Optimising Outcome for Achilles Tendinopathy: An Exploration into Cognitive and Contextual Factors

Achilles tendinopathy is a debilitating condition for both active and sedentary people. Clinically it is characterised by a painful response felt in and around the tendon predominantly during tasks involving plantarflexion load; hopping for example. Whilst exercise appears to be a promising intervention for the condition, it remains unclear how exercise influences outcome. Hence, in order to optimise outcomes for our patients, further research is required to better understand factors which may influence exercise-led interventions. It is acknowledged that further research is required to understand the ‘specific’ influences of exercise, for example, the ideal exercise type, number of sets and repetitions remain uncertain. However, this thesis aimed to develop insight into optimising outcomes by considering factors not previously investigated in tendinopathy research; the ‘non-specific’ influences of psychological, cognitive and contextual variables. To achieve this insight, this thesis comprises a systematic review investigating the association of psychological variables and tendinopathy. Overall, the review’s findings were contradictory, suggesting the need to consider further factors which may underpin psychological variables. Consequently, a further narrative review was undertaken. This review considers how the cognitive and contextual factors of working alliance, adherence, self-efficacy and outcome expectation might interact with psychological variables and potentially influence outcome from exercise-led interventions for people with tendinopathy. This is then highlighted as an area in need of research. Developed from this series of reviews, this thesis reports the feasibility of a study utilising a bespoke online platform for data collection to investigate the association of working alliance, self-efficacy, adherence and outcome expectation with clinical outcome for people with Achilles tendinopathy. The feasibility study comprised of a multi-centre, longitudinal cohort study (n=24) which was conducted in the UK. As part of the development for this study, a final narrative review was undertaken to evaluate the usefulness of the most commonly used patient reported outcome measure used for people with Achilles tendinopathy; the Victorian Institute of Sport- Achilles. Concerns over the measure’s validity, reliability and readability, led to the use of an alternative measure, the Lower Extremity Functional Scale. The feasibility study reports quantitative assessment of recruitment and retention rates alongside a qualitative study to identify obstacles and enablers to engagement with the untested online platform. The results suggest a future large cohort study is warranted and feasible; a basis from which future research has been developed, alongside an enhanced understanding of cognitive and contextual factors which may influence optimal outcome for people with Achilles tendinopathy and hence new knowledge has been generated.