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Isometric Exercise Induces Analgesia and Reduces Inhibition in Patellar Tendinopathy

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Isometric Exercise Induces Analgesia and Reduces Inhibition in Patellar Tendinopathy Downloaded from http://bjsm.bmj.com/ on January 8, 2016 - Published by group.bmj.com Original article Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy 1 2 3 1,4 5 Editor’s choice Ebonie Rio, Dawson Kidgell, Craig Purdam, Jamie Gaida, G Lorimer Moseley, Scan to access more 6 1 free content Alan J Pearce, Jill Cook 1Department of Physiotherapy, ABSTRACT competitive season, there has been poor adherence School of Primary Health Care, Background Few interventions reduce patellar due to increased pain, and either no benefit7 or Monash University, Melbourne, 8 Victoria, Australia tendinopathy (PT) pain in the short term. Eccentric worse outcomes. Athletes are reluctant to cease 2Department of Rehabilitation, exercises are painful and have limited effectiveness sporting activity to complete eccentric exercise pro- Nutrition and Sport, School of during the competitive season. Isometric and isotonic grammes9 and they may be more compliant with Allied Health, La Trobe muscle contractions may have an immediate effect on PT exercise strategies that reduce pain to enable University, Melbourne, Victoria, pain. ongoing sports participation. Australia 3Department of Physical Methods This single-blinded, randomised cross-over Exercise-induced pain relief would have several Therapies, Australian Institute study compared immediate and 45 min effects following clinical benefits. First, athletes may be able to of Sport, Bruce, Australian a bout of isometric and isotonic muscle contractions. manage their pain with exercises either immediately Capital Territory, Australia 4 Outcome measures were PT pain during the single-leg prior to or following activity. Second, exercise is University of Canberra, – Canberra, Australian Capital decline squat (SLDS, 0 10), quadriceps strength on non-invasive and without potential pharmacological Territory, Australia maximal voluntary isometric contraction (MVIC), and side effects or sequelae of long-term use that are 5Sansom Institute for Health measures of corticospinal excitability and inhibition. Data associated with some interventions. Third, exercises Research, University of South were analysed using a split-plot in time-repeated that reduce pain are likely to have greater adherence. Australia & Pain Adelaide, measures analysis of variance (ANOVA). Therefore, alternative muscle contraction types, Adelaide, South Australia, Australia Results 6 volleyball players with PT participated. other than eccentric exercises, warrant investigation. 6Cognitive Neuroscience Unit, Condition effects were detected with greater pain relief Isotonic exercise (heavy, slow, concentric and Deakin University, Burwood, immediately from isometric contractions: isometric eccentric resistance training) has been shown to be Victoria, Australia contractions reduced SLDS (mean±SD) from 7.0±2.04 to as effective as eccentric only exercise in patellar 0.17±0.41, and isotonic contractions reduced SLDS tendinopathy (PT) for tendon pain and activity par- Correspondence to 1 10 Ebonie Rio, Department of (mean±SD) from 6.33±2.80 to 3.75±3.28 (p<0.001). ticipation; however, the immediate effect of iso- Physiotherapy, School of Isometric contractions released cortical inhibition (ratio tonic exercise on pain has not been studied. Primary Health Care, Monash mean±SD) from 27.53%±8.30 to 54.95%±5.47, but Isometric muscle contractions have been shown to University, Peninsula Campus, isotonic contractions had no significant effect on reduce pressure pain thresholds in normal partici- P.O. Box 527, Frankston, 11 12 Melbourne, VIC 3199, inhibition (pre 30.26±3.89, post 31.92±4.67; pants, but have not been investigated in Australia; ebonie.rio@monash. p=0.004). Condition by time analysis showed pain tendon pain. The pain inhibition following a local edu reduction was sustained at 45 min postisometric but not isometric contraction, demonstrated in previous isotonic condition (p<0.001). The mean reduction in studies of normal participants, is widespread;12 this Accepted 20 April 2015 Published Online First pain scores postisometric was 6.8/10 compared with indicates central nervous system (CNS) involvement 15 May 2015 2.6/10 postisotonic. MVIC increased significantly and warrants investigation. following the isometric condition by 18.7±7.8%, and The effect of exercise on the motor cortex may was significantly higher than baseline (p<0.001) and be modulated in the presence of pain. Exercises isotonic condition (p<0.001), and at 45 min (p<0.001). that are painful to complete may change motor Conclusions A single resistance training bout of control and cause cortical reorganisation, as pain isometric contractions reduced tendon pain immediately itself is known to alter cortical representation.13 for at least 45 min postintervention and increased MVIC. This may contribute to persistence of tendon pain The reduction in pain was paralleled by a reduction in through the continuation of aberrant motor patterns. cortical inhibition, providing insight into potential In the CNS, the primary regions involved in motor mechanisms. Isometric contractions can be completed control are the primary motor cortex and corticosp- without pain for people with PT. The clinical implications inal tract, which activate the motor neurone pool and are that isometric muscle contractions may be used to control motor function. Changes in motor output, reduce pain in people with PT without a reduction in however, are a combination of changes in the excita- muscle strength. tory and inhibitory neural pathways. This motor neu- roaxis can be investigated using single-pulse transcranial magnetic stimulation (TMS). INTRODUCTION Paired-pulse TMS can measure short-interval intra- Tendinopathy (tendon pain and dysfunction) in ath- cortical inhibition (SICI), which is thought to be 14 letes is difficult to manage. Eccentric exercise, mediated at a cortical level via GABAA receptors which is the most commonly prescribed exercise rather than at the spinal cord and quantifies the effect for the treatment of tendinopathy,1–4 is often of the inhibitory neurons that synapse onto pyram- painful to complete.5 Tendinopathy is especially idal cells in the primary motor cortex.15 To cite: Rio E, Kidgell D, problematic in the competitive season, when there Exercise, the cornerstone of tendon rehabilita- Purdam C, et al. Br J Sports are constant time and performance pressures.6 tion, is capable of changing excitatory and inhibi- Med 2015;49:1277–1283. Where eccentric exercise has been completed in the tory measures.16 17 No study has examined if Rio E, et al. Br J Sports Med 2015;49:1277–1283. doi:10.1136/bjsports-2014-094386 1 of 8 Downloaded from http://bjsm.bmj.com/ on January 8, 2016 - Published by group.bmj.com Original article exercise can immediately reduce tendon pain and if exercise set up for each trial at 60° of knee flexion. The outcome was changes the motor neuroaxis. This may clarify the mechanism the maximum peak torque recorded during these three efforts. behind clinical improvement following exercise-based rehabilitation.18 TMS and electromyography The primary aim of this study was to determine if either iso- Baseline measures of corticospinal excitability and SICI were tonic or isometric exercise would induce immediate pain relief obtained using single-pulse and paired-pulse TMS, respectively. in PT. The secondary aim was to explore the mechanisms and We optimised the accuracy of TMS by aligning the coil with ref- investigate changes to cortical motor function. Therefore, this erence markers on a tight fitting cap worn by participants and study compared an acute bout of isometric and isotonic quadri- marked with a latitude–longitude matrix, positioned with refer- ceps loading on patellar tendon pain, maximal voluntary iso- ence to the nasion-inion and interaural lines.22 metric strength and measures of corticospinal excitability and Single-pulse stimulus-response curves were obtained during inhibition. low-level isometric contractions of the quadriceps muscle group. Low-level contractions were performed by maintaining the knee METHOD joint at 60° of flexion while performing a 10% MVIC, which This was a within respondents, single-blinded, randomised equated to 10±2% of root mean square (RMS) electromyogra- cross-over trial with two intervention arms (figure 1). Six male phy (rmsEMG) during MVIC (table 1). A 10% isometric con- volleyball athletes (median age 26.9 years, range 18–40 years) traction is a non-painful task for someone with PT. Consistent who were taking no medication were recruited for the study. muscle activation was confirmed by recording prestimulus Three had unilateral pain and three had bilateral patellar tendon rmsEMG throughout the session. For a single stimulus-response pain. This study was approved by university ethics committees curve, 10 stimuli were delivered in 20% increments from 90% and all athletes provided written informed consent. Diagnosis of of the participant’s active motor threshold (AMT) up to 170% of their AMT. The stimuli were delivered using a ramped proto- PT was made by the same experienced sports physiotherapist on 23 clinical presentation—pain localised to the inferior pole of the col. The amplitude of the motor-evoked potential (MEP) or slope of the stimulus-response curve represents corticospinal patella during jumping and landing activities, and during testing 24 on the single-leg decline squat (SLDS). The diagnosis was con- excitability. firmed by the presence of characteristic features on ultrasound SICI is a subthreshold
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