Dissertation
Achilles Tendon pain: patient treatment innovation and unraveling immune system contributions
University of Iowa
Doctor of Philosophy (PhD), University of Iowa
Summer 2024
DOI: 10.25820/etd.007617
Abstract
Chronic pain is considered a public health epidemic and is the primary reason patients seek out healthcare within the United States. While chronic pain impacts an individual’s function and activity level, poorly controlled pain may also negatively impact aspects of life that are not as apparent. This may include an individual’s emotionally well-being and overall quality of life, further warranting the need for utilization of a biopsychosocial approach to patient care. Furthermore, enhanced understanding of the underlying mechanisms that contribute to common musculoskeletal pain conditions may broaden our appreciation of the complexities of pain that reflect the variability within our patient’s pain experience that we see in clinical practice. Therefore, the overall goal of this work was to highlight innovative intervention approaches and underlying immune mechanisms outside of routine clinical practice for chronic Achilles tendinopathy.
We first sought to explore the effect of patient education that emphasized a pain neuroscience education approach when added to a progressive tendon loading exercise program compared to a pathoanatomical education program plus exercise on movement-evoked pain, disability, and pain-related psychological factors for individuals with chronic Achilles tendinopathy. Both educational approaches, when added to a tendon loading exercise protocol, resulted in similar reductions in movement-evoked pain, disability, and associated psychological factors while improving physical function. Therefore, clinical-decision making on patient educational content to best match a patient’s needs may assist with improved outcomes through individualization of the plan of care.
Next, I demonstrated that physical therapy delivery of interventions related to exercise and patient education through a virtual and hybrid format achieved outcomes that were no worse for pain and function when compared to an in-person format for those with chronic Achilles tendinopathy. During the beginning of the SARS-CoV-2 pandemic, we transitioned our study to a fully virtual format. After the re-opening of in-person human data collection, we offered both a virtual and in-person option to participants (hybrid mode of physical therapy delivery). I tested for the effect of the mode of physical therapy delivery through a non-inferiority analysis. Virtual and hybrid modes of physical therapy delivery demonstrated improvements in pain, physical function, and psychological factors that were no worse than those who completed only in-person physical therapy. Additionally, all three groups demonstrated similar levels of overall perceived improvement, development of therapeutic alliance, and engagement with their home exercise program. Provision of alternative options for completion of physical therapy allows for the incorporation of patient preference into the plan of care and may allow for greater follow-up attendance through enhanced accessibility to best practice for Achilles tendinopathy.
Lastly, to explore for potential underlying mechanisms outside of the musculoskeletal system that contribute to Achilles tendon pain, I was able to highlight immune cell population differences through flow cytometry analysis in both the myeloid and lymphoid lineage lines between individuals with chronic Achilles tendinopathy compared to healthy controls. Non-classical monocytes and B cells demonstrated a significant association with alterations in movement-evoked pain for those with chronic Achilles tendinopathy following a tendon loading exercise protocol.
Details
- Title: Subtitle
- Achilles Tendon pain: patient treatment innovation and unraveling immune system contributions
- Creators
- Andrew Post
- Contributors
- Ruth Chimenti (Advisor)Kathleen Sluka (Committee Member)Katherine Hadlandsmyth (Committee Member)Laura Frey Law (Committee Member)Jason Wilken (Committee Member)Cesar de Cesar Netto (Committee Member)
- Resource Type
- Dissertation
- Degree Awarded
- Doctor of Philosophy (PhD), University of Iowa
- Degree in
- Physical Rehabilitation Science
- Date degree season
- Summer 2024
- Publisher
- University of Iowa
- DOI
- 10.25820/etd.007617
- Number of pages
- xvii, 193 pages
- Copyright
- Copyright 2024 Andrew Post
- Grant note
- Funding for this study was provided by the National Institute of Arthritis Musculoskeletal and Skin Disease (NIAMS) research grant R00 AR071517 and by the Collaborative Research Grant from the International Association for the Study of Pain (IASP). Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR002537. These funding sources had no role in study design, collection, analysis/interpretation of data, or decision on submission for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. (41) This work was supported by the NIH through the NIH HEAL Initiative (award no.: UG3AR076387) from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. This work also received logistical and technical support from the PRISM Resource Coordinating Center (award no: U24AT010961) from the NIH through the NIH HEAL Initiative. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or its HEAL Initiative. (56)
- Language
- English
- Date submitted
- 07/18/2024
- Description illustrations
- illustrations, tables, graphs
- Description bibliographic
- Includes bibliographical references (pages 177-193)
- Public Abstract (ETD)
- Chronic Achilles tendinopathy pain is a common foot and ankle condition that results in reduced function and participation in activity. The origin of Achilles tendinopathy is not fully understood, yet high-level evidence recommends exercise as the best treatment to reduce pain and improve function. The goal of my dissertation work was to highlight alternative approaches to patient care for individuals with chronic Achilles tendinopathy and uncover potential contributors to the origin of tendon pain. We first demonstrated that providing patients with an educational program that focused on the science of pain and how the body processes pain when added to an Achilles tendon exercise program was able to achieve similar outcomes in pain reduction and enhanced function when compared to patient education that focused on the tendon disease. This provides clinicians with evidence to incorporate their decision- making into educational content based on the patient’s specific needs. During Covid-19, we transitioned our patient education study over to a fully virtual format that allowed us to continue enrollment. Our lab re-initiated in-person data collection in July 2020, and we then offered a hybrid (combination of telehealth and in- person) option of physical therapy. I was able to demonstrate that all three modes of physical therapy delivery were able to achieve similar outcomes with reductions in pain and improved function. Lastly, to explore for potential contributing factors to Achilles tendinopathy pain, I identified immune cell populations that were different between those with Achilles tendinopathy and controls, and that the unique cell populations were associated with increases in tendon pain following exercise.
- Academic Unit
- Physical Therapy and Rehabilitation Science
- Record Identifier
- 9984697846502771
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