Page 1 of 34 Delphi process for Core Domain Set for

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

Table1:Participantcharacteristicsofthehealthprofessionalscompletingthesurvey.28ofthe30

contactedresponded(93%responserate)

Characteristic N(%)

SexMale(%) 18(64%)

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%)

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%)

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

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.

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?)

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

Domainasonsurvey:RangeofMotion

ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin19papers(16%).

*Thiswasusuallymeasuredwithaspecialinstrument(goniometer,inclinometer,ordynamometer),butalsovisuallyina

fewreports.Notethatthisisasoledomainhere.Inanotherdomain('clinicalexaminationfindings')itisincludedina

combinedscore.

CommentsandresponsesareconsistentwithROMnotbeingcore

1.asabove

2.Basedprimarilyonaneliteathletepopulation,whereobjectivemeasuresoffunctionareimportantoutcomesof

treatment.

3.tendinopathy,inandofitself,doesnotBLOCKrangeofmotion,butpainrelateddecreasesoccur.

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

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.

Domainasonsurvey:Function

ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin8papers(7%).*This

domainisspecificallyabouttheparticipantratingtheirleveloffunctioninonescore(e.g.,PatientSpecificFunctionScale,

wherein100%isfullfunctionand0%isunabletousethelimbsuchasinaslingforthearmandnotweightbearingona

leg).Itdoesnotaskaboutthepain,justaboutthefunction.

Nine(/14)commentsfromtheagreeresponders(approx70%agreementhere,thirdhighestagreedto

domain)forFunction,withmanyofthecommentsfordisagreeandunsure(andsomeintheagree)indicating

thefocuswasmoreontendonrelatedpain,whichassomepointoutiscoveredindisability.Thisdomainis

justfunction-thatis,whatistheleveloffunctioning(disregardingpain)asinhowmuchcantheydo.

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

10.Iconsiderthedomain'disability'toprovidesynergisticinformation.

11.Ithinkthisisonlyrelevantwhenthepainistakenintoaccount(likeinallVISAscoresforexample).Someone

canhaveaperfectfunctionwithalotofpain,soasisolatedmeasureitislessvaluable.

12.Markedlylessspecificthanthemoretendon-relatedinstrumentsthathavebeendevelopedoverthelast2

decadesorso.

13.ThePSFScanbeusefulfortrackingchangeinaspecificfunctionforoneindividual,buttherearedifficultiesas

patientsoftenfinditverydifficulttoseparatepainandfunctionasmostoftenthereasonfortheirinabilityto

performataskisthepain.Also,itisimportanttoquestionregardingthesameparticularfunction/sovertime,as

givenablankPSFStorateatdifferenttimepoints,patientswilloftenfillindifferenttasks,resultingindifficulties

withcomparability.

14.tricky.Goodquestions.Willruleoutmanystudies.Isaonenumberscorevalid?

Domainasonsurvey:Patientperceptionofconditionstatus

*Twoexamplesofthetypesofoutcomemeasuresreportedbyauthorswere:globalratingofchange(e.g.,areyoubetter,

sameorworsethanimmediatelybeforetreatment),andpatientperceptionofstatusofcondition(e.g.,isyourcurrent

conditionsatisfactory,whenyoutakeyourgeneralfunctioningandcurrentpainintoconsideration).

Thishasthe4thhighestagreement,7thhighestofunsureandamongthelowestofthedisagree(20th/24).

Thereweremanycomments(11)bythosewhoagreedtotheeffectthatthismeasurereflectedthepatient's

overallperceptionoftheircondition,asopposedto2commentsbythosewhodidnotagreewhoindciated

themeasureistoosubjectiveorthetermisdifficulttounderstand,whilethe4commentsfromtheunsure

responsesthattendedtomirrorthedisagreecomments.Thedomaincouldberewordedto'patientoverall

assessmentofcondition'asthismightaccommodatecommentsherein-asitmoreclearlydescribesthe

overallratingbythepatientoftheirconditionandleavessilentatthisconceptuallevelifthisisachangeover

timeoraglobalratingofthecondition(consideringweareworkingtowardsaparsimoniouscoredomainset).

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

12.Idon'tunderstandtheterm,honestly.Howthepatientperceivestheircondition?Thinkingonthisfurther,I

amassumingthisiscomingfromsomeoftheworkstatingthatpatientswhohaveatendencytocatastrophizeare

thosewhopresentforcare.Istilldon'tthinkthisshouldbeincluded.

13.patientperceptionistoosubjective.Thereareunknownelementsthatmightinfluencetheoutcome/changes

inthisoutcome.theunknownelementincludepersonality,moodetc

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.

Domainasonsurvey:QualityofLife

ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedby21authors(17%).

*Thetypesofoutcomemeasuresreported:EQ-5D,AQoL,SF-36,internationalHipOutcomeTool(iHOT-33),SF-36,

WesternOntarioRotatorCuffIndex(WORC),Foot&AnkleOutcomeScore(FAOS).

Approx60%agreeand30%unsurehavingcommentsthatessentiallyagreewithQoL,butmanystipulatingthe

needforspecficityofmeasuresforthetendinopathypopulation.5thand4thhighestproportionofagreement

andunsureasopposedto21/24fordisagree,tendstosupportthisdomainascore.

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.

13.Notinthecore.

14.Toosubjectiveanddifficulttoassess

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.

Domainasonsurvey:Painelicitedwithclinicianappliedstresstest

*Cliniciansappliedaspecialstressororthopaedictestandtheparticipant(patientorcontrol)reporttheintensityofpain

theyfeelona10cmlineor11pointscale.Thisisnottheparticipantdoingthetestaswouldbethecasewhentheyhopor

jumporsquatinthedomainitem'painonactivityorloading'above.

With60%disagreeand20%unsure,theredoesnotappeartobesufficientsubstanceforthisinacoredomain

1.Obvious.

2.THisishowImeasurephysicalexamsigns

3.Idontseethisbeing"universal"enoughtogoincoreset-whichspecialtestwouldidoforpatella/achillesfor

example.

4.No.Perhapsonlyrelevantifthe'stress'couldbequantified.

5.Notanimportantoutcomeforpatients.

6.notreliable

7.Pleaseseequestion13.

8.unlikleytoloadthetendonenough

9.Unreliableandtendonspecific

10.Ispartofclinicalexamination

11.Notsurehowthisdiffersfrompainonpalpation.

12.Thismightprovideareasonablyobjectivemeasureofelicitedpainforcomparisonbetweenindividuals?

13.Yes-Butnotsurewehavetheappropriateknowledgeorconsensusonwhatthebest"stress"testsareforthe

relevanttendons

Domainasonsurvey:Sensory-modalityspecificpain

ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin8papers(7%).*The

amountofastimulus(suchaspressure,heat,cold)thatelicitspainismeasuredwithaninstrument(analgometer)forthis

domain.Soitisnotthelevelofpainthatisthefocusbuthowmuchstimuluselicitsthepain,andthestimulusisasensory

Commentsoftheunsurealignstronglywiththedisagreeresponseanddonotsupportsensorymodality

specificpainasacoredomain.

1.Anywaytoquantifypainiswelcome.Itshouldbenoted,however,thatpainonpalpationmaynotcorrespondto

painonuseofthelimb

2.Optionaldependingonequipmentavailableandexpertise

3.Asperimaging/rom/strength/costanalysis-greatifyoucandobutnot"core"

4.Difficulttoadequatelyevaluate

5.Interestingexplorativemeasure,butnotaC-TOM.

6.Maybeusefulforresearchstudies,butnotacoredomainthatwouldbewidelyclinicallyapplicable.

7.Morearesearch/mechanismsapplicationforme.

8.Notcriticalandnotreportedenough.

9.Toovariable

10.AlthoughIthinkthisisaveryimportantmetric-Iamnotsureweareatthepointwhereweknowenough

aboutQuantitativesensorytestingintendoncomplaintstomakeitacoredomainset

11.howvalidarethesemeasurementsandwhatdotheyad?

12.importantinstudiesdirectedatthis,butforclinicalstudiesno,willbedonebadlyunlessgoodequipmentand

thisistooexpensiveformanyresearchers

13.Maybenotacoredomain,butveryusefulinfurtherinvestigationintothegreaterchallengeofpaingeneration

andmodulation.

Domainasonsurvey:Physicalfunction

ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin6papers(5%).*The

typesofmeasuresusedforthisdomainwere:distancejumped,heighthopped,numberofsingleheelraises.Thatis,how

muchofatasktheparticipant(patientorcontrol)waswillingtoperform.

Thephysicalfunctiondomainalignsreasonablywellwiththeloadingtestsinthebaselinereporting

recommendationsurvey(61%agreethere).Someofthecommentsinhereneedtobeexploredatthe

meetingtoensurethatthereisadifferencebetween'function'and'disability'domains,aswellasphysical

activitypossibly.Otherwisethereappearstobesupportforthisasastandalonecoredomain.

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

9.combinewithabove?

10.Interestingexplorativeoutcomemeasure,butitisverydependedonpatient'smotivation.Asasportsphysician,

Iamnotusingitintheclinicalsetting.Soforme,thisisnotaC-TOM.

11.Isthatproventobereliableandrepeatableandsensitive?Idoubtit.

12.Whilesuchmeasuresareusefulforassessingimpairmentswithinanindividualwhichmightprovidesome

treatmentdirectioninclinicalpracticeforthatindividual,correlationwithoutcomesespimposingasinglemeasure

acrossagroupofindividualsasanindicatorofoutcomesislikelytobepoor.

13.Couldbeveryusefulbuthowtodefinewhichteststodoaccrosstheagerangesandabilityrangesuseein

practice.InAchillesImayhave65yroldgrandmawhocanthoponce-butneverneedsto-or20yearoldrunner

whocannail5hopsbutcantrun21kmatburningpace-sopassesthetestbutisstillrestricted.Soasaprinciple-

wouldbegreat-butmaybechallenginginpractice

14.Perhapsnotacoredomainastheapplicationwouldbecohort-specific.InAchillestendinopathyforexample,

normalisationofheightordistancehopcouldbeanimportantglobalparameterinahighfunctioninggroup,yetit

mustbeacknowledgedthiscouldnotbeapplieduniversally.

Domainasonsurvey:Pain',withoutanyfurtherspecification

*Theuniquefeatureofthisdomain(Pain)isthattheauthorsonlystatetheyreportedpainoftheparticipants.Thatis,

theydidnotspecifyifitwasunderloading(e.g.,activity,hoporwalk)orspecificcircumstances(e.g.,firststep)orina

particulartimeframeorataspecifictime(e.g.,morning).Sothisiteminthissurveyisaskingyoutoconsiderifpain

shouldbefurtherspecified,asinsomeoftheotheritemsinthissurvey.

Commentsbyagreeresponderslookliketheydidnotunderstandthedomainandwouldlikelydisagreewith

thisdomain.Thecommentsfromtheunsurerespondersalsotendtomirrorthosefromthedisagree.The

approx60%disagreementplacesith'asthe3rdhighestdisagreementproportion.Givencommentshereand

responseratesforotherpainrelateditems,painneedstobespecifiedincontext(egwithloading).

1.asabove

2.IrecommendpainbeingadomainonitsownANDhavingspecificationslisted.

3.thisisthereasonpatientspresent.Itisacriticaldomain.

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

20.Iamunsurehowtoanswerduetotheexplanation.YesIthinkpainquestionsneedfurtherexplanationsuchas

atrest,morningpainetc.ButstillnotsureifIshouldanswerthisquestionyesorno.

21.Painimportantonlyiflocatedinasoecifictendonandrelatedtoacertaintypeofloadingofthattendon.

22.Painseveritywithoutfurtherspecificationappearstobelessusefulthanspecifiedpain.Sometimeswherethis

canbedifficulthoweverisifthemostpainfultaskorsituationchangesovertime.So,worstpaincansometimesbe

usefultocapturethis.Painconstancy/frequencycanalsobeausefulmeasureofpain-%oftimeoverthelastweek

apatienthasexperiencedpain.

23.Wouldneedtobefurtherdefined.

Domainasonsurvey:Sportparticipation

ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin3papers(2.5%).

*Thesortsofmeasuresusedherewere:thetimetoreturntosport,thelevelofsportachieved,andarangeofdifferent

scalesofparticipationinsport(e.g.,socialorelitelevel).

Mostcommentsfromtheagreeresponders-buttheseseemtoreflecttheothersinthatitmightbetoo

restrictivefortendinopathygenerally.Giventheresponsestotheaggregate/removeitemsonthesurvey,it

wouldseemreasonablethatwediscusswherethisfits(eg,aspartofanotherdomain-likeparticipation?).

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,

12.Forsometendonproblems,thisisveryimportantbutnotsousefulforothersthataremoreprevalentinolder

peoplelessengagedinformalsport.Iftheaimistoachieveacoresetapplicableacrossalltendons,thenno.

13.Mostpatientspresentingarepasttheageofactivesports.

14.Noteveryoneparticipatesinsport

15.Unreliable

16.Againbestconsideredasupplementarydomain,astendinopathyisnotrestrictedtosportspeople.

17.Althoughthisisperhapsthemostsignificantactivityforalargeproportionoftendinopathypatients,thisseems

tooverlapwithpreviousquestionsonactivityanddisability?

Domainasonsurvey:Medicationuse

ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin3papers(2.5%).

Ratedatalmost60%,medicationuseisthe5thhighestrankedonagreementofalldomains.Theminimal

reportingofbaselinefeatureshasreturneda79%agreementthatthisshouldbereported.Thiswhen

consideredalonsidethecomments,allofwhicharebytheagreeresponders,itwouldseemthatthisdomain

iscore.

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

12.Doesnotlinktoseverity

nocomments

Domainasonsurvey:Participation

ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:IThisdomainwasreportedin1paper,butithad4

scales(3%ofallscales).*Thiswasmeasuredbyaskingparticipants(patientsandcontrols)whattheirlevelofactivitywas

withfamilyandathome,recreation,runningorotherphysicalactivity,andsocialactivities,usinga10cmline(0cm=no

limitation,100cm=completelimitation).

Commentsindicatingsomeuncertaintyaboutthisdomaingenerallyandoverall,suggestingitshouldbe

discussedinthemeeting.Itwouldseemthatsuchadiscussionwouldencompassthedomainsof

participation,physicalactivity,sportandworkrelatedparticipationasseparatedomains.

1.Aloadrelatedconditionoughttoencompassparticipation

2.asabove

3.CantseehowthisisdifferentfromPhysicalactivity-howphysicallyactiveareyoucanbeusedforathletesand

nonathletesalike?

4.combinedwithqualityoflifeoffunctionscales?

5.Difficulttovalidate

6.Ithinksitishardtotranslatethisoutcomemeasuretopatients.

7.needsmorequantifiedinformation

8.willnotaddmuch

9.Overlapsgreatlywithotherqueries.

10.Participationinwhat?Thisneedstobebetterqualified

11.Wouldneedtobespecifiedandcontextrelatedtoaddmeaning

Domainasonsurvey:Physicalactivity

ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedinatleast5papers

(4%).*Thisisabouttheparticipant(patientorcontrol)ratingoverallphysicalactivityregardlessofpainorthe

tendinopathy.

Physicalactivityisstronglysupportedasabaselinefeaturetobereportedinthatsurvey.Commentshereare

mainlyaboutitbeingcapturedinotherdomains-wewillneedtolookatthequestionsthatdealwith

aggregationanddeletiontotrytocometosomeagreementregardingcoredomainforphysicalactivity.

1.Aloadrelatedconditionoughttoencompassphysicalactivitycapacity

2.inviewoftherelationshipbetweentendinopathyandintensityofexercise/activitiy

3.partoftheoverallperspectiveoftheperson'sactivitylevel

4.Physicalactivityiskeybutcouldbeinferredfromotherdomains

5.Pleaserefertoquestionaboutsport

6.Theramificationsofnotbeingabletobephysicallyactiveareseriousformaintaininghealth.

7.work,sports,adl,hobby

8.couldbecapturedinfunction

9.Doesn'tchangetreatmentoreval.

10.Ithinkwouldneedtobespecified-asRTSabove

11.Ifthisisdifferentfromsportsactivity,Iwouldsayno.

12.Therearesomanyfactorsthatcaninfluencegeneralphysicalactivity,sounlikelytobeusefulasacoredomain.

13.Lessstringentreportingelementthanthetendon-specifictools.

Domainasonsurvey:Adverseeffects/events

ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:hisdomainwasreportedin9papers(7%).

*Adverseeffects/eventsareanyeventthatoccurstotheparticipant(patientorcontrol)whileinthestudy(orbeing

followedclinically).Theyneednotberelatedtoatreatmentforthetendinopathyortothestudyinparticular,butjustany

eventthatisadversetothehealthoftheindividual.

Thecommentsfromtheunsurerespondersalignwithsupportingadverseeventsasacoredomain,butwith

furtherqualification,possiblyinthemeasurementofthedomain.Veryfewcommentsofanysubstanceinthe

disagreeresponderslendssupporttothisobservation.

1.Beendonepoorlyinthepastbutveryimportanttohave!

2.Iwouldlikedocumentationoradverseeventspertainingtodropoutsordetailsonexacerbationofsymptomsetc

3.importantforallstudies

4.Importanttolookforpossibleissueswithtreatment

5.Theassociatedadversehealthissues,whetherrelatedtothetendonissueornot,shouldbepartoftheoverall

healthdomainsetofanymusculoskeletalcondition.

6.Thisisunderreported,butveryimportantwheninformingpatients.

7.Weneedtoknowwhatadverseeffectsagiventreatmentmayinduce

8.Notimportant.

9.Notsurehowthisisrelevant

10.provocativeactivity/testsaremoreappropriatetorule-in

11.Ithinkitisausefulitemespeciallyintreatmenttrials,butIbelievethenatureoftheadverseeventneedstobe

specifiedinmoredetail.

12.Maybeeventspecific.Ifthisextendedtosayutilisationofcoach-ratedperformanceinaprofessional

sportspersonthiswouldbequiteuseful,althoughmaybenotacoredomain.

13.notinallstudiesIthinkonlyininterventionstudies

Domainasonsurvey:Workparticipation

domainrelatestothingslikehowlongtoreturntowork,thelevelofwork(howstrenuousfortheparticulartendon).

Commentsaligningwiththeotherparticipationresponses.

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

9.Mosthavetoworkanyway.Lowreportingtoo.

10.Notnormallyrecordedandsoweknowlittleaboutthis

11.conditionspecific.becausetheinfluencewouldbedifferinsubjectswithelbowverseanklepainassociated

withtendinopathy

12.Deoendantontypeofworkandtendon.

13.Isthisrelevantforeverypatient-effectsoftendoncomplaintsonworkpracticesmaybeasmallsubsetforitto

beincludedasacoredomain.Enoughondisability/functiondatacapturedalreadyinpreviousstatements?

14.Maybesupplementary,onlyusefulinthosewholoadtheaffectedtendonintheirwork.

Domainasonsurvey:Discontinuetreatment(dropout)

ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thiswasnotextractedfromthereviewedreports

andisincludedhereforconsideration.

Approximately50%agreementandcommentsindicateneedclarityonreasonsfordis-continuingtreatment.

1.Ithinksthisshouldbepartoftheevaluation.Itisstrikingthatthiswasnotdoneinprevioustrials.

2.Obbious.”

3.Partofanywellconductedstudy

4.persistentpainstates,liketendinopathyinmanyinstances,ismarkedbyafrustratingoffandon,trymany

treatments,cyclicalpattern-sotreatmentadherenceorlacktherofisafunctionofthecondition

5.Yes-canhavebigimpactoninterpretingresults-againlikeGROC-thisisreallyafollowupmeasureandcould

bespecifiedasbeingsuch-ratherthansomethingdoneatbaselineandagainatf/u

6.Difficulttodefineeasily

7.No,therearemanyreasonswhypeoplemaydiscontinuetreatmentthathavenothingtodowiththeeffectof

theintervention.

8.Maybenotcorebutausefulsupplementaryquestionwhichmayempiricallyreflectabalanceoftreatment

burdenagainstefficacy.Reasonfordropoutwouldalsoneedtoberecordedasitmaybeinfluencedbynon-

treatmentrelatedissues.

9.notsurewhatthismeans,needscontext

10.Onlyininterventionstudies

Domainasonsurvey:Structure

ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin36papers(30%),as

51differentmeasuresor42%ofalldomainsextracted.*Thetypesofoutcomemeasuresreportedwere:MRI,US(grey

scale,Doppler),andXray.

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.

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!

12.Duetothemismatchbetweenpain&functionandimaging,Idon'tbelievestructureshouldbeapartofthe

'coredomainset'.Itmaystillbeofinterestwithinaresearchenvironmentandisanimportantriskfactorforthe

developmentofpainfultendinopathy,butusuallyhaspoorcorrelationwithoutcomes.

13.notalotofevidencethatthischangeswithinterventionand/orpain

14.Notasanoutcomemeasureasnotshowntocorrelatewithpatientstatus

15.Poorrelationshipwithpain,prognosis,andlimitedevidencethatitchangeswithloading.

16.Thereisalreadyevidencethatthisisnotrelatedtoseverityofsymptoms.Notinpresentstateduringexam,nor

inthefuture.Itmightbeaninterestingoutcomemeasureinsomecases,butnotaC-TOM.

17.Thereseemstobenorelationandactualpatientcontactisneeded

18.Thislimitsthepossibilityofstudiestocomplywiththeminumumsetcriteriaasitmakesreasearchmore

expensive.Iseearoleforimagingstudiesbutwouldnotconisderthosethathavenotusedimagingtohavefailed

orbelessuseful.

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

Domainasonsurvey:Painover24hours

*Themeasuresusedhereincludeaskingtheparticipant(patientsorcontrols)toratetheirpainoveraspecifiedtime

frame(s)(e.g.,lastweek,last24hours,inthemorning,atnight)ona10cmline(VisualAnalogueScale)oroutof10

(NumericalRatingScale).

Generalsensefromthecommentswasthattimeframeismuchlessimportantthantheloadingactivity

(whichwasthemostagreedupondomainofallherein).Someexpressionsthatatimeframeoverwhichthe

painisratedwasinsomecomments,butverymuchintheminority(andusuallyasasecondary

consideration)comparedtoloading/activity.Thereweresomecommentselsewhereforstartuppaininthe

morning-shouldweconsiderthatispartofthe24hourpainpicture?

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

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

15.Onlywhenconnectedtoactivity/loading

16.Specificationofthecircumstances(restvsactivity)whenpainisoccurringmaybenecessary.

17.Thismeasureofitselfdoesassumevarietyandmagnitudeareconstantsinsubjects.Lessrigorousthanother

measuresabove.Notcorebutmaybeuseful

Domainasonsurvey:Clinicalexaminationfindings

ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin28papers(/122;

23%).*Thisdomaincoversmeasuresthatreportasinglenumber/scoreforacombinationofclinicaltests(e.g.,combine

thetestresultsofrangeofmotion,strength,palpationintoonescore).Someexamplesofthesemeasures/scoresare:

UniversityofCalifornia-LosAngeles(UCLA);Constantscore;Liverpoolelbowscore.

Thecommentslargelyconcerncombininganumberofclinicaltestsintoonescore.Thepercentagreement

wasalmostsimilaracrossallresponseoptions(agree,disagree,unsure:30,40,30%),butthecommentsare

largelyalignedwithdisagree.

1.asabove

2.butnotsurewhichhavetobereportedindifferentconditions

3.Itwillbedifficult,butshouldbeincluded.

4.PleaserefertoArthroscopy.1998Nov-Dec;14(8):840-3.Overusetendonconditions:timetochangeaconfusing

terminology.MaffulliN1,KhanKM,PudduG.

5.Yes,butonlyspecifictendontelatedtests.

6.Anytimeyoutakedataandcombineyoulooseinformation.

7.Clinicalscoresofthisnaturearenotwellenoughworkedoutforalloftherequiredcommontendonissues

8.Clinicianmeasuresareatbestsurrogate.

9.Iwouldratherhavespecificclinicalfindingsreportedseperatley-onceyoumakeacompositescoreitgets

hardertointerpretfindingsandknowwhatthepatientslookedlikeonexamination

10.Manymaynotchangeaftertreatment/improvementofsymptomse.g.palpationtendernessisaverygood

exampleofthis.

11.Notspecificenoughwhencombinedintoonescore,interobserverreliabilityisoftenlow

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.

Domainasonsurvey:Economicimpact:costs

isusuallymeasuredfrommedical/healthrecords,questionnaires,diaries,orinterviews.

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.

1.Costeffectivenessisanecessityinthepresenthealthcareenvironment

2.Especiallywhendataaretobeusedincosteffectivenessanalysesorhealthtechnologyassessment.

3.Importanttonote

4.inoursocietyonewaywemeasureimpact/valueisthrougheconomicimpacts(directandindirectcosts,lost

timeatwork,etc)

5.thisneedsmoreattentiontogettpontheagenda

6.Againhereitsa"nicetohave"likestrength/ROM/Imaging-drivesupthecostofresearchandnothavingit

doenstde-valueastudy

7.AtasocietallevelthenMSKinjurycanhaveamajorburdenonmortalityrisk-butforanindividualdifficultto

include

8.Itisdifficulttoanalyzecostforthisinjuryduetotheslowinsidiousonsetandsincethepatientoftencanbe

activeduringtreatment.Surgeryisalsonotamaintreatment.

9.asecondarymeasureformoststudies,butincreasinglyimportantasmorepeopletrowmoneyatuseless

interventions

10.Couldbeusefulincertaincohortsegprofessionalsportspersonsortradespeople.Notsureifitshouldbeacore

domainbutagainusefulinappreciatingimpactoftendinopathyincertaincohorts.

11.Notsurethisisfeasibleasacoredomainset

12.Onlyinsomestudies.

13.Thisisimportantforfunding,butIamnotsurewhetheritshouldbeaC-TOM

14.Wontthatbeinsensitive?

Domainasonsurvey:Psychologicalimpact

ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Thisdomainwasreportedin3papers(2.5%),

accountingfor5%ofalldomainsextracted.*Thetypesofoutcomemeasureswere:paincatastrophizingscale,painself-

efficacy,anxietyanddepressionscales.

Basedonthecomments,whicharelargelyaboutthemeasureratherthantheconstruct,itwouldseemthat

combinedtheagreeanddisagreewouldmeetthe70%target.Thereisacommenttoconsiderifthisdomain

shouldbesplitfurtherintosmallerdomains-butnosuggestionofwhattheymightbe.

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.

6.Difficulttodefine-butcouldbeassessede.g.viaEQ5D

7.Interestingasexplorativeoutcomemeasure,butnotaC-TOM

8.Notreportedandnotimportant.

9.DoesthisdifferfromQOL?Ifso-ithinkweshouldhavethisaswell-givesholisticviewofimpact

10.Evsluationonlyinsomestudies.

11.Idoubtit-notsensitivenorspecific

12.Mybenotacoredomain,butaveryusefulsupplementarydomain,whereongoinglimitationhasmoregeneral

effectsonpatientwellbeing.

13.specificstudiesonthisimportantbutnotacoredomainformoststudies

14.Wouldthisperhapsprovideameansofcontrollingforcopingfactorsinotherdomains?

Domainasonsurvey:Palpation(painortenderness)

*Theclinicianpressesonthetendonwithathumborfingerandelicitspain(ornotincontrols)andtheparticipant

(patientorcontrol)reportsthispainortendernessinavarietyofways(e.g.,ona10cmline,outofa11pointratingscale

(0to10),bespokenominal/ordinalscales,orinsomecasesnotstatedinthepaper).

Eventhoughagreeanddisagreewereselectedaboutthesameproportions(40%each),thecomments

affirmingpalpationarelargelyaboutclinicalexaminationandinthemainmostcommentsdonotsupport

palpationasacoredomain.

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

7.forthetendonsofmyareaofinterestitisnotpossibletoaccuratelyidentifythestructuretherelationship

betweenpalpationandpainremainsuncertain

8.Hardlyeveruseful,asidefromrulingoutatendonissueinthediagnosticprocess.

9.Itisdifficulttopalpatemanytendonse.g.supraspinatus

10.Notdiagnosticoragoodoutcomemeasure,infactleadsmostpeopleastray

11.Palpationisoftenmostusefulasanegativepredictorofthepresenceofpainfultendinopathybutisnotagood

indicatorofoutcome.Tendernessonpalpationoftenremainsinthepresenceofsubstantialimprovementsin

outcome/function.

12.Palpationpainchangesappearpoorlycorrelatedtofunctionaloutcomes

13.Toopronetoerrors

14.Asainclusioncriteriaorasanoutcomemeasure?

15.Dependsontendon.Overall,no

Domainasonsurvey:Strength

*Strengthbeingmeasuredbyaninstrumentsuchas:adynamometersorforcetransducers.

Onbalancethecommentsindicatethatstrengthmightnotbeacoredomain,withmanycommentsinthe

agreerespondersnotfavouringitascore-whichwouldlikelyindicatethat70%wouldbereachedonfurther

discussion.

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

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.

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.

Thefollowingitemswereaboutdeleting,aggregating,addingorsplittingthedomainspreviously

presentedaboveinthesurvey:providedheretohelpwithdecisionsoneachdomainatthemeeting.

Orderofagreeordisagree:.

Domainasonsurvey:Adddomains?

ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Arethereanyotherdomainsthatyouconsider

importantenoughtobeincludedinacoredomainsetfortendinopathy?

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).

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

(nocomments)

11.Asanimager,Iamwonderingwhetheranyfeaturesrelatingtotendinopathyfromimaging(USorMRI)maybe

usefultoaddIFavailable.

12.Ialludedtotheutilisationinspecificcohortsofindependentlyratedsportsperformance,whichwouldalsobea

usefulsupplementaryratinginprofessionalsportonly.

13.Nonethatcurrentlycometomind-itwouldbegoodtostartwithaforementioneddomainsandworkfrom

14.sports-specificandtendon-specificmayneedtobeconsiderinacoredomainsetfortendinopathy.

Domainasonsurvey:Removedomains?

ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:ArethereanydomainsthatyouconsiderareNOT

importantenoughtobeincludedinacoredomainsetfortendinopathy?Thatis,theyshouldberemovedfromthislistof

domains.

Domainssuggestedforremoval:1discontinuetreatemtn/dropout,2sensorymodalitytests(x2),3palpation

(x3),4painwithclinicalappliedstress(x2),4structure/imaging(x4),5painwithoutcontextspecified(x2),6

clinexaminationfindingsasacombinedscore,7pover24hourperiod,8strength,9ROM(x2),10Function,

11physicalfunction,12Psychologicalimpact,13participationlife,

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)

6.Possiblypalpationbecausenotallcanbepalpatedeasily

7.Theyareworthyofconsideration.Answersaboverewhichwouldseemmostimportant.

8.Fromapracticalpointofviewitwouldbeimportanttokeepanyquestionnairemanageable/limited

9.Importantheretoalsoconsiderbothcoreandsupplementarydomains.Iconsiderpalpation,imaging(generally)

andthelessspecificactivitydomainscandidatesforremoval.

10.seerepsonsein1stsection

11.somecouldbecombinedegtheactivityones

Domainasonsurvey:Aggregateanydomains

ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Shouldanyofthedomainslistedabovebe

aggregated(combinedintooneorfewerdomains)beforebeingincludedinacoredomainsetfortendinopathy?

Somediscussionaroundwhatthedomainsmean(ratherthanthemeasures)intermsoftheconditionappears

necessaryasthereisconflationbetweenthetwoapparenthere.Forexamplepainanddisability,arethey

actuallyonedomainortwo?Function,disability,participationalsoappeartobeinneedofsome

considerationhere,asisdisability,QoLandpsychological.Perhapsbestconsideredforeachdomainasthey

areindividuallyconsidered.

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)

(nocomments)

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

Domainasonsurvey:Splittingdomains

ThedomainaslistedonthesurveyandEXAMPLEmeasuresforcontext:Shouldanyofthedomainslistedabovebefurther

splitupordividedintotwoormoredomainsbeforebeingincludedinacoredomainsetfortendinopathy?

Commentsfromtheagreeresponderstoconsiderare(i)splittinguppsychologicaljustaspainhasbeen,and

(ii)strength,endurance,powerfordifferentfunctionsofmuscle.

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

4.Enoughalready

5.Ifeeltheyareprettyspecificnow

6.ditto,toohardtoconsiderbasedonthesurveytodate

7.I'mnotquitesurewhatanexampleofthismightbe.Painonloadinganddisability/functionwouldhavea

numberoftendon-specifictasksassub-questions,butIwouldn'tconsidertheseseparatedomains.

8.Thereisacaseattimesforminingthetendonspecificinstrumentsforeffectofanintervention.ieinVISAX,

sportparticipationdidnotchangeover6-12weeksbutotherparametersdid...

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)

Table3a:Patientparticipantcharacteristicsofthecompletingthesurvey.

Characteristic N(%)

SexFemale(%) 24(77%)

Clinician 1(3%)

NeitherCliniciannorResearcher/Scientist 28(90%)

Other 2(6%)

Casespermonth:

0(Iamapatient) 29(94%)

Atleast4 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%)

Page 1 of 34 Delphi process for Core Domain Set for

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