Comparison of a Physiotherapy versus Extracorporeal Shockwave Therapy (ESWT) for treatment of Hamstring Tendon pain.

PHYSIOTHERAPY intervention Intervention in the individualised PHYSIOTHERAPY group will relate to known or hypothesised mechanisms underpinning the condition and have been informed by treatment shown to be effective in other lower limb tendinopathies. A key component of the program is a multi-stage, graded, individualised, strengthening/rehabilitation program, with consideration given to sporting and occupational demands. Graded reintroduction of compressive forces in loading programs is recommended for PHT and other lower limb tendinopathies and will be incorporated in the individualised PHYSIOTHERAPY treatment algorithms. Pain monitoring, both during and latent to loading, is a key component of the program. Use of a pain ‘ceiling’ during rehabilitation is thought to provide a safe guideline for exercise loads and avoids the need for a prolonged period of rest in which only pain free activity is allowed. A significant increase in symptoms lasting over 24 hours after activity is thought to indicate excessive loading of the tendon although the biological mechanism of this response is unknown. Stage 1 of the PHYSIOTHERAPY intervention will comprise isometric hamstring exercise aiming to safely commencing strengthening the hamstring complex and reduce pain levels. Stage 2 will incorporate progressive isotonic strengthening exercises of the hamstring musculature. Later stages will add strengthening of agonist muscles (calf, hip extensors, hip abductors and adductor magnus), and reintroduction of compressive load by increasing the hip flexion angle of hamstring strengthening exercises. High speed (energy storage and release) exercises will be included if required for the participant. Exercises options that are specific to sporting/occupational demands will be chosen where possible. Retraining of lower limb kinetic chain movements (e.g. lunge, squat, running) and lumbopelvic control rehabilitation will be incorporated if indicated by the assessment of the treating physiotherapist in line with recommendations for other lower limb tendinopathies. Progression to later stages of the program will be criteria driven with emphasis on absence of latent pain increase from rehabilitation. Return to sport advice will be provided. The treatment protocols have been developed by the research team including a clinical/research expert in this area (JC) The duration of the intervention is 12 weeks, with sessions provided at 0, 1, 2, 3, 6 and 12 weeks after randomisation. The first session is 60 minutes, and the remainder 30 minutes. All sessions will be undertaken in a one to one format in a physiotherapy clinic. Participating physiotherapists and treatment fidelity Physiotherapists from private practices in Victoria will provide treatment for both groups. To be eligible, the physiotherapists will need to have at least 2 years of clinical experience. Physiotherapists will then participate in a small group, 4-hour training session provided by the lead researcher (AR). The program will include review of previously provided material, and simulation of explanations and treatments to be used in the trial. Treating physiotherapists will be provided with a treatment manual (designed specifically for this study) detailing treatment algorithms, protocols and participant information sheets. Treatment methods will be clearly defined and standardised via a detailed session-by-session electronic clinical notes template that contains a series of decision-making algorithms. The algorithms and clinical notes will ensure that essential elements of the treatment program are consistently applied by all physiotherapists across all participants, while still allowing some opportunity for the treatment to be tailored to individual participants. The template will require treating physiotherapists to provide objective assessment findings, justification and rationale for clinical decision making, detail of treatment provision/prescription and response to treatment. Physiotherapists will be required to complete electronic clinical notes for each session which detail assessment findings, treatment provided, clinical decision-making justification and any adverse events from shockwave treatment or the exercise program. A quarterly face-to-face (or online if required due to COVID restrictions) meeting will be undertaken for 60 minutes involving all treating physiotherapists for the duration of the trial to review de-identified cases in the context of the treatment protocol. Evaluation of treatment fidelity and adherence by the physiotherapists for specific rehabilitation techniques will be achieved by checking the physiotherapist’s clinical notes for each participant after the second and fourth sessions of the program.