title: Do structural changes (eg, collagen/matrix) explain the response to therapeutic exercises in tendinopathy: a systematic review.
abstract: BACKGROUND
  Previous reviews have highlighted the benefit of loaded therapeutic exercise in the treatment of tendinopathy. Changes in observable structural outcomes have been suggested as a possible explanation for this response to therapeutic exercise. However, the mechanism for the efficacy of therapeutic exercise remains unclear.
  
  
  OBJECTIVE
  To systematically review the relationship between the observable structural change and clinical outcomes following therapeutic exercise.
  
  
  METHODS
  An electronic search of AMED, CiNAHL, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PEDro and SPORTDiscus was undertaken from their inception to June 2012.
  
  
  METHODS
  Any study design that incorporated observable structural outcomes and clinical outcomes when assessing the effect of therapeutic exercise on participants with tendinopathy.
  
  
  METHODS
  Included studies were appraised for risk of bias using the tool developed by the Cochrane Back Review Group. Due to heterogeneity of studies, a qualitative synthesis was undertaken.
  
  
  RESULTS
  Twenty articles describing 625 patients were included. Overall, there is a strong evidence to refute any observable structural change as an explanation for the response to therapeutic exercise when treated by eccentric exercise training. Moderate evidence does exist to support the response of heavy-slow resistance training (HSR).
  
  
  CONCLUSIONS
  The available literature does not support observable structural change as an explanation for the response of therapeutic exercise except for some support from HSR. Future research should focus on indentifying other explanations including neural, biochemical and myogenic changes.
  
  
  BACKGROUND
  Registered with PROSPERO, registration number CRD42011001638.
authors.affiliation: Musculoskeletal Physiotherapy Services, South Tees Hospitals NHS Foundation Trust, Northallerton, North Yorkshire, UK.
authors.forename: Benjamin T
authors.initials: BT
authors.lastname: Drew
authors.affiliation: University of East Anglia, Norwich, Norfolk, UK.
authors.forename: Toby O
authors.initials: TO
authors.lastname: Smith
authors.affiliation: School of Health & Related Research, University of Sheffield, Sheffield, South Yorkshire, UK.
authors.forename: Chris
authors.initials: C
authors.lastname: Littlewood
authors.affiliation: Department of Physiotherapy, University Hospitals Coventry and Warwickshire NHS trust, Coventry, Warwickshire, UK.
authors.forename: Ben
authors.initials: B
authors.lastname: Sturrock
mesh_terms: D000328:Adult; D000368:Aged; D003094:Collagen / Q000737:chemistry*; D005081:Exercise Therapy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D059352:Musculoskeletal Pain / Q000517:prevention & control; D017060:Patient Satisfaction; D016032:Randomized Controlled Trials as Topic; D052256:Tendinopathy / Q000473:pathology / Q000503:physiopathology / Q000628:therapy*; D013710:Tendons / Q000473:pathology / Q000503:physiopathology; D016896:Treatment Outcome
chemical_list: D003094:Collagen
keywords: Eccentric exercise; Exercise rehabilitation; Tendons; Ultrasound