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Comparison Of High And Low Volume Eccentric Resistance Training In Patients With Jumper´S Knee: 1631 Board #284 June 2, 8: 00 AM - 9: 30 AM

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  • Universität zu Lübeck and Sportclinic Zürich

Abstract and Figures

PURPOSE: Eccentric strength training has shown to reduce pain and improve functionality in patients with patellar tendinopathy (PT) known as “jumper’s knee. The purpose of this study was to compare the effects of a high and a low volume bodyweight strength training on a decline board on pain and functionality. METHODS: A total of thirteen physical active male patients with chronic PT (age 23,6 ± 3,80 years) participated in this study. Subjects were randomly assigned to two groups. Group 1 (low volume; n=7) trained three times per week for eight weeks on a decline board (25°) with one set of 15 repetition and at least 48 h rest between sessions. Group 2 (high volume, n=6) followed the same regime but with three sets of 15 repetitions. No other physical activities were allowed during the first 6 weeks. During the last two weeks of the study the participants returned to their individual sport in addition to the intervention. The Victorian Institute of Sportassessment questionnaire for functionality (VISA)and a numerical rating scale for pain (NRS) was observed at baseline, after week 4 and at the end of the intervention. RESULTS: Both groups showed similar improvements (time effect) during the 8 week intervention for the VISA and the NRS with no significant group effects. Visa: group one (low volume): 30.86 points and group two (high volume): 33 points. NRS: group one and group two: four points each. CONCLUSIONS: The results of this study showed that higher volume of eccentric training on a decline board had no significant advantage compared to lower volume in athletes with PT. However, more studies with a higher number of participants are needed to confirm our findings.
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Comparison of high And low volume Eccentric Resistance
Training in patients with Jumper Knee
Masterthesis (M.Sc. Sportphysiotherapie)
abridged version
Andreas Herbert Alt
Deutsche Sporthochschule Köln
Köln 2015
Supervisor: Prof. Dr. Stephan Geisler, Institut für Trainingsforschung und
Sportinformation
2
Table of content
1. Introduction ................................................................................................................. 6
1.1 Background ............................................................................................................... 6
1.2 Prevalence ................................................................................................................. 6
1. 3 Eccentric Training ............................................................................................... 7
1. 4 Diagnostic ............................................................................................................ 8
1. 5 Pathophysiology ................................................................................................... 8
1. 6 Treatment variations .......................................................................................... 10
2. Methods .................................................................................................................... 12
2.1 Patients .................................................................................................................... 12
2.2 Group explanation (Tab. 2 a / b) ............................................................................. 13
2.3 Therapy explanation ............................................................................................... 14
2.4. Measurements ........................................................................................................ 16
2.5 Inclusion and exclusion criteria .............................................................................. 16
2.6 Measurement systems ............................................................................................. 19
3. Statistics .................................................................................................................... 20
3.1 Utest between groups ............................................................................................ 21
3.2 Comparison VISA between den groups .................................................................. 21
3.3 Comparison NRS between groups .......................................................................... 22
3.4 Group comparison significance zero measurement VISA ...................................... 22
3.5 Group comparison significance zero measurement NRS ....................................... 22
4. Results ....................................................................................................................... 24
5.1 Reflexionen des wissenschaftlichen Standes .......................................................... 25
5.2 Critical comparison ................................................................................................. 25
5.3 Research Outlook .................................................................................................... 26
6. Literature ................................................................................................................... 27
3
List of tables
Tab. 1 Patients................................................................................................................... 12
Tab. 2 Group two .............................................................................................................. 13
Tab. 3 Group two .............................................................................................................. 13
Tab. 4 Inclusion and exclusion criteria ............................................................................. 16
Tab. 5 Utest between groups ........................................................................................... 21
Tab. 6 Comparison VISA between den groups ................................................................ 21
Tab. 7 Comparison NRS between groups ......................................................................... 22
Tab. 8 Group comparison significance zero measurement VISA ..................................... 22
Tab. 9 Group comparison significance zero measurement NRS ...................................... 22
List of figures
Fig. 1 Standard Goniometer .............................................................................................. 15
Fig. 2 Knee ankle .............................................................................................................. 15
Fig. 3 Start position ........................................................................................................... 15
Fig. 4 Methods .................................................................................................................. 17
Fig. 5 Drop outs ................................................................................................................ 18
Fig. 6 NRS course ............................................................................................................. 23
Fig. 7 VISA course ........................................................................................................... 23
4
Abstract
Comparison of high and low volume Eccentric Resistance Training in patients
with Jumper´s Knee
Purpose
The purpose of this study was to find a therapie concept wich save time and enable a more
efficent therapy. The economic factor out of this purpose is obvious through the time
reduction fact for this treatment. The these to find out the contents of a referring methode
produced the following consideration: Identify the effects of comparisson between a higher
volume eccentric training therapy, to a low volume eccentric therapy for reducing pain and
improve function in athletic, male patients with insertiotendinopathia patellae (ITP) or
jumper`s knee.
Background
The present study reported two clinical methodes in connection with the eccentric strength
training on a decline board to treat patients with IPT.
Methods
In this randomised controlled trial (mean age 24 years), 16 patients with jumper`s knee
were treated in two homogeneous groups. Every of both groups consists eight
participatients at the beginning. The allocation happened in a randomised way. The first
group (low volume) was treated with a one set eccentric force training with 15 repetitions,
three times a week. The second group (higher volume) passed a three set eccentric force
training with 15 repititions per set, also three times a week. Both groups used a 25° inclined
decline board. All patients reserved their sporting activities at the beginning of the
intervention for the following six weeks. After six weeks they get reintegrate in their
individual sport activities. The patients were functional assessed with the VISA (Victorian
Institute of Sport Assessment) score and for pain evaluation by the NRS (numeric rating
scale).
Results
The results of this study shows no significant measurement differences between the two
groups. Both groups improved their pain intensity (nrs) and their functional limitations
(visa scale) during the eight week treatment programm. Visa: group one low volume:
30. 86 points and group two higher volume: 33 points. NRS: group one and group two:
four points each.
5
Conclusion
The results of this randomized clinical trial advice, that there are no significant differences
between a higher volume or a low volume eccentric training, when patients with patella
insertiotendinopathia or jumper`s knee are treated over a period of eight weeks.
6
1. Introduction
1.1 Background
Insertiotendinopathia Patella (ITP) also Jumper`s Knee (JK) is associated with
patellofemoral pain syndrome (PFPS) and is a common soft tissue overuse syndrome in
athletes. It still counts as an incompletely studied pathology in the field of sports medicine.
The most common specific diagnosis to date is a pathology of the ligamentum (lig.) patellae
associated with a painful overload of the collagen fibrous tissue. It differs from the related
umbrella term "PFPS" in the following way: in contrast to the possible, but difficult to
prove exactly, specification of the physiological problem in ITP, PEPS corresponds to the
summary definition for diffuse pain in the anterior region of the knee joint. It is also
characterized by pain provocation by weight-bearing activities of the soft tissue structures
surrounding the knee joint, such as primarily the quadtriceps femoris muscle (Eapen et al.).
In particular, intense loading of the quadtriceps muscle is also listed below as a major cause
of ITP. The pathophysiology and symptoms of jumper`s knee were initially thought to be
caused by an inflammatory process, but this was not confirmed in subsequent studies.
However, this view has now been refuted with sufficient evidence (Alfredson et al.;
Backman and Danielson; Crossley et al.). Nevertheless, the pathophysiology of this
overload syndrome cannot be fully explained even today (Crossley et al.; Backman and
Danielson). Because of the associated pain in the proximal portion (origin of the tendon at
the distal pole of the patellae) at the lig. patellae and the resulting loss of function, this
overuse condition not infrequently leads to career termination in athletes (Saithna et al.).
1.2 Prevalence
The prevalence of this condition in the USA spreads across approximately 22% of all
athletically ambitious individuals (Lian et al.; Backman and Danielson). In basketball, the
prevalence is 32%, and in volleyball it is as high as 44% (Rutland et al.). Kettunen and
Coworkers found that 53% of American junior basketball players with jumper`s knee had
to end their athletic career due to high pain intensity (Kettunen et al.). A more specific
analysis regarding the prevalence of jumper`s knee was shown by Zwerver et al. who
determined a percentage incidence for this condition of 8.5% based on 891 athletes.
Interesting in this analysis is that male subjects (10.2%) suffered significantly more from
the pathology than females (6.4%). From these findings, they hypothesized that the
anthropometric characteristics of males (limb length ratios) may represent potential risks
for the development of insertiotendinopathia patellae (Zwerwer et al.).
7
However, it could not be proven whether some of these patients did not suffer from other
problems, in the sense of for example: cartilage injuries (Jonsson and Alfredson). In
general, it should be noted that this ligamentous, painful overload syndrome is
characterized by a high quantity in the sports field.
1. 3 Eccentric Training
For the treatment of ITP, eccentric training has been found to be effective. It was first
studied by Stanish and colleagues in 1985 with promising results at the time in terms of
pain relief (Stanish et al.). Their program included a general, full-body warm-up (without
performing knee extension) and stretching (30 seconds per exercise over three rounds)
before the main part. This consisted of performing drop - squats to take advantage of the
eccentric loading. On days one through two, the squats were performed at a slow speed, on
days three through five at a moderate speed, and on days six and seven at a fast speed.
Beginning on day seven, the intensity was increased by adding resistances and the cycle
was repeated as before. The workout included three sets of 10 repetitions, every day. After
six weeks, the frequency was reduced to three workouts per week with the same number of
repetitions. Each workout was finished with the same stretching exercises as in the warm-
up and with a five-minute application of ice. Currently, it is generally accepted that greater
effects in terms of muscle strength (Roig et al.; Hilliard-Robertson et al.), muscle growth
(Roig et al.; Seger et al.) and neural adaptations (Roig et al.; Hortobagyi et al.) can be
achieved through eccentric muscle loading than with purely concentric loading.
In eccentric training, one generates contraction intensities of the highest form (compared
to concentric and isometric muscle work). This gives the possibility to choose the muscle
stimulus higher than in concentric and static strength training. This basically represents an
improvement in strength performance. Due to the increased load on the contractile elements
of the muscle during the highest contraction form, the muscle is strongly challenged. The
associated metabolism intensified in its activity compared to all other forms (concentric,
isometric). Furthermore, this process provokes a reorientation (optimization) of the
collagenous fiber structures (Lindstedt et al.). Fyfe and Stanish explained the mode of
action of eccentricity by assuming that the higher loads applied by eccentrically acting
forces applied stronger stimuli within the tendon. This process, in their opinion, leads to
more effective adaptive processes at the ligament (Fyfe and Stanish). Another theory was
put forward by Ohlberg and Alfredson, who suggested that the extreme stimulation during
eccentric training provoked a local prevention of blood supply. The researchers assumed
that the oxygen depletion that occurs during this process damages the accompanying nerve
fibers as well as the blood vessels. This process is their explanation for the restoration of
8
normal, physiological ligamentous structures, which then also leads to pain reduction
(Ohlberg and Alfredson). However, using the Achilles tendon as an example, Rees et al.
were able to determine that the extreme tensile forces applied there, which were equally
pronounced during both eccentric and concentric loading, led to different results. These
include: Variations in forces during eccentric loading, which again were not detectable
during concentric loading. They explained this process of fluctuations by a sensorimotor
weakness of the muscles concerned within the eccentric phase. Which, however, could be
an important factor in the recovery of the ligament (Rees et al.).
1. 4 Diagnostic
The diagnostic options to identify the structural changes in this syndrome are ultrasound
diagnostics and palpatory diagnostics of the patellar ligament. Ultrasound diagnostics (US)
is a good if not completely sufficient method to identify insertiotendinopathies (Paavola et
al.). US - examination is not a sufficient method to clarify whether the lig. patellae is
clinically healed (Cook et al.). In chronic (from six weeks long persisting) Jumper`s Knee
patients, extensions and irregular arrangements of the collagenous fibers were detected by
US. These are related to the pathophysiology of patellar inertiotendinopathy (Khan et al.).
In addition to ultrasound diagnosis, painful palpation of the lig. patellae at the proximal
end, is another clear indication of this condition (Martens et al.; Jensen, Di Fabio).
1. 5 Pathophysiology
In some cases, localized collagen degeneration was found (Riley). Replacement of type one
collagenous fibrous tissue into type three, as well as sprouting of substance P positive nerve
endings were noted (Maffulli et al.). Danielson et al. found in athroscopically treated male
patients in the dorsal region of the ligamentum patellae, a diminished innervation with
respect to the sympathetic nervous system. The sympathetic nervous system controls,
among other things, blood vessels (constriction/dilation) and thus the strength and extent
of local blood flow (Danielson et al.). This finding seems interesting since high,
pathological blood flow was diagnosed in this injury using ultrasound studies of the blood
vessels in this area (Rodriguez-Merchan). This represents another indication of the
difficulty in understanding the pathophysiology of insertiotendinopathy. Cook and Purdam
created the "continuum model of tendinopathy" based on the many different descriptions
of this condition. This explains the pathological changes as a continuing process, which
could still be stopped up to a certain level. This progression contains three phases to
facilitate clinical decisions: healthy ligament, tendon deterioration and degenerative
tendinopathy. Amplification or regression in the continuum model appears to be due to
both reduction and intensification of loading (Cook and Purdam).
9
Phase one (reactive Tendinopathy)
Symptoms due to overload (Scott et al.). Here, an acute cross-sectional enlargement of
the ligament occurs which, however, decreases again after a short time without
adaptation of the collagenous fibrous tissue. No neurovascular changes are expected
during this phase. This is in contrast to an optimization of compression and tensile
stresses (Cook and Purdam). This short-term symptomatology should be countered with
relief as a treatment recommendation. In the absence of regeneration within this time,
ligamentous degeneration may subsequently begin, which may then trigger the second
phase.
Phase two (beginning tendon destruction)
Here, there is an increase in proteoglycan (synthesized protein). This process leads to
increased water retention in the tendon tissue, in conjunction with a roughening of the
collagenous tissue. The changes in the second phase are much more apparent on
ultrasound examination than those within the first phase (Cook and Purdam). The
duration of this phase may take years (Ohberg et al.). Healing can be successfully
pursued here as well, provided that attention is paid as closely as possible to the
application of the optimal loading stimuli, which help to intensify the synthesis of
matrix components (Ohberg et al.).
Phase three (degenerative Tendinopathy)
The third phase according to Cook and Pudram explains an acceleration of cell change
within the ligament. This process occurs when a permanent overstimulation of the
tendon is not stopped. This manifests itself to the detriment of structural regeneration.
The pathological results in this phase are considered to be hardly regenerable (Lian et
al.). The cell death of tendinocytes that occurs here in the sense of apoptosis causes
vessels to sprout into the acellular areas formed by cell death (Cook and Purdam).
Ultrasound Doppler diagnostics reveal symptoms of all phases of the "continuum -
model of tendinopathy" in an advanced tendon pathology. The quantity of collagenous
fibers of the ligament decreases sharply and there is a demonstrable, strongly
represented new formation of vessels (Cook and Purdam). Furthermore, it should be
noted that such a dominant irritable state of the tendon mainly affects elite and amateur
athletes. In addition to a natural occurrence in people of older age. In these patients, in
addition to the specifics from ultrasound diagnostics, thickening of the ligament can be
detected by means of MRI examination. These patients not infrequently go through
periods of varying symptom intensity.
10
When symptoms subside, a rapid flare-up can often occur, provided that the structural
irritant load increases again after the rest period. Tendon pathologies at such an intense
level are at risk for rupture (Nehrer et al.). Degenerative changes of these occurred in 97%
of all ligamentous ruptures beforehand (Kannus and Jozsa). In contrast to this finding,
Abate et al. created the "iceberg theory." They defined their finding by stating that pain is
merely the tip of the iceberg. In a tendon, overload-induced micro-injuries occur as soon
as the load is increased beyond the physiological level and is repeated at this level in the
long term. As long as the natural, individual ratio of stress to load capacity is in balance,
minor overuse injuries usually regenerate on their own if regular rest periods are observed
(Abate et al.). Within this state of injury, training is defined as a risky mix between catabolic
and anabolic stimuli (Abate et al.). Problematic in the recognition, treatment, and
management of this condition is that it is not uncommon for it to remain asymptomatic.
Once the sprouting on the nerve fibers has exceeded a certain limit, this results in a clear
pain symptomatology (Abate et al.).
1. 6 Treatment variations
Due to insufficient understanding of the pathomechanism in ITP, it is still not fully
understood which of the currently known treatment modalities is most effective (Rees et
al.; Rodriguez-Merchan). These consist of:
arthroscopic surgical techniques (Willberg et al.; Ogon et al.);
conservatively by means of active exercises, primarily eccentric training on the
Decline Board (a surface usually lowered at 25° to stand on to ensure plantar
flexion in the upper ankle joint (See 1.10) (Rees et al.; Hyman);
extracorporeal shock wave therapy (ESWT) (Zwerver) and
Injections with different substances: sclerosing polidocanol, corticosteroids, and
aprotinin platelet-rich plasma (PRP) (Van Ark).
Currently, the treatment method with the most benefits seems to be in the area of
therapeutic exercises, especially eccentric training of the quadriceps muscles (Rodriguez-
Merchan). The design of eccentric training is currently set to training programs of at least
three sets.
These include, for example:
11
an overload training using a hydraulically controlled training machine (Bromsman
machine) for 4 x 4 repetitions (Wh) v / 0.11 m / s per Wh;
an eccentric training program by means of a Decline Board mounted at an angle of
inclination of 25° and performed unilaterally (affected leg) over three sets of 15
Wh each.
Starting point in both examples is the standing position. Final position is a knee joint angle
of 110° (Frohm et al.). Other methods with the same volume are shown in the studies by
Cannell et al; Purdam et al; Rutland et al; Jonsson and Alfredson. An essential role in the
treatment of jumper`s knee is the exclusion of the athletes from their sport-specific training,
which is provocative for the overload due to the related movement and loading patterns
(Visnes et al.). In the comparison of a painful (subjective tolerance limit) eccentric to a
concentric training program, it was found that the concentrically loaded group (n 7) could
not be treated to the intended end (12 weeks) due to excessive shear intensity in the
participants, but had to stop after six weeks (n 4). The pain reduction within the eccentric
group compared to the concentric group, measured by VAS, was 22 counters (eccentric) to
68 counters on the side of the concentrically performed group. This result shows a clear
advantage for the eccentrically intervened group after a treatment period of 12 weeks. The
high pain intensity of the subjects within the concentric group was a reason for the
investigators not to pursue further research into the question of the effectiveness of
"eccentric and concentric training". No further research was developed beyond the pilot
study developed here. No recommendation for concentric oriented further research was
given (Jonsson and Alfredson ). Most treatments in other studies ran for a total period of
12 weeks. Some of them removed their subjects from the respective athletic training for
the complete treatment period (Cannell, et al.; Visnes et al.; Jonsson and Alfredson; Frohm
et al.).
12
2. Methods
2.1 Patients
All patients are active in amateur sports (at least three times per week). A total of 16
participants, divided into two groups of eight subjects each, randomly assigned (lottery:
Choice between group one and group two, described on slips of paper) were assigned (Tab.
1). Four subjects practiced weight training, three times running (long distance), twice
cycling, three times handball, twice volleyball, twice soccer;
Tab. 1 Patients
Proband
Group affiliation
BW (kg)
High (cm)
Sports
Age (y)
6
High vol.
75
178
Soccer
22
4
High vol.
84
183
Handball
24
3
High vol.
92
188
Handball
19
2
High vol.
85
189
Volleyball
26
1
Low vol.
89
191
Volleyball
22
7
Low vol.
79
181
Running
21
13
Low vol.
85
183
Weight
training
23
14
High vol.
80
183
Cycling
19
11
Low vol.
80
177
Weight
training
27
8
High vol.
74
177
Running
31
16
High vol.
80
187
Running
24
12
Low vol.
98
187
Weight
training
20
5
High vol.
74
175
Soccer
19
15
Low vol.
75
175
Cycling
21
9
Low vol.
72
175
Running
30
10
High vol.
95
188
Cycling
22
13
2.2 Group explanation (Tab. 2 a / b)
Group one (low volume)
Tab. 2 Group two
Group two (high volume)
Tab. 3 Group two
Proband nr.
Sports
6
Soccer
4
Handball
2
Volleyball
14
Cycling
8
Running
16
Running
5
Soccer
10
Weight training
Proband nr.
Sports
3
Handball
1
Volleyball
7
Running
13
Weight training
11
Weight training
12
Weight training
15
Cycling
9
Running
14
The experimental design was by random subject / group assignment, by lottery, and was
performed in a controlled manner. A total of 16 participants were divided into two groups:
high volume, three times 15 repetitions vs. low volume eccentric strength training, once 15
repetitions. Stimulus intensity was determined by the subjects' body weight, with no added
weight. Eight male patients per group, aged between 18 and 30 years, were treated over a
period of eight weeks, in this study. This corresponded to a total number of 16 patellar
tendons. In subjects with bilateral symptoms, the focus was on the side with the more
intense pain symptoms. From the sixth week, patients were reintegrated into their specific
sport (normal, seasonal load - without maximal loads). The treatment was performed three
times per week (Monday, Wednesday, Friday = group one (low volume and Tuesday,
Thursday, Saturday = group two (higher volume)). To save time, the intervention was
always performed in pairs. The time planned per group was calculated as approximately 15
minutes per treatment (content: briefing, warm-up, farewell, informing the next pair). The
daily time expenditure was about one hour.
2.3 Therapy explanation
All subjects should wear sportswear (especially shorts). The knee joint should be clearly
visible in order to be able to precisely maintain the previously defined flexion angle. The
exercise was always performed with the same sports shoes. Both groups warmed up for
five minutes per session on the ergometer with moderate resistance (100 revolutions per
minute, self-selected intensity). Warm-up was followed by a three-minute rest, and then
the first set of work was started. Subjects were informed that performance may be
accompanied by pain. They could determine the level of pain themselves, as long as the
cleanliness of the execution did not suffer. The intervention was performed with the leg
(knee flexion eccentric) on which the painful lig. patellae was located or, in the case of
bilateral symptoms, the most painful one. In the higher volume group, a pause of two
minutes was observed between sets. While one of the patients was active, the other paused.
The eccentric single-leg squat was performed on a 25° decline board. The starting position
was standing with subsequent knee flexion to an open knee joint angle of 110°. For this,
the patient sat on a height-adjustable massage bench with the legs almost extended from
the bench downwards (almost vertical). The bench was lowered to a height at which the
knee joint angle corresponded to 110° (measured with a standard goniometer (illustration
one) (Fig. 1, Fig. 2). This individually determined bench height served as orientation for
the exact flexion angle (illustration two). The knee extension returning to the starting
position (see figure three) was performed with the leg not to be treated (concentrically) and
with the help of the arms, which could be used on a bench to lift. During the entire
movement of the eccentric squat, permanent attention was paid to ensure that the trunk did
15
not leave a position as vertical as possible (Fig. 3). This ensured increased activity of the
quadtriceps femoris muscle and reduced strain on the gluteal muscles. In addition, a
deviation of the leg axis in lateral directions had to be avoided.The entire treatment process
of group one as well as group two was checked by a physiotherapist consulted for this
purpose.
Fig. 1 Standard Goniometer
Fig. 2 Knee ankle
Fig. 3 Start position
16
2.4. Measurements
At the beginning of the intervention (week zero), the first assessment was performed by
means of the VISA - Scale - questionnaire regarding functional ability and the NRS
regarding pain symptomatology. The second assessment (NRS) was taken after four weeks
of intervention and the third (NRS and VISA - Score) at the end of therapy after eight
weeks.
2.5 Inclusion and exclusion criteria
Only male subjects between 18 and 30 years of age were admitted. Pain symptoms had to
be chronic for at least six weeks prior to the study and related to the proximal, ventro/lateral
area of the patellar tendon in a load-dependent manner. Palpation of the patellar ligament
by a responsible physiotherapist had to be painfully interpreted by the patient. All subjects
were active in sports (at least three times per week, amateur level). Patients with
capsular/ligamentous injuries were excluded (Tab. 3). These types of injuries must never
have occurred in the life of the subjects. Patients who had received medication
(corticosteroids, painkillers), whether orally or by injection, and those with positive MC
Murray tests were excluded. The control of the inclusion and exclusion criteria was
performed by a physiotherapist trained for this purpose. The specificity and sensitivity of
the MC Murray provocation test varies depending on the study between specificity of 98%
and sensitivity of 16% (Evans et al.), to sensitivity of 29% and specificity 95% (Fowler and
Lubliner) and a sensitivity of 37% to a specificity of 77% (Kurosaka et al.). In comparison
to ultrasound diagnostics with a sensitivity of 81% and a specificity of 90% (J. Grifka et
al.), the provocation test (MC Murray) performs worse on average in the area of sensitivity.
Whereby it shows similarly good results in the area of specificity.
Tab. 4 Inclusion and exclusion criteria
Inclusion
Exclusion
Men
Capsule and ligament injuries
Age between 18 an 30 years
Corticosteroids, analgesics
Pain history: min. 6 weeks
Positive MC Murray test
Load related pain ventro- / lateral of patellae
tendon
Active in sports (three times per week)
Painful palpation of lig. patellae at the proximal
end
17
Fig. 4 Methods
18
Fig. 5 Drop outs
19
2.6 Measurement systems
VISA SCALE
The Victorian Institute of Sportassessment - questionnaire (VISA - scale) was used as a
simple and reliable measurement method to identify Jumper`s Knee, as well as to assess
the severity of it. This questionnaire is designed to determine symptoms, simple functional
tests, and the ability to perform physical tasks. Patients who have more severe injuries to
the knee will not score high on the VISA, as it can be assumed that function is drastically
limited (Visentini PJ. et al.). Six of eight questions are answered using the visual analog
scale (0 - 10 points, 10 = optimal health). A score between one and 10 is obtained on a
beam containing 100 units, at regular intervals marked one to 10. A normally healthy
person can achieve a maximum score of 100 on this questionnaire. The theoretical
minimum is 0 points (Visentini PJ. et al.). The VISA score has excellent short-term test-
retest and inter-tester reliability (both r = 0.95). As well as good short term (one week)
stability (r = 0.87). Visentini PJ et al. showed that the VISA scale is a reliable index for
determining the severity of Jumper`s Knee (Visentini PJ. et al.). The VISA- questionnaire
was used for specific data collection in this study, completed individually by the subjects
and scored by the study investigator. This assessment was used only twice (start - end after
eight weeks), unlike the NRS. Subjects were distanced from their specific sport for six
weeks.
NRS
The numerical rating scale (NRS) is a measurement tool in physiotherapy for the subjective
determination of pain intensity. The NRS is a reliable, valid and objective measurement
method. It is considered to have a high degree of sensitivity. When used, the NRS shows
similar values to the VAS, although the NRS is characterized by higher sensitivity to
change. The NRS is a 100 mm long scale on which the patient is asked to enter his or her
personal pain intensity. The further to the left on the scale the mark is placed, the lower the
pain intensity, the further to the right the higher. In order to give the patient an idea of the
function of the NRS, explanations such as: "no pain sensation corresponds to mark
maximum left (0) and maximum imaginable pain sensation corresponds to a mark on the
scale maximum right (10)". In the analysis of the NRS - markings, should be ideally put on
a percentage evaluation value, since this can be more exactly defined and computed in the
comparison to one purely based on numbers. For statistical analysis, it should be noted that
the NRS should be used for parametric tests in the case of normal distribution, since it
corresponds to a rational scale (J. Schomacher).
20
The subjects within this study were asked in relation to the NRS how intense they
personally rated their pain on a scale (written) from 0 - not at all, to 10 - maximum pain.
This subjective pain analysis referred to individual sensitivity at the last sentence of each
intervention. Question: "On average, how intense do you rate your pain on this scale from
0 - nothing, to 10 - maximum, during the course of the last sentence of treatment?"
3. Statistics
All statistics were performed with the program SPSS 22. The statistical calculations refer
to the final number of participants of 13 subjects from the beginning (measurement one in
VISA and NRS of both groups) (drop outs were subtracted). The descriptive statistical
analyses showed: means (MW), standard errors of means, median, standard deviations,
variances, minimum and maximum regarding the factors: body weight (KGew.), body
height (KGr.) and the age of all patients, as well as those in each group. The calculation of
mean values, standard deviation of MW, standard error of MW, median, standard
deviations, variances, minimum and maximum of all subjects in total in the range of VISA
and NRS can be seen in Tab. 5. The results of MW KGr., KGew. and age within the groups,
see. The group-dependent MW of the VISA and NRS, in connection with the standard
deviation of the MW, standard error of the MW, median, standard deviations, variances,
minimum and maximum can be found in exact definition.
All subjects as a whole conform to the normal distribution (NV). This analysis was
performed by Kolomogrow - Smirnow test and further by Shapiro-Wilk test (alpha < 10
%). The subjects of the individual groups were also normally distributed in both cases
(alpha < 10 %). Within the statistical analyses, it was found that all participants conformed
to the normal distribution at the beginning (measurement time point one) as well as at the
end (measurement time point two - VISA and measurement time point three - NRS). This
applies to the entire number of participants across groups, as well as within groups for the
factors: KGew., KGr. and age. The tests for the analysis of the normal distribution of all
subjects: NRS (ordinal) and VISA (ordinal) showed that for VISA one a normal distribution
can only be assumed by the Kolomogrow-Smirnow test. However, this result could not be
confirmed by applying the Shapiro-Wilk test. Due to this, no normal distribution is assumed
for the following calculations (Wilkoxen and U - Test) (Tab. 5). To analyze the normal
distribution of the subjects in the individual groups, the Shapiro-Wilk test and the
Kolmogorov-Smirnov test were also applied. Here, in contrast to the totals, the results
speak in favor of a normal distribution for VISA one. With regard to the NRS, the NV also
21
applies, except for the high-volume group with Shapiro-Wilk calculated. To analyze the
differences between measurement time point one and two at VISA, within groups, the
Wilcoxen test was used for calculation, with the result of significant differences (alpha <
5%) (Tab. 6). The analysis of the differences of group one and group two, at VISA one and
VISA two showed no significant differences (alpha < 5%) (Tab. 7). Calculation of group-
dependent measurement time points one to two, to three for NRS within each group was
performed using the Wilcoxen test and show significant (< 5%) differences in each of the
two groups from each other (Tab. 8). The U-test was used to determine the differences
between the two groups in the area of NRS at measurement points two and three. This
showed that there were no significant (> 5%) differences between the individual groups at
measurement points two and three. That is, there is no significant difference between the
high-volume and low-volume training in conjunction with the NRS (Tab. 9).
3.1 Utest between groups
Tab. 5 Utest between groups
2_NRS
3_NRS
Mann-Whitney-U-test
15.000
21.000
Wilcoxon-W
43.000
42.000
U
-.964
.000
Asymp. sig. (2-sided)
.335
1.000
Exact sig. [2*(1-sided sig.)]
.445b
1.000b
3.2 Comparison VISA between den groups
Tab. 6 Comparison VISA between den groups
Visa1_Gr1
Visa2_Gr1
Visa1_Gr2
Visa2_Gr2
N
valid
7
7
6
6
absent
19
19
20
20
Mean value
55.4286
86.2857
52.0000
85.0000
Standard error of the mean
5.36682
2.28571
6.96659
2.60768
Median
58.0000
90.0000
57.5000
87.5000
Standard deviation
14.19926
6.04743
17.06458
6.38749
Minimum
33.00
75.00
29.00
72.00
Maximum
70.00
91.00
71.00
88.00
22
3.3 Comparison NRS between groups
Tab. 7 Comparison NRS between groups
gr1nrs1
gr1nrs2
gr1nrs3
gr2nrs1
gr2nrs2
gr2nrs3
N
valid
7
7
7
6
6
6
absent
19
19
19
20
20
20
Mean value
4.60
2.14
.57
4.50
2.50
.50
Standard error of the mean
.23
.26
.30
.56
.22
.22
Median
4.00
2.00
.00
4.00
2.50
.50
Standard deviation
.79
.69
.79
1.38
.55
.55
Minimum
4.00
1.00
.00
3.00
2.00
.00
Maximum
6.00
3.00
2.00
7.00
3.00
1.00
3.4 Group comparison significance zero measurement VISA
Tab. 8 Group comparison significance zero
measurement VISA
1_VISA
Mann-Whitney-U-test
18.00
Wilcoxon-W
39.00
U
-.43
Asymp. sig. (2-sided)
.667
Exact sig. [2*(1-sided sig.)]
.731b
3.5 Group comparison significance zero measurement NRS
Tab. 9 Group comparison significance zero
measurement NRS
1_NRS
Mann-Whitney-U-test
18.00
Wilcoxon-W
39.00
U
-.469
Asymp. Sig. (2-sided)
.639
Exact sig. [2*(1-sided sig.)]
.731b
23
Fig. 6 NRS course
Fig. 7 VISA course
0
1
2
3
4
5
1 2 3
NRS Schmerzskala 0-10
NRS Verlauf
Gruppe 1
Gruppe 2
0
20
40
60
80
100
1 2
VISA Skala 100-0
VISA Verlauf
Gruppe 1
Gruppe 2
24
4. Results
All subjects were tested for the clinical picture "Jumper`s Knee" as described in the
methodology. All participants in this study suffered from this condition and were recruited
for this work using the inclusion/exclusion criteria described above over a total period of
eight weeks. They were divided into two groups with group one exercising eccentrically at
low volume (one set of five Wh) and group two exercising at higher volume (three sets of
15 Wh). In the course of the intervention there were a total of three drop - outs (graphical
representation drop - outs). In total, 13 of formerly 16 subjects reached the end of the
intervention. The average physical data of the participants in the respective groups showed
on average as follows: Group one KGew.: 81, 70 kg; KGr.: 181 cm and age: 23, 30 years.
Group two, KGew.: 81, 50 kg; KGr.: 184 cm and age: 24 years. There is no significant
difference of these data to the two groups. The results of the respective measurements
between the groups on average show no significant differences: VISA one, group one: 55,
43 to VISA two: 86, 29; group two VISA one: 52, 00 to VISA two: 85, 00. Both groups
improved functionally in terms of VISA significantly (group one: 30, 86 points and group
two: 33 points. The results between the groups regarding NRS also show no significant
differences to each other: group one NRS one: 4, 60 to NRS two: 2, 14 to NRS three: 0, 60.
group two, NRS one: 4, 50 to NRS two: 2, 50 to NRS three: 0.50. The zero measurements
of the respective measurements show significantly no differences to each other. Group one
improved in the NRS area by four points from the start of treatment to the end after eight
weeks, just like group two.
25
5. Discusion
5.1 Reflexionen des wissenschaftlichen Standes
Sufficient evidence for the effectiveness of the treatment of chronic ligamentous overuse
symptoms in sports, especially of the lig. patellae, is currently lacking. Evidence-based
proof of successful treatment is sporadic. However, it is often not sufficiently available
due to very small group sizes and lack of a uniform methodological approach to the
interventions (Rees JD. et al.; EC. Rodriguez-Merchan). Nevertheless, the most efficient
form of treatment methodology of Jumper`s Knee seems to be defined in the field of
eccentric load training. As it was also carried out in this study (E. C. Rodriguez-
Merchan). Furthermore, it is not sufficiently clear whether eccentric training parallel to
the performance of the primary sport achieves the same effect on pain relief and
functional improvement as an intervention that includes a distancing of the sport training
(Saithna A. et al.). A sufficient definition of the stimulus parameters (duration, intensity,
frequency, execution technique), have not yet been uniformly defined or defined via
guidelines. The reason for this study was to find out whether a therapy program based on
minimal stimulation frequency would produce the same effects in terms of pain relief and
functional improvement in athletes as a higher-volume training system? Currently, there
is an apparent dominance of higher frequency training content (Frohm A et al; Cannell LJ
et al; Purdam CR et al; Rutland M et al; Jonsson P and Alfredson H).
5.2 Critical comparison
Compared to the studies mentioned above with similar subject matter, the study presented
here is as follows: the duration of the intervention differs with the work of: Frohm et al,
Cannell et al, Pudram et al; Jonsson and Alfredson (all 12 weeks) and Bahr et al (12 months)
by at least two weeks less. Measurement systems were consistent in all papers including
the present study (at least one of VISA or NRS). Measurement was always in terms of pain
or function. In contrast to all other studies, this corresponds to a homogeneous expression,
which suggests more accurate comparisons. In all the studies listed above, the subjects were
temporarily removed from a sport (Jonsson and Alfredson; Pudram et al.; Cannell et al.;
Frohm et al.). This also occurred in the intervention shown here. The number of participants
appears to be rather small compared with other studies, with an initial 16 subjects (Table
21). All of the studies mentioned showed significant improvements with regard to their
measurement parameters (pain / function), up to complete freedom from pain (Tab. 21).
Significant improvements in both groups are also evident in the present study, with no
significant difference (results).
26
Criticism of this study:
Negative:
Comparatively short intervention duration (eight weeks),
comparatively low number of subjects per group (beginning with eight per group),
no US - diagnostics;
Positives:
New findings regarding training parameters (volume per unit),
intervention was exclusively eccentric training,
homogeneous groups;
5.3 Research Outlook
The new findings from this study do not show any differences regarding the results in the
area of pain (measured by NRS) and function (measured by VISA - Scale). The differences
are defined in the execution of an eccentric training. One program included three sets of 15
repetitions and the other one set of 15 repetitions. This fact obtained from this can be further
used to address the questions about the basic effectiveness of eccentric training in the
diagnosis of Jumper`s Knee or Insertiotendinopathia Patellae. This should arise under the
generation of larger numbers of subjects, more accurate staging of the clinical picture by
means of apparative diagnostics (ultrasound Doppler sonography) and shorter sports
distance of the subjects within the study. The distancing from the supposedly disease-
pattern provoking sports, which is evident in this study as well as in all studies listed here,
may be one reason why a significant improvement of the measured symptoms (pain and
function) is present in both groups in the area of the eccentric treatment methodology.
Therefore, further work should investigate the question, among others, "What leads to the
positive effects in terms of pain and functional improvement in Jumper's Knee - load
reduction or eccentric training?" This is what we need to pay attention to: Only do eccentric
training in the intervention. No other factors such as stretching, ice applications, etc. to
reduce confounding variables that may affect outcome.
27
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