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| Name | Class |
|---|---|
| Danderyd Hospital | OTHER |
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Acute Achilles tendon rupture (ATR) is an injury that is commonly associated with complications, such as blood clotting, muscle loss and tendon lengthening, all of which affect the long-term outcome and return to sports. These complication are related to the treatment of ATR with lower leg immobilization in a boot.
The investigators aim to demonstrate that an intervention with calf neuromuscular electrical stimulation (C-NMES) during leg immobilization after ATR can 1) reduce blood clots, 2) lower the degree of muscle loss, 3) decrease tendon lengthening and 4) improve long-term outcome.
The participants will be divided by chance into two separate groups that compare standard treatment (control group) with C-NMES in addition to standard treatment (intervention group).
A total of 220 patients with diagnosed ATR will be included. The control group will be treated according to the standard regimen with a lower leg immobilization in a stable orthosis during eight weeks. The intervention group will during the eight weeks lower limb immobilization receive an additional intervention with C-NMES underneath the orthosis.
The total number of blood clots, venous thromboembolism incidence, up to mobilization, is defined as deep venous thrombosis (leg blood clots) assessed by screening duplex ultrasound, or pulmonary embolism (lung blood clots). Calf muscle loss, tendon length, and weight-bearing, will be studied at two and eight weeks. At six weeks and 12 months, validated self-reported function (ATRS) and self-reported health, return to sports, calf muscle function, and tendon length will be recorded for comparison between the two treatment groups. Secondary outcomes are coagulation factors, healing biomarkers and cardiovascular biomarkers.
The results of this study should contribute to an improved treatment regimen after ATR that allows for a safer and quicker return to activity and sports. Adjuvant NMES can readily be implemented in daily healthcare to lower complication risks, improve healing, reduce healthcare costs and improve return to sports.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Control group with standard lower-limb immobilization | No Intervention | The control group will be treated according to the standard regimen with a lower limb immobilization in a stable orthosis during eight weeks. | |
| Intervention group with additional Neuromuscular Electrical Stimulation' | Experimental | The intervention group will during the eight weeks lower limb immobilization receive an additional intervention with calf Neuromuscular Electrical Stimulation (C-NMES) underneath the orthosis. |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Neuromuscular Electrical Stimulation | Device | Patients will be instructed to apply the wearable NMES-therapy continuously, both day and night at least 10h/daily. |
|
| Measure | Description | Time Frame |
|---|---|---|
| Incidence of Venous thromboembolic events (VTE) | VTE, is defined as symptomatic/ asymptomatic DVT assessed at the end of immobilization, i.e. 8 weeks, by compression duplex ultrasound (CDU) screening, or symptomatic pulmonary embolism detected by computer tomography. Assessors of CDU will be skilled ultrasonographists, masked to the treatment allocation. The CDU-examination will document absence/presence of thrombus in the calf, popliteal and femoral veins separately | 8 weeks |
| Measure | Description | Time Frame |
|---|---|---|
| Patient function | Functional evaluation of healing will be performed by the validated heel-rise test at one-year post-injury. | 12 months |
| Callus production | Callus production will be assessed at eight weeks using microdialysis followed by quantification of procollagens for tendon healing. |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Luigi Belcatro, Res.Nurse | Contact | 0046-735060907 | luigi.belcastro@regionstockholm.se |
| Name | Affiliation | Role |
|---|---|---|
| Paul Ackermann, Prof,MD,PhD | Karolinska Institutet and Karolinska University Hospital | Principal Investigator |
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| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 37887696 | Background | Alharbi A, Li J, Womack E, Farrow M, Yarar-Fisher C. The Effect of Lower Limb Combined Neuromuscular Electrical Stimulation on Skeletal Muscle Signaling for Glucose Utilization, Myofiber Distribution, and Metabolic Function after Spinal Cord Injury. Int J Environ Res Public Health. 2023 Oct 21;20(20):6958. doi: 10.3390/ijerph20206958. | |
| 29161465 |
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On reasonabe request data will be shared.
June 2025 and will be available 2 years
On reasonabe request data will be shared.
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| ID | Term |
|---|---|
| D054556 | Venous Thromboembolism |
| D009133 | Muscular Atrophy |
| ID | Term |
|---|---|
| D013923 | Thromboembolism |
| D016769 | Embolism and Thrombosis |
| D014652 | Vascular Diseases |
| D002318 | Cardiovascular Diseases |
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| ID | Term |
|---|---|
| D004558 | Electric Stimulation |
| ID | Term |
|---|---|
| D010812 | Physical Stimulation |
| D008919 | Investigative Techniques |
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|
| 8 weeks |
| Treatment adherence | Treatment adherence to allocated treatment, NMES, will be registered by the patient and by the device. | 8 weeks |
| Adverse events | Adverse events that will be registered are 1) Any damage to the skin of the legs including infection. 2) Any reasons for prematurely stopping the NMES. 3) Any fall associated with significant injury occurring within 6 weeks of enrollment. The frequency of the adverse events of each group will be presented. | 8 weeks |
| Fasting blood glucose | Fasting blood glucose will be assessed at inclusion and at eight weeks. A fasting blood sugar level less than 100 mg/dL (5.6 mmol/L) will be considered normal. A fasting blood sugar level from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) will be considered considered prediabetes. If it is 126 mg/dL (7 mmol/L) or higher it will be considered diabetic. | 8 weeks |
| Cholesterol levels | Will be assessed at inclusion and at eight weeks. Total cholesterol less than 200 Mmol/l will be considered good. Total cholesterol 200-239 Mmol/l will be considered moderately elevated. Total cholesterol 240 Mmol/l or higher will be considered high. | 8 weeks |
| Blood pressure | Systolic blood pressure less than 120 mmHg and diastolic blood pressure less than 80 mmHg will be considered optimal. Systolic blood pressure between 120-129 mmHg and diastolic blood pressure between 80-84 mmHg will be considered normal. Systolic blood pressure between 130-139 mmHg and diastolic blood pressure between 85-89 mmHg will be considered slightly high. Systolic blood pressure greater or equal to 140 mmHg and diastolic blood pressure greater or equal to 90 mmHg will be considered high. | 8 weeks |
| Muscle atrophy | At 2 and 6 weeks and 6 and 12 months postoperatively, B-mode ultrasound imaging will be performed to assess the cross-sectional area (CSA) of the Achilles tendon, the gastrocnemius CSA, as well as the thickness of soleus. The injured and healthy sides will be compared. | 12 months |
| Tendon lengthening | At 2 and 6 weeks and 6 and 12 months postoperatively, B-mode ultrasound imaging will be performed to assess the length of the Achilles tendon. The injured and healthy sides will be compared. A larger difference between the sides will be considered a worse outcome. | 12 months |
| Patient-reported outcome - ATRS | The validated Achilles Tendon total Rupture Score (ATRS) will be assessed at 6 and 12 months. [0-100, a higher score mean a better outcome]. | 12 months |
| Patient-reported outcome - EuroQol (EQ-5D-5L) | The validated EuroQol (EQ-5D-5L), will be assessed at 6 and 12 months. [A five-digit code will be generated, where each digit will be between 1-5, a lower digit in each position mean a better outcome in that dimension]. The five-digit code will generate an index between 0-1, where a lower value is worse outcome. The index will be compared with a country specific index. | 12 months |
| Blood-flow quantification | VTE-preventive mechanisms will be analyzed at the eight week visit by assessments by blood-flow quantification using ultrasound. Peak popliteal/femoral blood velocity (cm/second) will be calculated using custom ultrasound software. | 8 weeks |
| Coagulation factors | VTE-preventive mechanisms will be analyzed at the baseline and eight week visit by assessments of coagulation factors. Overall hemostatic potential (OHP), D-dimer, endogen trombin potential, fibrinogen, trombin antitrombin complex, plasmin antiplasmin complex, will be assessed in blood samples. The percentage increase/decrease between baseline and eight weeks assessment will be compared between groups. | 8 weeks |
| Hajibandeh S, Hajibandeh S, Antoniou GA, Scurr JR, Torella F. Neuromuscular electrical stimulation for the prevention of venous thromboembolism. Cochrane Database Syst Rev. 2017 Nov 21;11(11):CD011764. doi: 10.1002/14651858.CD011764.pub2. |
| 32206673 | Background | Aufwerber S, Heijne A, Edman G, Silbernagel KG, Ackermann PW. Does Early Functional Mobilization Affect Long-Term Outcomes After an Achilles Tendon Rupture? A Randomized Clinical Trial. Orthop J Sports Med. 2020 Mar 16;8(3):2325967120906522. doi: 10.1177/2325967120906522. eCollection 2020 Mar. |
| 38796725 | Background | Aufwerber S, Svedman S, Silbernagel KG, Ackermann PW. Long-term patient outcome is affected by deep venous thrombosis after Achilles tendon rupture repair. Knee Surg Sports Traumatol Arthrosc. 2024 Aug;32(8):2184-2193. doi: 10.1002/ksa.12240. Epub 2024 May 26. |
| 39040046 | Background | Svedman S, Marcano A, Ackermann PW, Fellander-Tsai L, Berg HE. Acute Achilles tendon ruptures between 2002-2021: sustained increased incidence, surgical decline and prolonged delay to surgery-a nationwide study of 53 688 ruptures in Sweden. BMJ Open Sport Exerc Med. 2024 Jul 18;10(3):e001960. doi: 10.1136/bmjsem-2024-001960. eCollection 2024. |
| D020879 |
| Neuromuscular Manifestations |
| D009461 | Neurologic Manifestations |
| D009422 | Nervous System Diseases |
| D001284 | Atrophy |
| D020763 | Pathological Conditions, Anatomical |
| D013568 | Pathological Conditions, Signs and Symptoms |
| D012816 | Signs and Symptoms |