaria
*Raynaud’s Phenomenon
*Skin Conditions

Study design
Purpose of the study
Treatment
Allocation to intervention
Non-randomised trial
Procedure for enrolling a subject and allocating the treatment (allocation concealment procedures)
Non-randomized.
Methods used to generate the sequence in which subjects will be randomised (sequence generation)
Non-randomized.
Masking / blinding
Blinded (masking used)
Who is / are masked / blinded?


The people assessing the outcomes
The people analysing the results/data
Intervention assignment
Single group
Other design features
Phase
Not Applicable
Type of endpoint(s)
Safety/efficacy
Statistical methods / analysis
10 points of improvement on the VISA-A from baseline will be considered as meeting the MCID. Setting alpha as 0.05 and beta as 0.8 it was calculated that a total of 25 patients will enter these within group cohort studies when accounting for a 30% drop out rate.

The data will be described using count, frequency, means and SDs. Correlations between the change in the CPM, Tampa and Hop stiffness from baseline to the 12 week follow-up will be correlated to the changes of the VISA-A and PGIC from baseline to the 12 week follow-up. Pearson's correlation co-efficient will be determined for parametric data and the spearmans rank-order correlation will be determined for non-parametric data. P-values will be reported to four decimal places with p-values less than 0.001 reported as p < 0.001. Up-to-date versions of SPSS (Chicago, IL) will be used to conduct analyses. For all tests, we will use 2-sided p-values with alpha = < 0.05 level of significance.

Recruitment
Recruitment status
Recruiting
Date of first participant enrolment
Anticipated
Actual
Date of last participant enrolment
Anticipated
Actual
Date of last data collection
Anticipated
Actual
Sample size
Target
Accrual to date
Final
Recruitment in Australia
Recruitment state(s)
WA
Recruitment postcode(s) [1] 15922 0
6008 - Subiaco
Recruitment postcode(s) [2] 15923 0
6959 - Fremantle

Funding & Sponsors
Funding source category [1] 296379 0
University
Name [1] 296379 0
The University of Notre Dame Australia
Address [1] 296379 0
School of Physiotherapy
The University of Notre Dame Australia
19 Mouat Street
Fremantle
WA 6959
Country [1] 296379 0
Australia
Primary sponsor type
University
Name
The University of Notre Dame Australia
Address
School of Physiotherapy
The University of Notre Dame Australia
19 Mouat Street
Fremantle
WA 6959
Country
Australia
Secondary sponsor category [1] 295325 0
University
Name [1] 295325 0
La Trobe University
Address [1] 295325 0
Sports and Exercise Medicine Research Centre
La Trobe University
Bundoora
VIC 3086
Country [1] 295325 0
Australia

Ethics approval
Ethics application status
Approved
Ethics committee name [1] 297617 0
Univerisity of Notre Dame Human Research Ethics Committee
Ethics committee address [1] 297617 0
Human Research Ethics Committee
University of Notre Dame Australia
Fremantle
WA 6959
Ethics committee country [1] 297617 0
Australia
Date submitted for ethics approval [1] 297617 0
07/05/2017
Approval date [1] 297617 0
01/06/2017
Ethics approval number [1] 297617 0
017067F

Summary
Brief summary
The proposed research aims to provide insight into the mechanism(s) behind the improvement patients with Achilles tendon pain experience from rehabilitation. Specifically is there an association between the neural mechanisms associated with pain. Therefore this body of work may enable clinicians to more effectively understand the mechanisms which drive improvement in pain and function in people with Achilles tendon pain. Investigating these mechanisms of action may serve to refine and optimise rehabilitation strategies to improve outcomes.
Trial website
Trial related presentations / publications
Public notes

Contacts
Principal investigator
Name 74602 0
Mr Myles Murphy
Address 74602 0
School of Physiotherapy
University of Notre Dame Australia
19 Mouat Street
Fremantle
WA 6959
Country 74602 0
Australia
Phone 74602 0
+61 414015434
Fax 74602 0
Email 74602 0
myles.murphy1@my.nd.edu.au
Contact person for public queries
Name 74603 0
Mr Myles Murphy
Address 74603 0
School of Physiotherapy
University of Notre Dame Australia
19 Mouat Street
Fremantle
WA 6959
Country 74603 0
Australia
Phone 74603 0
+61 414015434
Fax 74603 0
Email 74603 0
myles.murphy1@my.nd.edu.au
Contact person for scientific queries
Name 74604 0
Mr Myles Murphy
Address 74604 0
School of Physiotherapy
University of Notre Dame Australia
19 Mouat Street
Fremantle
WA 6959
Country 74604 0
Australia
Phone 74604 0
+61 414015434
Fax 74604 0
Email 74604 0
myles.murphy1@my.nd.edu.au

No data has been provided for results reporting
Summary results
Not applicable