This study examined whether a biopsychosocial education to explain Achilles Tendinopathy was superior to a biomedical education for pain and function
Both groups participated in the same exercise and home exercises
It appears that it does not matter which type of education you deliver to explain Achilles Tendinopathy
Achilles tendinopathy is a condition characterized by an extended period of symptoms that may affect a person’s quality of life and ability to participate in sports or physical activity. Despite exercise-based rehabilitation being the go-to option, many people continue to have symptoms when discontinuing their rehabilitation. In this light, it is often thought to deliver exercise therapy combined with pain education so the individual learns about the condition. The biopsychosocial model is widely incorporated into rehab and research but often gets blamed for forgetting the “bio” part. In this study, the authors tried to compare pain education delivered through a biopsychosocial explanation versus pathoanatomical education which was more biomedically oriented, on the outcomes of pain and function.
This study sought whether it matters how you explain Achilles tendinopathy to a patient. Therefore, they compared participants with chronic Achilles tendinopathy who participated in an exercise program and were randomly allocated to receive either a biopsychosocial or a biomedical pain explanation on top. The primary aim was to compare the difference in pain and functional outcomes at 8 weeks.
Both people with midportion and insertional Achilles tendinopathy could be included when the Achilles tendon was the primary pain location. Symptoms had to be provoked by weight-bearing activities and rise to at least 3/10 when walking, doing heel raises, or hopping.
The participants were enrolled in an exercise program for 7 weeks where they received 6 to 7 supervised sessions of 30 minutes. The first session had a duration of 45 minutes. Those with aggravated pain during ankle dorsiflexion were given additional heel raises. During the second period between 9 and 12 weeks, the participants were instructed to perform home exercises.
The only difference between the groups was the content of the education program. The biopsychosocial explanation was based on selected content but emphasized a biopsychosocial perspective on the neurophysiology of pain. Further, it touched on the impact of pain catastrophizing and kinesiophobia. It promotes physical activity to improve pain to create lasting effects. Participants receiving the biomedical explanation of Achilles tendinopathy learned about the pathophysiology of the condition and biomedical sources of pain. Further, they had to apply the knowledge during participation in the tendon loading program. Similar to the other group, the program promoted participation in exercise as a means of improving overall physical health.
What did the exercise program consist of? For both groups, the same program was held. In phase 1, the emphasis of the program was on isometric exercises. Phases 2 and 3 focussed on heel raises and the spring function of the Achilles tendon, respectively. Progressions were made based on time and predetermined criteria based on symptoms and ability to complete the exercises, as depicted hereunder.
As both participants with midportion and insertional Achilles tendinopathy were included in the RCT, the heel raises were standardized to be performed on level ground without a decline phase. Participants were encouraged to participate in recreational exercise and to gradually increase this with the weeks going by. To promote this, modifications were given to minimize aggravation of their pain during participation in recreational activities. Examples of modifications were heel lifts, shorter stride lengths, and altering the duration of the activity.
The outcome measures were obtained at baseline and the primary endpoint of 8 weeks. A follow-up was held at 12 weeks. A total of 5 domains were assessed:
Sixty-six participants with chronic Achilles tendinopathy were included in this RCT. They suffered from Achilles tendinopathy for on average 14 to 18 months in the biopsychosocial education and biomedical education groups, respectively. In both groups, slightly more people were affected by insertional Achilles tendinopathy. On average, they had sought care from 2 providers, most of whom were physiotherapists. They tried 5 treatments on average. More than 60% of them previously tried strengthening. It seems a pretty therapy-resistant population.
The groups were well balanced at baseline except for the heel raise work and hop height. Heel raise work was quantified as the sum of the change in ankle height times body weight for the maximum number of heel raises (n) that they were able to complete. In the group receiving biopsychosocial education, this was on average 619 Nm but in the group receiving the biomedically-oriented education, this equaled 834 Nm. Hop height at baseline was around 4 centimeters less in the group receiving biomedical education.
At eight weeks, biopsychosocial pain science education was not more effective than biomedical-oriented education. In both groups, similar improvements were seen in movement-evoked pain, without the superiority of one above another. On average, a 3-point reduction was observed from baseline to week 8.
Function, measured with the PROMIS Physical Function, did not increase over time.
Both groups managed to improve their maximal number of heel raises over time, again without one group being superior to the other.
The reported level of kinesiophobia decreased throughout the study in both groups and this improvement was maintained at 12 weeks. No improvements were seen in the conditioned pain modulation measured with the PPT.
This study investigated the effect of pain education delivered through a biopsychosocial explanation versus pathoanatomical education on the outcomes of pain and function. The pain education was integrated into an exercise program. From the outcomes, it appears that it does not matter how you explain Achilles Tendinopathy to your patient. At eight weeks, neither biomedical-focused education nor education in biopsychosocial pain science was more beneficial. Similar reductions in movement-evoked pain were observed in both groups, without any clear favoring of one group over the other. Between baseline and week 8, an average 3-point decline was seen.
Chimenti RL, Post AA, Rio EK, Moseley GL, Dao M, Mosby H, Hall M, de Cesar Netto C, Wilken JM, Danielson J, Bayman EO, Sluka KA. The effects of pain science education plus exercise on pain and function in chronic Achilles tendinopathy: a blinded, placebo-controlled, explanatory, randomized trial. Pain. 2023 Jan 1;164(1):e47-e65. doi: 10.1097/j.pain.0000000000002720. Epub 2022 Jun 17. PMID: 36095045; PMCID: PMC10016230.
Hancock MJ, Maher CG, Laslett M, Hay E, Koes B. Discussion paper: what happened to the ‘bio’ in the bio-psycho-social model of low back pain? Eur Spine J. 2011 Dec;20(12):2105-10. doi: 10.1007/s00586-011-1886-3. Epub 2011 Jun 25. PMID: 21706216; PMCID: PMC3229745.
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