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CoreDomainSetforTendinopathy:SurveyData
DelphiprocessforCoreDomainSetforTendinopathy:Surveydata.
Context:
1. Synthesisingresearchfindingsfromclinicaltrialsofhumantendinopathyiscurrentlydifficultfora
numberofreasons,oneofthembeingalackofagreeduponcoresetofoutcomemeasures(thatare
valid,responsiveandfeasible).
2. Acriticalandprimaryconsiderationofanoutcomemeasureisthatittargets/measuresahealth
domainofthecondition(tendinopathyinthiscase).
3. Therearecurrentlynocorehealthdomainsfortendinopathythatareagreedupon.
4. OncethereisanagreedCoreDomainSetforTendinopathy,thenthetaskofagreeingtothe
outcomemeasuresforeachspecifictendinopathycancommence.
Methods:
ThedevelopmentoftheCoreDomainSetisbeingdevelopedasperthefollowingprocess:
1. Literaturereviewofdomainsandinstrumentspreviouslyusedintendinopathy(notethatthe
instruments/measuresusedwereonlyincludedinthesurveytohelpputincontextthedomain.The
surveywasnotaboutthemeasures,butratherthedomains)
2. Structuredenquirywithstakeholdersontheirviewsondomainsofimportance–surveyandthen
meeting
3. Fullparticipationofallstakeholders(includingpatients)inaconsensusprocesstodetermine
agreementonwhatshouldbe–theCoreDomainSet
Results:
TheresultsoftheexpertsurveyareshownhereininTable1and2.Table1showsthecharacteristicsof
theexpertsrespondingtothesurvey.Table2reportsthe%agreement,disagreementandunsure,the
commentsalignedtotheseresponderlevels,followedbyabriefoverviewmadebythecommitteeanda
proposalforthemeeting.
Insummary,therearetwodomainsthatareabovethe70%agreementthreshold:
• PainonActivityorLoading(aratingofpainwhenthepatientisdoinganactivityorunderload)
• Disability(thisisapatientratingofthedisability,orabilitydependingonanchorsand
wording/orientation,onamulti-itemquestionnaire)
Therewasonedomainthatwasabovethe70%disagreementthreshold:
• RangeofMotion
Therewereanumberofdomainsinthe50-70%agreementrange,whichwillneedconsideration,and
theyare:
Agreement:Function,Patientratingofstatus,QoL,PhysicalFunction,SportsParticipation,Medication
use*,PhysicalActivity*.
Disagreement:painonclinicalstresstest,sensorymodalityspecificity,painwithoutspecificcontext.
*notethatmedicationuseandphysicalactivitywere79%and86%agreement,respective,intheminimal
reportingstandards,whichwillneedtobereconciledatthemeeting.Theissuethatcomesintoconsiderationis
thatminimalreportingstandardswillrequirevalidandfeasiblemeasures,whichareincommonwiththeoutcome
measuresforthedomains.Thisoughtbediscussed.
Inaddition,acohortofpatientsinAustraliawerealsosurveyedontheDomainsquestionnaire.A
summaryofthepatientresponsestothesurveyisincludedinTable3(pages33-&34).
Supplementary material Br J Sports Med
doi: 10.1136/bjsports-2019-100894–451.:444 54 2020;Br J Sports Med, et al. Vicenzino B
Page 2 of 34
CoreDomainSetforTendinopathy:SurveyData
Table1:Participantcharacteristicsofthehealthprofessionalscompletingthesurvey.28ofthe30
contactedresponded(93%responserate)
Characteristic N(%)
SexMale(%) 18(64%)
Role:
Clinicianonly 0
Researcher/Scientistonly 5(18%)
ClinicianandResearcher 23(82%)
Casespermonth:
0(Iamaclinician/scientist) 5(18%)
Atleast4 1(4%)
Between5and10 2(7%)
Between11and15 7(25%)
Morethan16 13(46%)
Yearsmanagingtendonproblem: /27
Atleast4 0
Between5and10 2(4%)
Between11and15 6(22%)
Morethan16 19(70%)
Highestacademicqualification(/26):
Master 1(4%)
PhD 23(88%)
ClinicalDoctorate 2(8%)
Healthcareprofession(somecitedmorethanone~):
Physiotherapy 13
Sportsphysician 5
Orthopaedicsurgery~ 4
Rheumatology~ 3
SportandExerciseMedicine~ 3
Radiology 1
Humanmovementscientist~ 1
Epidemiology~ 1
Surgery 1
Currentlyhavetendonproblem: 8(29%)
Pasthistoryoftendonproblem: 19(68%)
Country(wherework):
Australia 8(29%)
UnitedKingdom 5(18%)
Netherlands 5(18%)
Canada 2(7%)
USA 2(7%)
Denmark 2(7%)
Qatar 1(4%)
Sweden 1(4%)
HongKong 1(4%)
Norway 1(4%)
Supplementary material Br J Sports Med
doi: 10.1136/bjsports-2019-100894–451.:444 54 2020;Br J Sports Med, et al. Vicenzino B
Page 3 of 34
CoreDomainSetforTendinopathy:SurveyData
Table2:Surveydata.
Orderofagreeordisagree:1.
PercentAgree/Disagree/Unsure:93%/0%/7%
Domainasonsurvey:PainonActivityorLoading
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thedomainaslistedonthesurvey:Thisdomain
wasreportedon60occasionsin45papers(37%),assomeauthorsusedmultipleloadingtests(e.g.;oftenthehop,jump
andsquat).*Thetypesofoutcomemeasuresusedbyauthorsforthisdomainwereusuallya10cmline(VisualAnalogue
Scale)anda11pointNumericalRatingScales(0to10)bywhichtheparticipant(patientsorcontrols)reportedthelevelof
painoncertaintasksthatareknowntoaggravatetendons.Someexampleoftasksarehopping,jumping,squatting,
gripping,lifting.
Committee’scomments:Stronglysupportwithnodisagreement.
CommentsofAgreeresponders:
1.Acriticalpartofassessment
2.Certainlyamainstayinlowerlimbandelbowtendinopathy.Lesssureoftheuniversalityinshoulder
tendinopathybeyondactivitiesofdailyliving.
3.Differencesbetweenupperandlowerlimbmaycauseproblems
4.Iagreethatpainonactivityandloadingshouldbeincludedasoneofthecoredomainsetfortendinopathy.
However,theintensityofactivityandloadingmightdifferinsubjectswithdifferentlevelofparticipation.To
standardizethemagnitudeofhabitualloadingisessentialbutdifficult.e.g.thetrainingintensity/competitiontime
neededtoberecordedandincludedasco-variate.Tostandardizetheintensityofloadingduringcertain
provocativetestmaybepossible.Inthisconnection,singe-leggeddeclinedtestisbeingusedasaprovocativetest
forindividualwithpatellartendinopathy.Theintensityofpainisquantifywhensubjectperformssingle-legged
squatttoapre-setangle.Nevertheless,notallsubjectwouldhavepainbeingproducedatthepre-setangle.
Hence,Iagreethatpainonactivity/painunderpre-definedloadingshouldbeincludedasoneofthecoredomain
set.
5.Ithinkitisimportant,asIfrequentlyuseitasmeasureforprogressionintheclinicalsetting.However,itmight
bemoreimportantwhetherapatientthinksthisisrelevant.
6.IngeneralIagree-fortendonssuchasachillesandpatellartendinopathyandalsotenniselbow(grip),testsfor
painonactivityorloadingisalreadyfairlywelldefinedandveryuseful.Forothertendons,suchtestsmayneed
furtherdevelopmentandstandardisationtobeabletorecommend.Theseverityoftheconditionwillalsoinfluence
abilitytoreproducepainduringafunctionaltestinclinic-sometimesthepainiscumulativeandonlyreproducible
afteralongrunorahillrunningsession(e.g.forproximalhamstringtendinopathy),butasweusemultipledomains
inexamination,thisoneisusefulasaseverityguide.
7.Painiswhatpatientspresenttouswith!Onehastobeverycarefulwithpainintrials-becausetendonpainis
relapsingandremittingtoadegree(i.e.ifyoutrainmorethereismorepainandifyourestthereisless).Alsopain
canstaystaticwhistfunctionimproves(ordisabilityrecedes)althoughthereisanimprovement.
8.Seemsmoresensitivetochangeandpatientunderstandsthedomain
9.Tendinopathyusuallyandmostlypresentsasapainrelatedtoloadingmusculoskeletalcondition,sothisisan
importantdomain.Itrelatesdirectlytowhatmightbeviewedasthecurrentclinical'diagnosis'oftendinopathy(ie,
tendonlocalisedpainrelatedto/associatedwithloading)
10.Theclinicaldefinitionoftendinopathyshouldincludepain,localchanges,anddecreasedlevelsofability(i.e.
disability)inducedbythecondition
11.Thistypeofinjuryisrelatedtoloadingandmanyhavenopainatrest.
12.Veryimportantinfo.Painduringasoecifictypeofloading-likepainduringwalkig,runningandjumping.
13.Veryimportantmeasure-andthemainreasonthatpatientsseesportsphysicians
14.VERYimportant.Thisisacorecomplaintofpatients.
15.Yes-oncetheloadingtestsareappropriateloadingtestsasdeemedatalaterdatefollowingfurtherwork.
CommentsofDisagreeresponders:none
CommentsofUnsureresponders:
16.NotsureofthisisrelevantforALLsubjectswithtendinopathyoronlyforpatientswithspecificactivitiessuchas
athletes.
Supplementary material Br J Sports Med
doi: 10.1136/bjsports-2019-100894–451.:444 54 2020;Br J Sports Med, et al. Vicenzino B
Page 4 of 34
CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:2.
PercentAgree/Disagree/Unsure:86%/7%/7%
Domainasonsurvey:Disability
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin75papers(/122;
62%).*Thetypesofoutcomemeasuresthatareusedbyauthorsforthisdomainare:(a)allpatientrated(completedby
thepatient);(b)askaseriesofquestionsabouthowthetendonproblemaffectsarangeofactivities(e.g.,daytoday
activities,sport,recreation)toscoredisability(orthelimitstofunction/doingthings);and(c)giveonenumberto
representthepatient'sproblem.SomeofthemeasuresthatareusedareVISA-A,-P,-G;DisabilityoftheArm,Shoulderand
Hand(DASHandquickDASH);PatientRatedTennisElbowEvaluation(PRTEE);FootandAnkleOutcomeScore(FAOS);
WesternOntarioandMcMasterUniversityOAIndex(WOMAC);RolesMaudsleyScore.
Committee’scomments:
Strongsupportfortheconceptofdisability,withsomecommentssurroundingaspectsofterminology(ability,
function,disability)andissuesofmeasurement(specifictoatendon,orsportetc,validity?)
CommentsofAgreeresponders:
1.Disability-intermsofwhetherornotyouareabletocompleteyoursport/activityisprobablysecondonlyto
paininimportance
2.Disabilitybeingacompositemeasurethatassociatesthelevelofability/functionoftheindividualwiththeir
condition(painstate).
3.disabilityisakeyfactorinthecondition
4.Disabilityisdefinedas:aphysicalormentalconditionthatlimitsaperson'smovements,senses,oractivities.our
shoulderresearchhttps://bjsm.bmj.com/content/52/4/269https://www.ncbi.nlm.nih.gov/pubmed/28106306
hasidentifiedthatbioandpsychosocialfactorsareimportanttomeasure
5.Disabilityisoneofthemostimportantindicatorsoftheimpactoftendinopathyonavarietyofactivities.
6.Idon'tthinkthattendinopathyisdisabling-rather,annoyingandfunctionallydifficult.However,Irecognizethat
outcomesmeasurementsusethistermanditsdefinitionissomewhatfluid.
7.Itishowtheinjuryaffectsthepatientthatisthecoreofpatientcenteredtreatments.
8.Itwouldbegoodtohaveconsistentmeasuresusedinthefutureaswellasdevelopmoreifthereisagap
9.Limitationoffunctionisoneoftheprimaryreasonsapersonwithtendonrelatedissuespresentstoahealth
professionalforassistance.
10.Mainreasonforpresentationinmostcases.
11.PROMSimportant.Theoutcomemeasureslistedarevaluable(declaredinterest,IwaspartofVISA-PandVISA-
Ateams)
12.Tendinopathyisclinicallyrelevant,anddoescausedisability
13.Tendon,isthekeycomponentofthemuscle-tendon-boneunit,andisthecontrollerofthelocalmotionsystem.
Tendinopathyisadiseasethatcausesgreatimpactonindividual'sability.Thisdiseaseisnotassociatedwithlife-or-
deathbutessentiallyisadiseasethatlinktoindividual'sabilityonmotion.
14.Vitalinformationalongwithpainonspecifiedcircumstances
CommentsofDisagreeresponders:
15.Iratherfocusonexactlywhattypeofexercise/loadingthepatientcannottolerate.
16.Relevantasadomainbutnotsensitivenorreliabletomeasure.Patientsstrugglewithratingit,andtoolsare
oftennotsensitivetomanypatientssymptomsnorchange
CommentsofUnsureresponders:
none
Supplementary material Br J Sports Med
doi: 10.1136/bjsports-2019-100894–451.:444 54 2020;Br J Sports Med, et al. Vicenzino B
Page 5 of 34
CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:3.
PercentAgree/Disagree/Unsure:11%/75%/14%
Domainasonsurvey:RangeofMotion
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin19papers(16%).
*Thiswasusuallymeasuredwithaspecialinstrument(goniometer,inclinometer,ordynamometer),butalsovisuallyina
fewreports.Notethatthisisasoledomainhere.Inanotherdomain('clinicalexaminationfindings')itisincludedina
combinedscore.
Committee’scomments:
CommentsandresponsesareconsistentwithROMnotbeingcore
CommentsofAgreeresponders:
1.asabove
2.Basedprimarilyonaneliteathletepopulation,whereobjectivemeasuresoffunctionareimportantoutcomesof
treatment.
3.tendinopathy,inandofitself,doesnotBLOCKrangeofmotion,butpainrelateddecreasesoccur.
CommentsofDisagreeresponders:
4.Again,usuallypoorcorrelationwithoutcomeandfunction.
5.Generallynot,yettheremaybeacaseintheshoulder.
6.IseeROMasIseestrength+imaging-itsanicetohave-butnotamusthavedomain.Forthesamereasons-I
thinkyoucanhaveawellsetupandusefulstudywithoutROMmeasures.
7.Limitstorangeofmotionarenotacommonfeaturetoalltendoncomplaints-Ifeelresponsetoloadingismore
tendonspecificandhencefeelthatrangeofmotionshouldnotbeincludedinacoredomainset
8.Oftenlowinterobserverreliability,tellsmenothingaboutimpactorconsequencesofthedisabilityforaspecific
person.
9.oftennotrelevant
10.Patientsdonotcomplainabouttheirrestricted(orincreased)ROM.
11.Pleaseseequalificationtoquestion11.
12.Relatedtopainandswellingofparatenon.
13.ROMhasnotbeenconsistentlyrelatedtotendinopathyinjury.
14.ROMnotrelevantinmosttendons,althoughdecreasedDFassociatedwithtendonpain
15.Toomanyothervariables
CommentsofUnsureresponders:
16.Also,itdependsontheaimofthepaper.Itmaynotberequiredundertheinclusion/exclusioncriteria.Itcanbe
usedasanoutcomesincertaintendinopathictendon.However,whichjointrangetobeincludedissport-specific
asidefromtendonspecific.E.g,kneeflexion/extensionandankledorsiflexionrangemightbeimportantfor
volleyballplayerswithpatellartendinopathy.However,badmintonrequiresgoodrangeofhiprange(IR/ER)for
appropriatealignmentofthekneeduringforward/backwardlounging.
17.Hardlyeveranissueforpeopleinthelowerlimb,butmaybeintheshoulder.Dependsonthescopeofthis.
18.seeabove.
Supplementary material Br J Sports Med
doi: 10.1136/bjsports-2019-100894–451.:444 54 2020;Br J Sports Med, et al. Vicenzino B
Page 6 of 34
CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:4.
PercentAgree/Disagree/Unsure:68%/11%/21%
Domainasonsurvey:Function
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin8papers(7%).*This
domainisspecificallyabouttheparticipantratingtheirleveloffunctioninonescore(e.g.,PatientSpecificFunctionScale,
wherein100%isfullfunctionand0%isunabletousethelimbsuchasinaslingforthearmandnotweightbearingona
leg).Itdoesnotaskaboutthepain,justaboutthefunction.
Committee’scomments:
Nine(/14)commentsfromtheagreeresponders(approx70%agreementhere,thirdhighestagreedto
domain)forFunction,withmanyofthecommentsfordisagreeandunsure(andsomeintheagree)indicating
thefocuswasmoreontendonrelatedpain,whichassomepointoutiscoveredindisability.Thisdomainis
justfunction-thatis,whatistheleveloffunctioning(disregardingpain)asinhowmuchcantheydo.
CommentsofAgreeresponders:
1.FullreturntofunctionisgenerallyamaingoalbothfortreatingMD/PTandpatient.
2.Ifitiswellspecifieditaddsvalueforsure-especiallyinathtletes
3.Ifrelatedtocertsintendon
4.Keyreasonpatientspresent.
5.Overlapswithdisability.Oneortheother.
6.PartofthetriadasdescribedinArthroscopy.1998Nov-Dec;14(8):840-3.Overusetendonconditions:timeto
changeaconfusingterminology.MaffulliN1,KhanKM,PudduG.
7.tailoredtoeachtendon
8.TheleveloffunctionanindividualisabletoattainisapartoftheICFframeworkandshouldbecapturedfora
loadrelatedconditionliketendinopathy.
9.Yesbecauseweaimtorehabilitatefunction
CommentsofDisagreeresponders:
10.Iconsiderthedomain'disability'toprovidesynergisticinformation.
11.Ithinkthisisonlyrelevantwhenthepainistakenintoaccount(likeinallVISAscoresforexample).Someone
canhaveaperfectfunctionwithalotofpain,soasisolatedmeasureitislessvaluable.
CommentsofUnsureresponders:
12.Markedlylessspecificthanthemoretendon-relatedinstrumentsthathavebeendevelopedoverthelast2
decadesorso.
13.ThePSFScanbeusefulfortrackingchangeinaspecificfunctionforoneindividual,buttherearedifficultiesas
patientsoftenfinditverydifficulttoseparatepainandfunctionasmostoftenthereasonfortheirinabilityto
performataskisthepain.Also,itisimportanttoquestionregardingthesameparticularfunction/sovertime,as
givenablankPSFStorateatdifferenttimepoints,patientswilloftenfillindifferenttasks,resultingindifficulties
withcomparability.
14.tricky.Goodquestions.Willruleoutmanystudies.Isaonenumberscorevalid?
Supplementary material Br J Sports Med
doi: 10.1136/bjsports-2019-100894–451.:444 54 2020;Br J Sports Med, et al. Vicenzino B
Page 7 of 34
CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:5.
PercentAgree/Disagree/Unsure:61%/14%/25%
Domainasonsurvey:Patientperceptionofconditionstatus
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin37papers(30%).
*Twoexamplesofthetypesofoutcomemeasuresreportedbyauthorswere:globalratingofchange(e.g.,areyoubetter,
sameorworsethanimmediatelybeforetreatment),andpatientperceptionofstatusofcondition(e.g.,isyourcurrent
conditionsatisfactory,whenyoutakeyourgeneralfunctioningandcurrentpainintoconsideration).
Committee’scomments:
Thishasthe4thhighestagreement,7thhighestofunsureandamongthelowestofthedisagree(20th/24).
Thereweremanycomments(11)bythosewhoagreedtotheeffectthatthismeasurereflectedthepatient's
overallperceptionoftheircondition,asopposedto2commentsbythosewhodidnotagreewhoindciated
themeasureistoosubjectiveorthetermisdifficulttounderstand,whilethe4commentsfromtheunsure
responsesthattendedtomirrorthedisagreecomments.Thedomaincouldberewordedto'patientoverall
assessmentofcondition'asthismightaccommodatecommentsherein-asitmoreclearlydescribesthe
overallratingbythepatientoftheirconditionandleavessilentatthisconceptuallevelifthisisachangeover
timeoraglobalratingofthecondition(consideringweareworkingtowardsaparsimoniouscoredomainset).
CommentsofAgreeresponders:
1.Asinglenumerical/categoricalassessmentofthepatient'sstatus(withtheirtendinopathy)providesanoverall
assessmentfromtheirperspective.Theywillinherentlyapportiondifferentaspectsoftheirconditionavaluein
comingtoasingleassessmentnumberorcategory.Inourpatientconsultationmeetings(focusgroups)wherewe
discussoutcomemeasures-patientsfavourtheGROC-iehowareyounowcomparedtobeforetreatment(eg,
better,same,worse-acrossseveralcategories).
2.Asubjectmayshowchangesatimaging,andnotmanifestanysymptoms.Inthesedaysofpatientsbased
outcomes,theperceptionofthepatientisofcapitalimportance
3.Alsousefullforresposivenessstudies
4.asabove
5.aslongasitisnotusedinisolation
6.Embracespatientresponsetoalldomainsofmanagement...
7.IthinkaGROCisuseful-icanbeusedtocompareaccrossmanydiseasesandconditionsthroughoutthewhole
ofmedicineandiseasyininterpretforbothcliniciansandpatients.Itishoweveranitemthatonlyreallyhasuseat
followupmomentsandnotduringabaselinemeasure
8.Patientefficacyorrecoveryexpectationsisanimportantconsideration.
9.Stronglyagree-theseareoftenthesortofquestionsthatpatientsseemtofindeasiesttorelateto.
10.Thisisadefiniteforme.Althoughwemaythinkweknowwhatisimportanttopatientsiedisability,pain,etc,
wecannotknowthisforallpatients.Thismeasurethereforeinmyopinionispatientcenteredandimportant.
11.Thisisessential
CommentsofDisagreeresponders:
12.Idon'tunderstandtheterm,honestly.Howthepatientperceivestheircondition?Thinkingonthisfurther,I
amassumingthisiscomingfromsomeoftheworkstatingthatpatientswhohaveatendencytocatastrophizeare
thosewhopresentforcare.Istilldon'tthinkthisshouldbeincluded.
13.patientperceptionistoosubjective.Thereareunknownelementsthatmightinfluencetheoutcome/changes
inthisoutcome.theunknownelementincludepersonality,moodetc
CommentsofUnsureresponders:
14.Depends.Thefirstexampleisverydifferentthanthesecond.Ratingofchangeonalikertscale/similaris
seeminglymorereliableandthanothers.Thesecondsampleismoredifficultforpatientstoanswer
15.Ibelievethatthe(perceived)ratingofchangeisimportantwhenassessingtherapy.Notsurewhetherthe
perceivedstatusofconditionisofaddedvaluetootherscores.Itmaybeimportanttocheckwhetherthereisan
overlapofthisquestionwithotherquestionse.g.oncopingstrategies.
16.I'mnotconvincedofthisbecauseitisnotparticularlyobjective
17.Maybenotimportant.Moreimportanttoknowifremainingpainaftertreatmentduringwalking,runningor
jumping.
Supplementary material Br J Sports Med
doi: 10.1136/bjsports-2019-100894–451.:444 54 2020;Br J Sports Med, et al. Vicenzino B
Page 8 of 34
CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:6.
PercentAgree/Disagree/Unsure:57%/11%/32%
Domainasonsurvey:QualityofLife
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedby21authors(17%).
*Thetypesofoutcomemeasuresreported:EQ-5D,AQoL,SF-36,internationalHipOutcomeTool(iHOT-33),SF-36,
WesternOntarioRotatorCuffIndex(WORC),Foot&AnkleOutcomeScore(FAOS).
Committee’scomments:
Approx60%agreeand30%unsurehavingcommentsthatessentiallyagreewithQoL,butmanystipulatingthe
needforspecficityofmeasuresforthetendinopathypopulation.5thand4thhighestproportionofagreement
andunsureasopposedto21/24fordisagree,tendstosupportthisdomainascore.
CommentsofAgreeresponders:
1.Absolutelyimportant.
2.Althoughnotcommonlyutilised,itdoesgenerallyreflectapatient'sstatusagainsttheirnormalleveloffunction.
Someinstrumentsabovearelessspecifictotendon-relatedlimitationstofunctionorperformance.
3.asabove
4.Comparisontootherdisabilitiespossible
5.especiallyfordemonstratingtheimpactoftponADL/QOLimportanttogettp'ontheagenda'
6.Howtheinjuryisaffectingtheindividualisofimportancesincepatientshavedifferentgoals,activity
requirementsandexpectations.
7.Inmostcasesnotveryspecificandhardtocompleteforthispatientgroup,butimportantforfunding
8.QoLisanimportantoutcomemeasureforevaluation(cost-effectiveness)researchwhenappropriateoutcome
measuresareused.InadditiontothegeneralQoLquestionnairesitisnecessarytohaveamorespecific
anatomy/lesionbasedscore.IamtoounfamiliarwiththeWORC,IHOT-33,andFAOStojudgethese.
9.Reallyimportantandhasnotbeendonewellinthepast
10.ultimatelyitisthevalueapersonplacesontheirqualityoflifethatdeterminestheimpactofthecondition
11.Yes-butneedtocreatemorespecifictendonspecificqualityoflifemeasures?
12.Yes,itmightbeofimportancetoshowhowsometendonconditionsaffectsdailylife.
CommentsofDisagreeresponders:
13.Notinthecore.
14.Toosubjectiveanddifficulttoassess
CommentsofUnsureresponders:
15.Dependsonthepatientpopulation.MyresponsesaremainlybasedonthepopulationIworkwith,(elite)
athletes.Forathletes,IdonotthinkthegeneralQoLinstrumentsareappropriate(andthereforeathletesfindthem
irrelevantandcumbersome).
16.dependsonthetendon,reductionofactivityinanAchillesmayresultinanOKQoL,samenottrueinglut
tendon
17.Dependsonwhichtendon.Overallnotsensitiveinmanypatients
18.QoLisanimportantdomainbutisperhapsreflectedinotherdomainssuchasfunctionandquestionssuchas
theGROC.Iwouldbehappytoincludeifthemajoritydecidestoinclude.
19.Qualityoflifemaybeaffected
20.Yesinplaces-IliketheEQ5Dbecauseitisaquickeasytomeasureassessment.SF36becomesmoredifficult
butpossible;asdosomeoftheothersmentioned.
Supplementary material Br J Sports Med
doi: 10.1136/bjsports-2019-100894–451.:444 54 2020;Br J Sports Med, et al. Vicenzino B
Page 9 of 34
CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:7.
PercentAgree/Disagree/Unsure:18%/61%/21%
Domainasonsurvey:Painelicitedwithclinicianappliedstresstest
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin9papers(7%).
*Cliniciansappliedaspecialstressororthopaedictestandtheparticipant(patientorcontrol)reporttheintensityofpain
theyfeelona10cmlineor11pointscale.Thisisnottheparticipantdoingthetestaswouldbethecasewhentheyhopor
jumporsquatinthedomainitem'painonactivityorloading'above.
Committee’scomments:
With60%disagreeand20%unsure,theredoesnotappeartobesufficientsubstanceforthisinacoredomain
set.
CommentsofAgreeresponders:
1.Obvious.
2.THisishowImeasurephysicalexamsigns
CommentsofDisagreeresponders:
3.Idontseethisbeing"universal"enoughtogoincoreset-whichspecialtestwouldidoforpatella/achillesfor
example.
4.No.Perhapsonlyrelevantifthe'stress'couldbequantified.
5.Notanimportantoutcomeforpatients.
6.notreliable
7.Pleaseseequestion13.
8.unlikleytoloadthetendonenough
9.Unreliableandtendonspecific
CommentsofUnsureresponders:
10.Ispartofclinicalexamination
11.Notsurehowthisdiffersfrompainonpalpation.
12.Thismightprovideareasonablyobjectivemeasureofelicitedpainforcomparisonbetweenindividuals?
13.Yes-Butnotsurewehavetheappropriateknowledgeorconsensusonwhatthebest"stress"testsareforthe
relevanttendons
Supplementary material Br J Sports Med
doi: 10.1136/bjsports-2019-100894–451.:444 54 2020;Br J Sports Med, et al. Vicenzino B
Page 10 of 34
CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:8.
PercentAgree/Disagree/Unsure:11%/54%/36%
Domainasonsurvey:Sensory-modalityspecificpain
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin8papers(7%).*The
amountofastimulus(suchaspressure,heat,cold)thatelicitspainismeasuredwithaninstrument(analgometer)forthis
domain.Soitisnotthelevelofpainthatisthefocusbuthowmuchstimuluselicitsthepain,andthestimulusisasensory
one.
Committee’scomments:
Commentsoftheunsurealignstronglywiththedisagreeresponseanddonotsupportsensorymodality
specificpainasacoredomain.
CommentsofAgreeresponders:
1.Anywaytoquantifypainiswelcome.Itshouldbenoted,however,thatpainonpalpationmaynotcorrespondto
painonuseofthelimb
2.Optionaldependingonequipmentavailableandexpertise
CommentsofDisagreeresponders:
3.Asperimaging/rom/strength/costanalysis-greatifyoucandobutnot"core"
4.Difficulttoadequatelyevaluate
5.Interestingexplorativemeasure,butnotaC-TOM.
6.Maybeusefulforresearchstudies,butnotacoredomainthatwouldbewidelyclinicallyapplicable.
7.Morearesearch/mechanismsapplicationforme.
8.Notcriticalandnotreportedenough.
9.Toovariable
CommentsofUnsureresponders:
10.AlthoughIthinkthisisaveryimportantmetric-Iamnotsureweareatthepointwhereweknowenough
aboutQuantitativesensorytestingintendoncomplaintstomakeitacoredomainset
11.howvalidarethesemeasurementsandwhatdotheyad?
12.importantinstudiesdirectedatthis,butforclinicalstudiesno,willbedonebadlyunlessgoodequipmentand
thisistooexpensiveformanyresearchers
13.Maybenotacoredomain,butveryusefulinfurtherinvestigationintothegreaterchallengeofpaingeneration
andmodulation.
Supplementary material Br J Sports Med
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CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:9.
PercentAgree/Disagree/Unsure:57%/21%/21%
Domainasonsurvey:Physicalfunction
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin6papers(5%).*The
typesofmeasuresusedforthisdomainwere:distancejumped,heighthopped,numberofsingleheelraises.Thatis,how
muchofatasktheparticipant(patientorcontrol)waswillingtoperform.
Committee’scomments:
Thephysicalfunctiondomainalignsreasonablywellwiththeloadingtestsinthebaselinereporting
recommendationsurvey(61%agreethere).Someofthecommentsinhereneedtobeexploredatthe
meetingtoensurethatthereisadifferencebetween'function'and'disability'domains,aswellasphysical
activitypossibly.Otherwisethereappearstobesupportforthisasastandalonecoredomain.
CommentsofAgreeresponders:
1.asaloadrelatedcondition,tendinopathyoughtbedescribedintermsofthephysicalfunctionoftheindividual
2.Asabove,overlapswithfunction,disability.Mypreferencefromallofthesewouldbephysicalfunction.
3.definitelykey.
4.Especiallyforphysicallyactiveindividualsthereturnoffunction(toatleastreachingtheuninjuredside)isof
importanceforfullrecovery.
5.forstudiesinthemoreactivedefinitelyandagainmorespecificforsometendons,suchaswalkingdistancefor
glutmed
6.Thiscanbemeasuredalongsidethepainmeasurementsduringthesetaskssodoesnottakeadditionaltime.
7.YesPleaserefertoArthroscopy.1998Nov-Dec;14(8):840-3.Overusetendonconditions:timetochangea
confusingterminology.MaffulliN1,KhanKM,PudduG.
8.YesbutnotinadditiontoQ18
CommentsofDisagreeresponders:
9.combinewithabove?
10.Interestingexplorativeoutcomemeasure,butitisverydependedonpatient'smotivation.Asasportsphysician,
Iamnotusingitintheclinicalsetting.Soforme,thisisnotaC-TOM.
11.Isthatproventobereliableandrepeatableandsensitive?Idoubtit.
12.Whilesuchmeasuresareusefulforassessingimpairmentswithinanindividualwhichmightprovidesome
treatmentdirectioninclinicalpracticeforthatindividual,correlationwithoutcomesespimposingasinglemeasure
acrossagroupofindividualsasanindicatorofoutcomesislikelytobepoor.
CommentsofUnsureresponders:
13.Couldbeveryusefulbuthowtodefinewhichteststodoaccrosstheagerangesandabilityrangesuseein
practice.InAchillesImayhave65yroldgrandmawhocanthoponce-butneverneedsto-or20yearoldrunner
whocannail5hopsbutcantrun21kmatburningpace-sopassesthetestbutisstillrestricted.Soasaprinciple-
wouldbegreat-butmaybechallenginginpractice
14.Perhapsnotacoredomainastheapplicationwouldbecohort-specific.InAchillestendinopathyforexample,
normalisationofheightordistancehopcouldbeanimportantglobalparameterinahighfunctioninggroup,yetit
mustbeacknowledgedthiscouldnotbeapplieduniversally.
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CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:10.
PercentAgree/Disagree/Unsure:25%/57%/18%
Domainasonsurvey:Pain',withoutanyfurtherspecification
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin36papers(30%).
*Theuniquefeatureofthisdomain(Pain)isthattheauthorsonlystatetheyreportedpainoftheparticipants.Thatis,
theydidnotspecifyifitwasunderloading(e.g.,activity,hoporwalk)orspecificcircumstances(e.g.,firststep)orina
particulartimeframeorataspecifictime(e.g.,morning).Sothisiteminthissurveyisaskingyoutoconsiderifpain
shouldbefurtherspecified,asinsomeoftheotheritemsinthissurvey.
Committee’scomments:
Commentsbyagreeresponderslookliketheydidnotunderstandthedomainandwouldlikelydisagreewith
thisdomain.Thecommentsfromtheunsurerespondersalsotendtomirrorthosefromthedisagree.The
approx60%disagreementplacesith'asthe3rdhighestdisagreementproportion.Givencommentshereand
responseratesforotherpainrelateditems,painneedstobespecifiedincontext(egwithloading).
CommentsofAgreeresponders:
1.asabove
2.IrecommendpainbeingadomainonitsownANDhavingspecificationslisted.
3.thisisthereasonpatientspresent.Itisacriticaldomain.
CommentsofDisagreeresponders:
4."Pain"provideslimitedinformationandcannotberegardedasacoredomainsetfortendinopathy.Theintensity
ofpainunderwhat"kind"ofloading,what"intensity"ofloading,and"time"
5.conditioninwhichpainoccursshouldbespecified
6.Inastimulus-responseparadigmbothelementsshouldbereportedforrigourandadeeperunderstanding.
Perhapspainatrestmaybeusefulthoughinsomeoftheupperlimbtendinopathieswheretheseaffectdaily
function.
7.Maydependonthepatientpopulation.MyresponsesaremainlybasedonthepopulationIworkwith,(elite)
athletes.Forthese,itisimportanttouseintrumentsthatclearlyseparaterest/nightpainwithpainduringandafter
activity(activity-rleatedpain).Otherwise,anathletewhocannottrainmayreportnopain,becauseheisnot
training...
8.Needsmoredetails
9.Needssomeformofclarification
10.Needstobeclearunderwhatcircumstance
11.Needstobespecified
12.notspecificenough,sourceofpoordiagnosis
13.Painifdescribedshouldbespecified
14.Painisthemainreasonwhypatientsconsult,yetifreportedwithoutcontextishasnovalueasyoucant
inpterpret/understandit
15.Painshouldbequalified
16.Painshouldberatedinaspecificcontext.
17.Seemstovaguetobevaluable.RestpainNOTafeatureofmosttendinopathyasuknow
18.Whenpainisasked,itshouldbespecifiedunderwhichconditionsthepainisoccurring,otherwisethismaybe
misleading.
19.Withoutspecificationitisuselessimo
CommentsofUnsureresponders:
20.Iamunsurehowtoanswerduetotheexplanation.YesIthinkpainquestionsneedfurtherexplanationsuchas
atrest,morningpainetc.ButstillnotsureifIshouldanswerthisquestionyesorno.
21.Painimportantonlyiflocatedinasoecifictendonandrelatedtoacertaintypeofloadingofthattendon.
22.Painseveritywithoutfurtherspecificationappearstobelessusefulthanspecifiedpain.Sometimeswherethis
canbedifficulthoweverisifthemostpainfultaskorsituationchangesovertime.So,worstpaincansometimesbe
usefultocapturethis.Painconstancy/frequencycanalsobeausefulmeasureofpain-%oftimeoverthelastweek
apatienthasexperiencedpain.
23.Wouldneedtobefurtherdefined.
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CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:11.
PercentAgree/Disagree/Unsure:57%/29%/14%
Domainasonsurvey:Sportparticipation
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin3papers(2.5%).
*Thesortsofmeasuresusedherewere:thetimetoreturntosport,thelevelofsportachieved,andarangeofdifferent
scalesofparticipationinsport(e.g.,socialorelitelevel).
Committee’scomments:
Mostcommentsfromtheagreeresponders-buttheseseemtoreflecttheothersinthatitmightbetoo
restrictivefortendinopathygenerally.Giventheresponsestotheaggregate/removeitemsonthesurvey,it
wouldseemreasonablethatwediscusswherethisfits(eg,aspartofanotherdomain-likeparticipation?).
CommentsofAgreeresponders:
1.Aloadrelatedconditionoughttoencompassparticipation,includingsport.
2.activityratherthansport,returntotheirlevelofactivitycritical
3.Andnotjustparticipationlevel,butperformancerelatedtonormalperformancelevel.
4.Andnotonlysportparticipation/RTSyesornobutalsotheparticipationlevel(egOSTRCquestionnaire)
5.Appliestoasubset.Again,willdependontendonandscope.
6.Importantforpatientsandsomethingwealwaysaskashealthcareprovidersduringfollow-up.Myimpressionis
thatthistypeofoutcomemeasuredescriptioninliteratureisveryheterogeneous.Couldweprovideastandardfor
tendinopathyonthissubject?
7.itmaybeanoptionalquestionforthoseactivelyparticipateinsport
8.OfimportanceinathletesItshouldberecognised,though,thatmanysedentaryindividualssufferfrom
tendinopathy
9.PartofVISAofcourse-insportsmedicineIthinkitis:)
10.Thiscanreallyvarydependingontypeandsiteoftendinopathy.Meaningistheinjurymainlyasport/physical
activityrelatedinjurythenveryimportant.Istheinjurymoreworkrelatedthanlessimportant.
11.Yes-butneedstobedefined-BernconsensusonRTSinBJSMwouldseemgoodplacetostart.Justas"pain"is
uselessdomainwithoutspecifics-RTSdoesnothelpwithoutcontextandspecifics,
CommentsofDisagreeresponders:
12.Forsometendonproblems,thisisveryimportantbutnotsousefulforothersthataremoreprevalentinolder
peoplelessengagedinformalsport.Iftheaimistoachieveacoresetapplicableacrossalltendons,thenno.
13.Mostpatientspresentingarepasttheageofactivesports.
14.Noteveryoneparticipatesinsport
15.Unreliable
CommentsofUnsureresponders:
16.Againbestconsideredasupplementarydomain,astendinopathyisnotrestrictedtosportspeople.
17.Althoughthisisperhapsthemostsignificantactivityforalargeproportionoftendinopathypatients,thisseems
tooverlapwithpreviousquestionsonactivityanddisability?
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CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:12.
PercentAgree/Disagree/Unsure:57%/29%/14%
Domainasonsurvey:Medicationuse
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin3papers(2.5%).
Committee’scomments:
Ratedatalmost60%,medicationuseisthe5thhighestrankedonagreementofalldomains.Theminimal
reportingofbaselinefeatureshasreturneda79%agreementthatthisshouldbereported.Thiswhen
consideredalonsidethecomments,allofwhicharebytheagreeresponders,itwouldseemthatthisdomain
iscore.
CommentsofAgreeresponders:
1.Corticosteroidsandfluoroquinolonesdoinfluencetheonsetandcourseoftendinopathy
2.dependsifitincludesthosethatareusedforthetendon,thinkinghereofthepolypilletcalsomaygive
indicationofsystemicconditionssuchasdiabetesthataffecttendon
3.Ithink'medicationuse'needstobespecifiedegtendoninjectionororalanti-inflammatorymedication.
4.Ithinkalco-medicationshouldbereported,asitisconsideredanimportantmeasurethatcaninfluenceprimary
outcome.
5.influencesothermeasures
6.Mayneedfurtherconsensus/agreementonwhatexactlywemeanbymedicationuse(i.e.Whatmedicationsare
relevantintendinopathyspecifically?)
7.Theusageofco-interventionsisalwaysimportanttorecord.
8.thiscanbeanextrainformation.Butnotsurewhetheritiscommonlyusedorseldomuseduetothechronicity
natureofthedisease
9.Thisiscriticalasitisafunctionofmedicalisationofwhatisessentiallyahealthrelatedissue-ieloading
associatedpainstate
10.Wouldbeimportanttoknow.
11.Yes-easytodo
CommentsofDisagreeresponders:
12.Doesnotlinktoseverity
CommentsofUnsureresponders:
nocomments
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CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:13.
PercentAgree/Disagree/Unsure:25%/50%/25%
Domainasonsurvey:Participation
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:IThisdomainwasreportedin1paper,butithad4
scales(3%ofallscales).*Thiswasmeasuredbyaskingparticipants(patientsandcontrols)whattheirlevelofactivitywas
withfamilyandathome,recreation,runningorotherphysicalactivity,andsocialactivities,usinga10cmline(0cm=no
limitation,100cm=completelimitation).
Committee’scomments:
Commentsindicatingsomeuncertaintyaboutthisdomaingenerallyandoverall,suggestingitshouldbe
discussedinthemeeting.Itwouldseemthatsuchadiscussionwouldencompassthedomainsof
participation,physicalactivity,sportandworkrelatedparticipationasseparatedomains.
CommentsofAgreeresponders:
1.Aloadrelatedconditionoughttoencompassparticipation
CommentsofDisagreeresponders:
2.asabove
3.CantseehowthisisdifferentfromPhysicalactivity-howphysicallyactiveareyoucanbeusedforathletesand
nonathletesalike?
4.combinedwithqualityoflifeoffunctionscales?
5.Difficulttovalidate
6.Ithinksitishardtotranslatethisoutcomemeasuretopatients.
7.needsmorequantifiedinformation
8.willnotaddmuch
CommentsofUnsureresponders:
9.Overlapsgreatlywithotherqueries.
10.Participationinwhat?Thisneedstobebetterqualified
11.Wouldneedtobespecifiedandcontextrelatedtoaddmeaning
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CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:14.
PercentAgree/Disagree/Unsure:54%/32%/14%
Domainasonsurvey:Physicalactivity
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedinatleast5papers
(4%).*Thisisabouttheparticipant(patientorcontrol)ratingoverallphysicalactivityregardlessofpainorthe
tendinopathy.
Committee’scomments:
Physicalactivityisstronglysupportedasabaselinefeaturetobereportedinthatsurvey.Commentshereare
mainlyaboutitbeingcapturedinotherdomains-wewillneedtolookatthequestionsthatdealwith
aggregationanddeletiontotrytocometosomeagreementregardingcoredomainforphysicalactivity.
CommentsofAgreeresponders:
1.Aloadrelatedconditionoughttoencompassphysicalactivitycapacity
2.inviewoftherelationshipbetweentendinopathyandintensityofexercise/activitiy
3.partoftheoverallperspectiveoftheperson'sactivitylevel
4.Physicalactivityiskeybutcouldbeinferredfromotherdomains
5.Pleaserefertoquestionaboutsport
6.Theramificationsofnotbeingabletobephysicallyactiveareseriousformaintaininghealth.
7.work,sports,adl,hobby
CommentsofDisagreeresponders:
8.couldbecapturedinfunction
9.Doesn'tchangetreatmentoreval.
10.Ithinkwouldneedtobespecified-asRTSabove
11.Ifthisisdifferentfromsportsactivity,Iwouldsayno.
12.Therearesomanyfactorsthatcaninfluencegeneralphysicalactivity,sounlikelytobeusefulasacoredomain.
CommentsofUnsureresponders:
13.Lessstringentreportingelementthanthetendon-specifictools.
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CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:15.
PercentAgree/Disagree/Unsure:50%/29%/21%
Domainasonsurvey:Adverseeffects/events
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:hisdomainwasreportedin9papers(7%).
*Adverseeffects/eventsareanyeventthatoccurstotheparticipant(patientorcontrol)whileinthestudy(orbeing
followedclinically).Theyneednotberelatedtoatreatmentforthetendinopathyortothestudyinparticular,butjustany
eventthatisadversetothehealthoftheindividual.
Committee’scomments:
Thecommentsfromtheunsurerespondersalignwithsupportingadverseeventsasacoredomain,butwith
furtherqualification,possiblyinthemeasurementofthedomain.Veryfewcommentsofanysubstanceinthe
disagreeresponderslendssupporttothisobservation.
CommentsofAgreeresponders:
1.Beendonepoorlyinthepastbutveryimportanttohave!
2.Iwouldlikedocumentationoradverseeventspertainingtodropoutsordetailsonexacerbationofsymptomsetc
3.importantforallstudies
4.Importanttolookforpossibleissueswithtreatment
5.Theassociatedadversehealthissues,whetherrelatedtothetendonissueornot,shouldbepartoftheoverall
healthdomainsetofanymusculoskeletalcondition.
6.Thisisunderreported,butveryimportantwheninformingpatients.
7.Weneedtoknowwhatadverseeffectsagiventreatmentmayinduce
CommentsofDisagreeresponders:
8.Notimportant.
9.Notsurehowthisisrelevant
10.provocativeactivity/testsaremoreappropriatetorule-in
CommentsofUnsureresponders:
11.Ithinkitisausefulitemespeciallyintreatmenttrials,butIbelievethenatureoftheadverseeventneedstobe
specifiedinmoredetail.
12.Maybeeventspecific.Ifthisextendedtosayutilisationofcoach-ratedperformanceinaprofessional
sportspersonthiswouldbequiteuseful,althoughmaybenotacoredomain.
13.notinallstudiesIthinkonlyininterventionstudies
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CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:16.
PercentAgree/Disagree/Unsure:46%/29%/25%
Domainasonsurvey:Workparticipation
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin2papers(2%).*This
domainrelatestothingslikehowlongtoreturntowork,thelevelofwork(howstrenuousfortheparticulartendon).
Committee’scomments:
Commentsaligningwiththeotherparticipationresponses.
CommentsofAgreeresponders:
1.Aloadrelatedconditionoughttoencompassparticipation,definitelywork(whichmightbesportinprofessional
sport)
2.Butdependsonthepatientpopulation.Insports,workequalsreturntosport.
3.forsometendonsmorethanothers,upperlimbespecially
4.Importantaspartofdisabilitythattendinopathyinduces
5.Importantforfunding.Andnotonlythisdichotomousoutcome,butalsolimitationsduringworkanddaysabsent
fromwork.
6.Importanttodeterminetheimpactonworkperformanceandviceversa,workloadontendonproblems
7.Sameanswerasabovetosports.Itdependsonsiteandcauseofinjury.Ifworkrelatedthenyesofgreat
importance.
8.Yes-easytodoandnotbeendonewellinpast
CommentsofDisagreeresponders:
9.Mosthavetoworkanyway.Lowreportingtoo.
10.Notnormallyrecordedandsoweknowlittleaboutthis
CommentsofUnsureresponders:
11.conditionspecific.becausetheinfluencewouldbedifferinsubjectswithelbowverseanklepainassociated
withtendinopathy
12.Deoendantontypeofworkandtendon.
13.Isthisrelevantforeverypatient-effectsoftendoncomplaintsonworkpracticesmaybeasmallsubsetforitto
beincludedasacoredomain.Enoughondisability/functiondatacapturedalreadyinpreviousstatements?
14.Maybesupplementary,onlyusefulinthosewholoadtheaffectedtendonintheirwork.
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CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:17.
PercentAgree/Disagree/Unsure:46%/32%/21%
Domainasonsurvey:Discontinuetreatment(dropout)
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thiswasnotextractedfromthereviewedreports
andisincludedhereforconsideration.
Committee’scomments:
Approximately50%agreementandcommentsindicateneedclarityonreasonsfordis-continuingtreatment.
CommentsofAgreeresponders:
1.Ithinksthisshouldbepartoftheevaluation.Itisstrikingthatthiswasnotdoneinprevioustrials.
2.Obbious.”
3.Partofanywellconductedstudy
4.persistentpainstates,liketendinopathyinmanyinstances,ismarkedbyafrustratingoffandon,trymany
treatments,cyclicalpattern-sotreatmentadherenceorlacktherofisafunctionofthecondition
5.Yes-canhavebigimpactoninterpretingresults-againlikeGROC-thisisreallyafollowupmeasureandcould
bespecifiedasbeingsuch-ratherthansomethingdoneatbaselineandagainatf/u
CommentsofDisagreeresponders:
6.Difficulttodefineeasily
7.No,therearemanyreasonswhypeoplemaydiscontinuetreatmentthathavenothingtodowiththeeffectof
theintervention.
CommentsofUnsureresponders:
8.Maybenotcorebutausefulsupplementaryquestionwhichmayempiricallyreflectabalanceoftreatment
burdenagainstefficacy.Reasonfordropoutwouldalsoneedtoberecordedasitmaybeinfluencedbynon-
treatmentrelatedissues.
9.notsurewhatthismeans,needscontext
10.Onlyininterventionstudies
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CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:18.
PercentAgree/Disagree/Unsure:43%/29%/29%
Domainasonsurvey:Structure
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin36papers(30%),as
51differentmeasuresor42%ofalldomainsextracted.*Thetypesofoutcomemeasuresreportedwere:MRI,US(grey
scale,Doppler),andXray.
Committee’scomments:
Structurewasthe13thmostagreedanddisagreeddomainwiththe6thhighestproportionofunsure.The
latterreflectstheuncertaintyoftherelationshipbetweenstructuralchangeandsymptoms,asreflectedin
manycomments.Thenumberofcommentswasalmosttwiceasmanyfromtheagreeresponders(11)than
thedisagree(7)andunsure(6)-manyoftheseagreecommentsacknowledgetheissueswithmeasurement
ofstructureandthepresentingsignsandsymptomsofthepatientwithtendinopathy,butfeltitanimportant
healthdomain,sufficienttobeacoredomain.Thoseinthedisagreecounteredbymeansofhighlightingthe
disconnectbetweenstructureandclinicalpresentation.Thecommentsfromtheunsureresponderslargely
reflectthedisagreecomments.Thiswillbeadomaintodiscussatthemeeting-weneedtoconsiderthe
following:Agreethatitisacoredomain,butnothaveavalid(responsive,feasible)measure-thiswouldbe
basedonthetendonstructure(changesintendinopathy)arecoretotheconditionoftendinopathy.Onthe
otherhand,ifwedisagreethatitisacorehealthdomainoftendinopathy,itdoesnotmatterifthereexistsa
valid,responsiveandfeasiblemeasure.
CommentsofAgreeresponders:
1.asidentifiedinourresearchandreviewseghttps://bmjopensem.bmj.com/content/3/1/e000279.info
https://www.ncbi.nlm.nih.gov/pubmed/26666736https://onlinelibrary.wiley.com/doi/full/10.1002/jcu.22318
2.Functiondeterminesstructureandstructureinfluencesfunction.Thereseemsnotastrongrelationshipbetween
tendonstructure,painandfunction.Sameasforlowbackpain.X-ray,MRIdoesn'tassociatewithpainor
dysfunctioninthosewithlowbackpain.However,imagingcanfurtherconfirmclinical/physicaldiagnosis.
3.Iagreeitshouldbeacoredomainandconsensusregardingthetypesofoutcomemeasuresisneeded.However,
acknowledgementthatfeasibility/fundingetcmayprecludemeasuresof'structure'beingreportedinallfuture
studiesmaybeworthwhile.
4.Ithinkitiscriticaltolookatstructureinadditiontosymptomsanddisability,sinceweneedtounderstandmore
abouttherelationshipbetweenstructuralchangesandsymptoms.Bylookingatstructurewemayalsoidentify
subgroupsofdifferenttendinopathyphenotypesaswellasstratifypatientsforspecifictreatmentsinregardsto
subgroupsofprognosis.
5.Inpatientswithsymptoms,structurerelatestosymptoms.Inadditionmanytreatmentsareaimedatimproving
structure,andstructurerelatestofunction.
6.IssuesaretendonspecificHowtohandlepoorcorrelationbetweenstructureandsymptomsSomemodalities
egultrasoundareinvestigatordependent
7.MyyesisbecauseIbelieveweneedmuchmoreresearchtounderstandtherelationshipbetweenstructurand
function/symptoms.Butstructuredoesnotneedtobecore,assuch.
8.Structureimportant-butdifficulttoaccuratelyvisualize.UTCisasfarasIknowtheonlyobjectiveevsluationof
structure.
9.Structurereferringtoanatomicregionaffected?YES.
10.THeissueofstructuralchangesisimportant,butnotofessentialimportance.Somepatientsmayhavepainand
disabilitywithoutevident(orwithminimallyevident)changes.Clinicalsymptomsandtheclinicalpictureshould
guideinthediagnosisandmanagement
11.Toughoneandwillbeasourceofdebate.Theproblemwithexcludingitisthatfolkswillarguethatthetendon
conditionmayhavebeensomethingelse,e.g,inferiorpolepatellararticularcartilagedamageratherthanpatellar
tendinopathy.Ifyouincludeimagingaspartofthecoreyoustillhavethechoiceofincluding'normalimaging'in
astudycohort.(earlytendinopathy).goodluckwiththisone!
CommentsofDisagreeresponders:
12.Duetothemismatchbetweenpain&functionandimaging,Idon'tbelievestructureshouldbeapartofthe
'coredomainset'.Itmaystillbeofinterestwithinaresearchenvironmentandisanimportantriskfactorforthe
developmentofpainfultendinopathy,butusuallyhaspoorcorrelationwithoutcomes.
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CoreDomainSetforTendinopathy:SurveyData
13.notalotofevidencethatthischangeswithinterventionand/orpain
14.Notasanoutcomemeasureasnotshowntocorrelatewithpatientstatus
15.Poorrelationshipwithpain,prognosis,andlimitedevidencethatitchangeswithloading.
16.Thereisalreadyevidencethatthisisnotrelatedtoseverityofsymptoms.Notinpresentstateduringexam,nor
inthefuture.Itmightbeaninterestingoutcomemeasureinsomecases,butnotaC-TOM.
17.Thereseemstobenorelationandactualpatientcontactisneeded
18.Thislimitsthepossibilityofstudiestocomplywiththeminumumsetcriteriaasitmakesreasearchmore
expensive.Iseearoleforimagingstudiesbutwouldnotconisderthosethathavenotusedimagingtohavefailed
orbelessuseful.
CommentsofUnsureresponders:
19.Depends.Notsurewhatyouaregettingat,apartfromusingimaging(US)todescribegradeandphysiology.
20.Giventhedisconnectbetweenstructureandpain,Iamnotsurethisshouldbeincludedinacoredomainsetfor
tendinopathy
21.Incontemporarythinkingappearsless/unrelatedtopatientoutcomes.GoodanalogiestoOA.....howeverin
thatfieldjointchangesarestilltrackedandpublished.Perhapsusefultounderstandsomesubsetsofthecondition
butnotacoredomain.
22.Itdependsonwhatthedomainsetislookingat.Ifitisessentiallyaclinicaltoolthen,giventhatthereislittle
relationshipbetweenstructureandfunction/painthenstructureisnottooimportant.Structurealsoappearsto
changelittle,atleastintheshorttomediumterm.Ifitismoreofascientificassessment,oryouwanttolink
structuretotendonseveritythenthereismoremeritinthis.
23.Nodoubtthetendonstructureisanintegralpartofthecondition,butnotsureifitshouldbeadomain-
becauseadomainwillneedtobemeasuredinclinicaltrials-reliably,validly,discriminativelyandfeasibly.
24.painandfunctionnotrelatedtostructureontheotherhanditisanobjectiveoutcomemeasure
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CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:19.
PercentAgree/Disagree/Unsure:32%/43%/25%
Domainasonsurvey:Painover24hours
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin23papers(19%).
*Themeasuresusedhereincludeaskingtheparticipant(patientsorcontrols)toratetheirpainoveraspecifiedtime
frame(s)(e.g.,lastweek,last24hours,inthemorning,atnight)ona10cmline(VisualAnalogueScale)oroutof10
(NumericalRatingScale).
Committee’scomments:
Generalsensefromthecommentswasthattimeframeismuchlessimportantthantheloadingactivity
(whichwasthemostagreedupondomainofallherein).Someexpressionsthatatimeframeoverwhichthe
painisratedwasinsomecomments,butverymuchintheminority(andusuallyasasecondary
consideration)comparedtoloading/activity.Thereweresomecommentselsewhereforstartuppaininthe
morning-shouldweconsiderthatispartofthe24hourpainpicture?
CommentsofAgreeresponders:
1.akeyresponseforthosewithtendonpain
2.Dependsonthepatientpopulation.MyresponsesaremainlybasedonthepopulationIworkwith,(elite)
athletes.Forthese,itisimportanttouseintrumentsthatclearlyseparaterest/nightpainwithpainduringandafter
activity(activity-rleatedpain).Otherwise,anathletewhocannottrainmayreportnopain,becauseheisnot
training...
3.Describingpainpatternovera24hourperiodinconjunctionwithanappropriatepainscaleisanimportant
featureoftendinopathy
4.Iagreethisisimportantbutveryhardtoassessinpractice.Patientsmaybedoingactivitiesthataggravatedaily,
ortheymaynothaveanaccurateunderstandingofthe24hourresponse.Thismaybelesstrueforsomesports
andtendinopathies,forexamplepatellartendinopathyamongjumpers.Oftentheyhaveabetterunderstandingof
the24hourresponse.
5.ifnot24hoursthenoveradeterminedperiodoftime
CommentsofDisagreeresponders:
6.Dependsonwhatpatienthasdoneinthattimeframe
7.Ithinkitisimportanttobeawarethatpainintendinopathycanfluctuateovertime.Myimpressionisthatthere
isnotsomuchchangein24hours,soIdon'tthinkthisisuseful.However,Ithinkthatweshouldagreeonacertain
timeframewhenweassesssubjectiveoutcomemeasures(e.g.meanpainduringADLactivitiesduringthepast
week).
8.incidenceofpainnormallyassociatedwithloadingbutnottime
9.Itdoesnotchangemanagement
10.Mypreferencewouldbeworstpainoverlastweektocaptureactivitiesthatarenotperformedonadailybasis.
11.Seemyanswersabove.
12.Smallnumberofpapersreporting;it'snothowpatientsperceiveorreportpain.Italsodoesn'taffecthowwe
treatthisproblem.
13.Toorestrictive
14.Withoutspecifyingwhattheydidinlast24hoursdoesnotreallyhelpmeinterpret
CommentsofUnsureresponders:
15.Onlywhenconnectedtoactivity/loading
16.Specificationofthecircumstances(restvsactivity)whenpainisoccurringmaybenecessary.
17.Thismeasureofitselfdoesassumevarietyandmagnitudeareconstantsinsubjects.Lessrigorousthanother
measuresabove.Notcorebutmaybeuseful
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CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:20.
PercentAgree/Disagree/Unsure:29%/39%/32%
Domainasonsurvey:Clinicalexaminationfindings
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin28papers(/122;
23%).*Thisdomaincoversmeasuresthatreportasinglenumber/scoreforacombinationofclinicaltests(e.g.,combine
thetestresultsofrangeofmotion,strength,palpationintoonescore).Someexamplesofthesemeasures/scoresare:
UniversityofCalifornia-LosAngeles(UCLA);Constantscore;Liverpoolelbowscore.
Committee’scomments:
Thecommentslargelyconcerncombininganumberofclinicaltestsintoonescore.Thepercentagreement
wasalmostsimilaracrossallresponseoptions(agree,disagree,unsure:30,40,30%),butthecommentsare
largelyalignedwithdisagree.
CommentsofAgreeresponders:
1.asabove
2.butnotsurewhichhavetobereportedindifferentconditions
3.Itwillbedifficult,butshouldbeincluded.
4.PleaserefertoArthroscopy.1998Nov-Dec;14(8):840-3.Overusetendonconditions:timetochangeaconfusing
terminology.MaffulliN1,KhanKM,PudduG.
5.Yes,butonlyspecifictendontelatedtests.
CommentsofDisagreeresponders:
6.Anytimeyoutakedataandcombineyoulooseinformation.
7.Clinicalscoresofthisnaturearenotwellenoughworkedoutforalloftherequiredcommontendonissues
8.Clinicianmeasuresareatbestsurrogate.
9.Iwouldratherhavespecificclinicalfindingsreportedseperatley-onceyoumakeacompositescoreitgets
hardertointerpretfindingsandknowwhatthepatientslookedlikeonexamination
10.Manymaynotchangeaftertreatment/improvementofsymptomse.g.palpationtendernessisaverygood
exampleofthis.
11.Notspecificenoughwhencombinedintoonescore,interobserverreliabilityisoftenlow
CommentsofUnsureresponders:
12.Dependsonwhichtendon
13.dependswhattheseare,manyclinicaltestsspecifiedabovewillnotbevalidfortendonpain
14.Eachtendinopathyisindividualinpresentation.Here,painfreeshoulderROMforexampleisausefulreflection
ofchangeinstatus,whereasinlowerlimbtendonsthisisalessusefulmeasure.Anyamalgamationofclinical
findingsisonlyasgoodastherigourofeachportion.Thatsaid,asinglescoreisusefulinportrayingoverallstatus.
15.Ithinktheadditionofanumberofreliableclinicaltestsforeachspecifictendinopathylocationcanbevaluable.
ButIamnotsurewhetherthesecombinationtestsshouldbeaC-TOM.
16.Notsurewhetheranaggregatescoreisveryuseful.Iamassumingthatwhenthecombinedscoreisavailable,
thereshouldalsobeinformationontheindividualclinicaltests,whichmaybemoreinformative.
17.theuseofcompositemaybe"condition"specific.Tendinopathyintheupperlimb(rangeofmotionandmuscle
functionarenormallyaffected)mayhavedifferentdomainfromthelowerlimb(moreassociatedwithimpact
loading,lessassociatedwithphysicalfindingssuchrangeofmotion/musclestrength).
18.Theremaybeahugevariationinthenumberofclinicalteststhatmaybeusedtocreatethiscompositescore.I
amnotsureweareaatastageyetwerewehaveareliableanddefinedsetof"tests"thatcouldthebeusedto
createareliablecompositescore.
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CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:21.
PercentAgree/Disagree/Unsure:29%/39%/32%
Domainasonsurvey:Economicimpact:costs
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin4papers(3%).*This
isusuallymeasuredfrommedical/healthrecords,questionnaires,diaries,orinterviews.
Committee’scomments:
30/40/30%spreadacrossagree/disagree/unsureindicatesthisisundecidedasputinthesurvey.Butlookingatthe
commentsthedisagreehasfewestcomments(3/14)andtheseholdanelementoffeasibilityintheirwording(nice
tohavebutnotdevaluestudy,societalnotindividual,difficulttoanalyse).Theothercommentsintheunsureare
alsoalongtheselines.Therearecommentselsewhereintheadditionofdomainsitemforexamplethatindicate
healthcareutilisationandcostsshouldbeincluded,andothercommentsthatindicateissueswithmeasuringit.If
weforthisstageoftheprocessignorethemeasure,thenthequestionbecomesisthecostsoftendinopathy
(individualandsocietal)adomainthatoughtbeinthecoreset.
CommentsofAgreeresponders:
1.Costeffectivenessisanecessityinthepresenthealthcareenvironment
2.Especiallywhendataaretobeusedincosteffectivenessanalysesorhealthtechnologyassessment.
3.Importanttonote
4.inoursocietyonewaywemeasureimpact/valueisthrougheconomicimpacts(directandindirectcosts,lost
timeatwork,etc)
5.thisneedsmoreattentiontogettpontheagenda
CommentsofDisagreeresponders:
6.Againhereitsa"nicetohave"likestrength/ROM/Imaging-drivesupthecostofresearchandnothavingit
doenstde-valueastudy
7.AtasocietallevelthenMSKinjurycanhaveamajorburdenonmortalityrisk-butforanindividualdifficultto
include
8.Itisdifficulttoanalyzecostforthisinjuryduetotheslowinsidiousonsetandsincethepatientoftencanbe
activeduringtreatment.Surgeryisalsonotamaintreatment.
CommentsofUnsureresponders:
9.asecondarymeasureformoststudies,butincreasinglyimportantasmorepeopletrowmoneyatuseless
interventions
10.Couldbeusefulincertaincohortsegprofessionalsportspersonsortradespeople.Notsureifitshouldbeacore
domainbutagainusefulinappreciatingimpactoftendinopathyincertaincohorts.
11.Notsurethisisfeasibleasacoredomainset
12.Onlyinsomestudies.
13.Thisisimportantforfunding,butIamnotsurewhetheritshouldbeaC-TOM
14.Wontthatbeinsensitive?
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CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:22.
PercentAgree/Disagree/Unsure:36%/29%/36%
Domainasonsurvey:Psychologicalimpact
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin3papers(2.5%),
accountingfor5%ofalldomainsextracted.*Thetypesofoutcomemeasureswere:paincatastrophizingscale,painself-
efficacy,anxietyanddepressionscales.
Committee’scomments:
Basedonthecomments,whicharelargelyaboutthemeasureratherthantheconstruct,itwouldseemthat
combinedtheagreeanddisagreewouldmeetthe70%target.Thereisacommenttoconsiderifthisdomain
shouldbesplitfurtherintosmallerdomains-butnosuggestionofwhattheymightbe.
CommentsofAgreeresponders:
1.Iwouldarguethatwedonotcurrentlyhaveappropriatetendonspecificoutcomemetricstoquantifythis-have
FABQetcbeenvalidatedinatendonpopulation?
2.Painisusuallyamainpresentingfeature,andnotuncommonlypersistently,whichisassociatedwithvarious
levelsofpsychologicaldistress.
3.Somesortofscreeningforpsychologicalimpact/factorsmayhelpprovideearlyindicationoftreatment
requirementsforanindividual.Painself-efficacycanbeusefulinprovidinganindicationofeffectofinterventions
suchaseducationandfunctionalretraining,improvingapatientsconfidenceintheirabilitytoengagein
activity/recreation/normallifestyle.Thismaybeanimportantmechanismbywhichourinterventionsprovide
effect.Highlevelsofanxiety,depressionandcatastrophisingarenotascommoninthosewithanisolated
tendon,butwhentheyarepresenttheymaypresentasignificantimpedimenttorecovery.Soearlyscreeningfor
thesecouldbeusefultodirectmostappropriatetreatment,butasanoutcomemeasureforthemajorityofthose
withtendonrelatedproblems,changesinthesemeasuresovertimeareunlikelytobeastrongindicatorof
recovery.
4.Thisdimensionhasbeensparselystudied.Personally,Ibelievethatpersonalitytraitsmakeadifferencein
treatmentandimpact.Iamnotapsychologist,though,andappropriatequestionnairesneedtobetestedinthis
respect.
5.Yes!Seemstobeanimportantfactorbutisnotgivenenoughattentioninstudiessofar.
CommentsofDisagreeresponders:
6.Difficulttodefine-butcouldbeassessede.g.viaEQ5D
7.Interestingasexplorativeoutcomemeasure,butnotaC-TOM
8.Notreportedandnotimportant.
CommentsofUnsureresponders:
9.DoesthisdifferfromQOL?Ifso-ithinkweshouldhavethisaswell-givesholisticviewofimpact
10.Evsluationonlyinsomestudies.
11.Idoubtit-notsensitivenorspecific
12.Mybenotacoredomain,butaveryusefulsupplementarydomain,whereongoinglimitationhasmoregeneral
effectsonpatientwellbeing.
13.specificstudiesonthisimportantbutnotacoredomainformoststudies
14.Wouldthisperhapsprovideameansofcontrollingforcopingfactorsinotherdomains?
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CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:23.
PercentAgree/Disagree/Unsure:39%/43%/18%
Domainasonsurvey:Palpation(painortenderness)
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin11papers(9%).
*Theclinicianpressesonthetendonwithathumborfingerandelicitspain(ornotincontrols)andtheparticipant
(patientorcontrol)reportsthispainortendernessinavarietyofways(e.g.,ona10cmline,outofa11pointratingscale
(0to10),bespokenominal/ordinalscales,orinsomecasesnotstatedinthepaper).
Committee’scomments:
Eventhoughagreeanddisagreewereselectedaboutthesameproportions(40%each),thecomments
affirmingpalpationarelargelyaboutclinicalexaminationandinthemainmostcommentsdonotsupport
palpationasacoredomain.
CommentsofAgreeresponders:
1.Istillplaceclinicalvalueonpalpationandfindituseful-itsquick,universallyaccessibleandeasytounderstand
forpatientsandclinicians.Amhoweverhappytobevoteddownhere-iknowithasdrawbackstoo-standardising
pressuresetc
2.Itisimportant,butitshouldbeagainbetterqualified.Algometryshouldbeemployed
3.Itisveryhardtostandardize,sothismeasurehasalotoflimitations.Itis,however,oneofthemaindiagnostic
criteriafortendinopathyandmosthealthcareprovidersuseitintheclinicalsetting.Fromthatperspective,itis
importanttoknowmoreaboutitsclinicalvalue.
4.Painonpalpationisoneoftheclinicaltestsindefiningtendon-relatedproblem.
5.Thisispartofthediagnosisbutnotactuallysurehowthatwoulddifferentiatefromcoredomain.
6.VeryimportantforatleastAchilles.Alsotolocalusewherepainislocated-superficial,deep,medialorlateral
side.
CommentsofDisagreeresponders:
7.forthetendonsofmyareaofinterestitisnotpossibletoaccuratelyidentifythestructuretherelationship
betweenpalpationandpainremainsuncertain
8.Hardlyeveruseful,asidefromrulingoutatendonissueinthediagnosticprocess.
9.Itisdifficulttopalpatemanytendonse.g.supraspinatus
10.Notdiagnosticoragoodoutcomemeasure,infactleadsmostpeopleastray
11.Palpationisoftenmostusefulasanegativepredictorofthepresenceofpainfultendinopathybutisnotagood
indicatorofoutcome.Tendernessonpalpationoftenremainsinthepresenceofsubstantialimprovementsin
outcome/function.
12.Palpationpainchangesappearpoorlycorrelatedtofunctionaloutcomes
13.Toopronetoerrors
CommentsofUnsureresponders:
14.Asainclusioncriteriaorasanoutcomemeasure?
15.Dependsontendon.Overall,no
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CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:24.
PercentAgree/Disagree/Unsure:36%/39%/25%
Domainasonsurvey:Strength
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin19papers(16%).
*Strengthbeingmeasuredbyaninstrumentsuchas:adynamometersorforcetransducers.
Committee’scomments:
Onbalancethecommentsindicatethatstrengthmightnotbeacoredomain,withmanycommentsinthe
agreerespondersnotfavouringitascore-whichwouldlikelyindicatethat70%wouldbereachedonfurther
discussion.
CommentsofAgreeresponders:
1.asabove
2.Basedprimarilyonaneliteathletepopulation,whereobjectivemeasuresoffunctionareimportantoutcomesof
treatment.
3.Notasaninnercoredomain.Asanouterdomain.
4.Oftenaperceivedissue;functionimpactedbydecreasedstrength
5.Strengthchangesarelesscommonlyinvestigatedinmuchoftheliteratureasperhapsoverthedecadesthere
hasbeentoomuchfocusonthetendoninisolation.Morerecentpapershaveidentifiedstrengthchangesthat
appeartohavesomerelationtooveralloutcome,yetmoreworkisrequiredinthearea.
6.tendonsjoinmuscletobone-andstrengthtestingisofthemuscle-acriticalimpairmenttocapture
7.Thisisimportant,sincetheinjuryisanoverloadinginjuryandtreatmentisoftenaimedatimprovingstrength
8.Yesbecausestrengthisfundamentaltofunctionandmanyofourrehabilitationtechniques
CommentsofDisagreeresponders:
9.Alimbcanbestrongandstillnotfunction.Whileitisaninterestingvariabletoknow,strengthinandbyitself
doesnotcarrymuchclinicalrelevance
10.Feasibilityandreproducibilityissues
11.Idontthinkstrengthnecessarilyneedstobeevaluated.Painverymuchaffectsstrength,andIhaveseenthat
efterlocalanestesiathestrengthvaluesarecompletelydifferentandnotseldomnormal.
12.IseestrengthasIseeimaging-itsanicetohave-butnotamusthavedomain.Forthesamereasons-Ithink
youcanhaveawellsetupandusefulstudywithoutstrengthmeasures.
13.Interestingexplorativeoutcomemeasure,butnotaC-TOM.
14.Needforspecificmeasurementapparatus
15.notthecore-willruleouttoomanyinvestigators
16.Strengthseemstobeapoorindicatorofoutcomeandfunctioninapainfulpopulation.
CommentsofUnsureresponders:
17.iftheseswererelevantandstandardisedpossibly,buthardtodoacrossstudiesandcouldbetooexpensiveto
doforsomeinvestigators
18.Noneedundertheinclusion/exclusionpart.ButcanberegardedasoneoftheoutcomemeasuresHowever,it
shouldincludemuscleinthekineticchain.e.g.forpatellar/achillestendinopathy,musclestrengthofthehip
shouldbeincludedaswell;supraspinatus/ECRL/ECRBtendinopathy,musclestrengthofthescapularmuscleshould
beincluded.
19.Notsureiagreewiththetermstrengthasthishasvariousinterpretations-iwouldfavourfunction.AlthoughI
thinkfunctionisanimportantcoredomainsetIamnotsureweareinapositionthatweappropriateknowledgeof
whatthecorrectfunctionaltestsare.
20.Thisoverlapswiththequestiononclinicalexamination.Iamtoounfamiliarwiththistopictojudgethe
differencesinstrengthassessmentswithandwithoutinstruments.
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CoreDomainSetforTendinopathy:SurveyData
Thefollowingitemswereaboutdeleting,aggregating,addingorsplittingthedomainspreviously
presentedaboveinthesurvey:providedheretohelpwithdecisionsoneachdomainatthemeeting.
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CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:.
PercentAgree/Disagree/Unsure:36%/43%/21%
Domainasonsurvey:Adddomains?
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Arethereanyotherdomainsthatyouconsider
importantenoughtobeincludedinacoredomainsetfortendinopathy?
Committee’scomments:
Somenewdomainstoconsiderare:(i)co-morbidities(otherconditions,otherareasofpain),(ii)Family
history,(iii)somedomainthatcoverspersistency-previoustendinopathy,andtreatments,(iv)painconstancy
asopposedtointensity,(v)bothersomeness/impactofinterferenceofpain,(vi)durationofsymptoms.Many
oftheothersuggestionsarealreadyincludedinthedomains.Forexamplehealthcareconsumptioniscovered
undereconcostsandmedicationuse;andpatientsatisfactionissimilartopatientstatusasagenericoverall
domain,asopposedtoameasureofthatdomain.Thenthefollowingaredirectlyincluded:participation
(sportslevel,performance,sportsspecific),imaging/structure,andstartuppaininmorning(ie,24hourpain).
CommentsofAgreeresponders:
1.healthcareconsumptionbeforethestartofatrialandduringthetrial(othertreatments/visitstohealthcare
providers).Thiscouldalsobeimportantintermsofeconomicanalysisandfinallyforfundingpurposes-patient
satisfaction(excellent/good/moderate/poor)isnotexplicitlymentioned.Whileithassomedisadvantagesas
outcomemeasure,itishelpfulforpatientinformationbeforestartingatreatment.-thereisnoinformation
regardingtherecommendedtimepointswhenC-TOMsshouldbetaken,butitiscertainlyimportanttodiscussthis
aswell
2.Asmentionedabove,inthesportssetting,ourpastmeasureshavebeencrude(professional/amateurlevel,
divisionlevel,etc.).Ibelieveweneedtotrytomeasure/gradeperformancelevel(comparedtonormal
performance,teammateperformance,etc).
3.FamilyhistoryPrevioustreatments
4.familyhistoryoftendonconditionsandothersystemicconditions
5.Lengthoftimeofsymptoms.Thedataonself-limitedvspersistentnatureoftendinopathyiscontroversial.It
wouldbeimportanttogatherthesedata.
6.longtermimpactrecurrencelevelofparticipationconfidenceforshortmediumandlongtermparticipation
7.OnequestionIaskiswhatdoesyourtendonpainstopyoudoing.Thisisnotnecessarilylinkedtosportbutadds
tomyassessmentclinically
8.Painconstancy/frequency-thepaindomainsmentionedalreadyappearedtobeprimarilyrelatedtoseverityor
intensityofpain.Inclinicalpracticepatientsmaynotethatalthoughthepainseverityissimilar,theremayhave
beenasubstantialreductionintheamountoftimetheirpainispresent.Ibelievethisisausefulpaindomain.
9.Paininotherbodilyareas,eitherindividualareas(egneck)orsumofareas.Bothersomeness/impactor
interferenceofpainDurationofsymptoms
10.startuppainonrisinginmorning(likert)nightpain
CommentsofDisagreeresponders:
(nocomments)
CommentsofUnsureresponders:
11.Asanimager,Iamwonderingwhetheranyfeaturesrelatingtotendinopathyfromimaging(USorMRI)maybe
usefultoaddIFavailable.
12.Ialludedtotheutilisationinspecificcohortsofindependentlyratedsportsperformance,whichwouldalsobea
usefulsupplementaryratinginprofessionalsportonly.
13.Nonethatcurrentlycometomind-itwouldbegoodtostartwithaforementioneddomainsandworkfrom
there
14.sports-specificandtendon-specificmayneedtobeconsiderinacoredomainsetfortendinopathy.
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CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:.
PercentAgree/Disagree/Unsure:21%/43%/36%
Domainasonsurvey:Removedomains?
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:ArethereanydomainsthatyouconsiderareNOT
importantenoughtobeincludedinacoredomainsetfortendinopathy?Thatis,theyshouldberemovedfromthislistof
domains.
Committee’scomments:
Domainssuggestedforremoval:1discontinuetreatemtn/dropout,2sensorymodalitytests(x2),3palpation
(x3),4painwithclinicalappliedstress(x2),4structure/imaging(x4),5painwithoutcontextspecified(x2),6
clinexaminationfindingsasacombinedscore,7pover24hourperiod,8strength,9ROM(x2),10Function,
11physicalfunction,12Psychologicalimpact,13participationlife,
CommentsofAgreeresponders:
1.asanswered!
2.DiscontinuetreatmentSensorymodalitytestsPalpationPainwithclinicianappliedstressStructure
3.Imaging-againgiventhetheinconsistentrelationshipbetweenstructureandpainIamnotsurewecanjustifyas
acoredomainset.AlsoifacoredomainsetdoesthatmeanallHCP'smusttraininimagingmodalitiestoinclude
thisdomain?
4.StructurePainwithoutcontextspecifiedClinicianexaminationfindingsasacombinedscorePainovera24hour
periodStrength(muscle)RangeofmotionSensorymodalitytestsFunctionPhysicalFunctionPsychological
impactParticipation(life)
5.Thedomainsthatarenotcontextspecificormainlyinvolvearatingbytheclinician(i.e,Painwithoutcontext
specified,Clinicianexaminationfindingsasacombinedscore,RangeofmotionPalpation,Painwithclinician
appliedstress)
CommentsofDisagreeresponders:
6.Possiblypalpationbecausenotallcanbepalpatedeasily
7.Theyareworthyofconsideration.Answersaboverewhichwouldseemmostimportant.
CommentsofUnsureresponders:
8.Fromapracticalpointofviewitwouldbeimportanttokeepanyquestionnairemanageable/limited
9.Importantheretoalsoconsiderbothcoreandsupplementarydomains.Iconsiderpalpation,imaging(generally)
andthelessspecificactivitydomainscandidatesforremoval.
10.seerepsonsein1stsection
11.somecouldbecombinedegtheactivityones
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CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:.
PercentAgree/Disagree/Unsure:46%/7%/46%
Domainasonsurvey:Aggregateanydomains
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Shouldanyofthedomainslistedabovebe
aggregated(combinedintooneorfewerdomains)beforebeingincludedinacoredomainsetfortendinopathy?
Committee’scomments:
Somediscussionaroundwhatthedomainsmean(ratherthanthemeasures)intermsoftheconditionappears
necessaryasthereisconflationbetweenthetwoapparenthere.Forexamplepainanddisability,arethey
actuallyonedomainortwo?Function,disability,participationalsoappeartobeinneedofsome
considerationhere,asisdisability,QoLandpsychological.Perhapsbestconsideredforeachdomainasthey
areindividuallyconsidered.
CommentsofAgreeresponders:
1.AggregrationintothenextgroupsHistoryActivity&LoadPainFunctionClinicalexaminationImaging
Impact(Disability,psycholol,QOL,costs)
2.cantrememberexactlywhattheywerecalledsomeoftheclinicalexaminationandclinicalstresstestsseemto
overlap
3.Disability,function,physicalfunctionParticipation,work/sportparticipation,physicalactivity
4.Palpationandpainwithstress.Painquestionscouldbecombined.
5.Quiteafew.Disability,QoL,psychologicaleffect-couldbecoveredbyEQ5Dforexample
6.ROMcombinedintoclinicalexamination.
7.Severalofthepainandactivitydomainsarehighlyoverlappingandcouldperhapsbeaggregated.
8.Someofphysicalactivity&participationdomainsmaybeaggregatedandpossiblyloading/stresstestrelated
statementsalso
9.SportsparticipationandphysicalactivityFunctionshouldincludework,strength
10.Thereshouldbeonefunctionalcapacitydomainthatencompasses(a)function,and(b)physicalfunction.How
thisismeasuredisanothermatter,butthereshouldbeadomainforfunction,whichisdifferenttodisability-there
shouldbeadistinctionbetweenfunctionanddisability.Functionbeingabilityandcapacity.Thereshouldbe
considerationforoneparticipationdomainthatencompasses(a)'generallife'participation(life),(b)sport
participation,and(c)workparticipation.Thereasonbeingthatmeasuresthatcapturethis'participation'domainto
bevalid,discriminatingandfeasiblewillneedtocapturetheoverallparticipationrelevantfortheindividual,
regardless(orencompassing)iftheyareeliteathletes,non-athleticworkersorotherwise.These(functionand
participation)oughttobedifferenttophysicalactivitylevel.
11.Whereapplicable,Ifavorcombiningpainfunctionandsportsparticipation(asinVISAscores)
CommentsofDisagreeresponders:
(nocomments)
CommentsofUnsureresponders:
12.Aggregatinglessspecificdomainsachieveslittle(garbagein-garbageout!)Thatsaid,ifsomeofthemore
rigorousinstrumentscanbecombinedforaglobaleffectIwouldsupportthis,howeverbecauseofthesignificantly
differentcohortsencountered,(tendonaffected,activitylevel)applyingthisuniversallymaybechallenging.
13.IthinkthisistheperfecttopicformeetingThingsthatcometomindwouldbeQOL-psychologyParticipation-
sportsVariouspainmeasures
14.needsdiscussion
15.tendinopathyisthe"failure"onmultiplefactorsthatmaybetendon-specific,sport-specificandgender-specific.
Iamnotsurewhetherwecanfindaggregateddomains
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CoreDomainSetforTendinopathy:SurveyData
Orderofagreeordisagree:.
PercentAgree/Disagree/Unsure:14%/43%/43%
Domainasonsurvey:Splittingdomains
ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Shouldanyofthedomainslistedabovebefurther
splitupordividedintotwoormoredomainsbeforebeingincludedinacoredomainsetfortendinopathy?
Committee’scomments:
Commentsfromtheagreeresponderstoconsiderare(i)splittinguppsychologicaljustaspainhasbeen,and
(ii)strength,endurance,powerfordifferentfunctionsofmuscle.
CommentsofAgreeresponders:
1.Aspainissplitupintoseveraldomains,thedomainpsychologicalimpactcanalsobesplitup
2.Iconsiderstrengthandendurancebothmeasureofmuscle.Idonotthinkheel-risetestshouldbeconsidereda
functionthesamewayasjumpingetc.
3.Thedemandonatendonissport/activity-specific.Itmaybeworthinconsidersplittingthedomainaccordingto
differentsportgroup.e.g.jumping/landingsport(volleyballandbasketball);lungingsport(badminton/fencing)for
thelowerlimb.throwingsports(cricket,volleyball);racketsports(badminton,tennis);crawlingsports(swimming)
fortheupperlimb.Thedomainscanbedesignedinvolvingthekineticchainaccordingtosport-specific
requirement
CommentsofDisagreeresponders:
4.Enoughalready
5.Ifeeltheyareprettyspecificnow
CommentsofUnsureresponders:
6.ditto,toohardtoconsiderbasedonthesurveytodate
7.I'mnotquitesurewhatanexampleofthismightbe.Painonloadinganddisability/functionwouldhavea
numberoftendon-specifictasksassub-questions,butIwouldn'tconsidertheseseparatedomains.
8.Thereisacaseattimesforminingthetendonspecificinstrumentsforeffectofanintervention.ieinVISAX,
sportparticipationdidnotchangeover6-12weeksbutotherparametersdid...
Supplementary material Br J Sports Med
doi: 10.1136/bjsports-2019-100894–451.:444 54 2020;Br J Sports Med, et al. Vicenzino B
Page 33 of 34
CoreDomainSetforTendinopathy:SurveyData
Patientsurvey:
InBrisbaneandMelbourne(Australia),219patientparticipantsonthedatabaselistsofthreeresearch
centerswereaskedtocompletetheDomainssurvey(i.e.,emailedwiththelinktotheDomains
survey).56participants(26%)wenttothelinkand32(57%)thenprovidedconsenttocompletethe
survey.Onlythedomainssurveywassenttotheseparticipants.Theresponsesofthepatientsis
summarizedinTable3,andtheircharacteristicsareinTable3a.
ThegreencodinginTable3highlighttheitemsreaching70%agreement.Notethatthereareno
disagreementsreachingthe70%threshold.
Thesedataareprovidedforclinicianstoconsiderwhenreviewingthecliniciandataandinpreparation
fortheconsensusmeetinginGroningen.
Table3:Summarystatisticsofpatient*responsestotheDomainsSurvey(n=56)
Item Domain Responses(rate%) AgreeN(%) DisagreeN(%) UnsureN(%)
4 PainonActivityorloading* 32(57%) 31(97%) 0(0%) 1(3%)
11 Strength 32(57%) 29(91%) 0(0%) 3(9%)
10 QoL 32(57%) 29(91%) 1(3%) 2(6%)
5 Patientperceptionofcondition
status
32(57%) 29(91%) 2(6%) 1(3%)
18 Function 31(55%) 27(87%) 2(6%) 2(6%)
12 ROM^ 32(57%) 27(84%) 2(6%) 3(9%)
24 Physicalactivity 32(57%) 25(81%) 3(10%) 3(10%)
20 Psychologicalimpact 32(57%) 24(77%) 6(19%) 1(3%)
8 Clinicalexamfindings 32(57%) 24(75%) 4(13%) 4(13%)
21 Sportparticipation 32(57%) 23(74%) 5(16%) 3(10%)
22 Medicationuse 32(57%) 23(74%) 4(13%) 4(3%)
3 Disability* 32(57%) 22(69%) 3(9%) 7(22%)
9 Painover24hours 32(57%) 22(69%) 7(22%) 3(9%)
13 Palpation 32(57%) 21(68%) 5(16%) 5(16%)
19 Physicalfunction 32(57%) 21(68%) 5(16%) 5(16%)
23 Workparticipation 32(57%) 20(65%) 6(19%) 5(16%)
25 Participation 32(57%) 20(65%) 8(26%) 3(10%)
7 Painwithoutfurtherspecification 32(57%) 20(63%) 8(25%) 4(13%)
14 Painelicitedwithclinician
appliedstresstest
32(57%) 19(61%) 3(10%) 9(29%)
26 Discontinuetreatment 32(57%) 19(61%) 5(16%) 7(23%)
15 Adverseeffects/events 32(57%) 18(58%) 6(19%) 7(23%)
16 Economicimpact:costs 32(57%) 17(55%) 7(23%) 7(23%)
17 Sensorymodalityspecificpain 32(57%) 13(42%) 7(23%) 11(35%)
6 Structure 32(57%) 11(34%) 4(13%) 17(53%)
*Theseitemsreached70%agreementinthecliniciansurvey(i.e.,cliniciansindicatedthesetobeacoredomain
^Thisitemreached70%disagreementinthecliniciansurvey(i.e.,cliniciansdidnotthinkitacoredomain)
Supplementary material Br J Sports Med
doi: 10.1136/bjsports-2019-100894–451.:444 54 2020;Br J Sports Med, et al. Vicenzino B
Page 34 of 34
CoreDomainSetforTendinopathy:SurveyData
Table3a:Patientparticipantcharacteristicsofthecompletingthesurvey.
Characteristic N(%)
SexFemale(%) 24(77%)
Role:
Clinician 1(3%)
NeitherCliniciannorResearcher/Scientist 28(90%)
Other 2(6%)
Casespermonth:
0(Iamapatient) 29(94%)
Atleast4 1(3%)
Between11and15 1(3%)
Highestacademicqualification:
UndergraduateDiploma/Certificate 5(16%)
Bachelor 14(45%)
Master 4(13%)
PhD 5(16%)
Other 3(10%)
Currentlyhavetendonproblem: 26(84%)
Pasthistoryoftendonproblem: 21(68%)
Supplementary material Br J Sports Med
doi: 10.1136/bjsports-2019-100894–451.:444 54 2020;Br J Sports Med, et al. Vicenzino B