Cognitive and contextual factors to optimise clinical outcomes in tendinopathy

Tendinopathy, a clinical term used to describe ‘tendon-related pain’, is a heterogeneous clinical presentation, reflected by the wide-ranging pain presentations and functional deficits.1 For this population, load-based exercise is effective; however, the ‘optimal’ type of exercise, intensity, frequency and duration are not known.2 3 Substantial variety has been a feature of the exercise prescription used in tendinopathy research to date. However, this variation does not appear to have impacted the results. Exercise programmes as different as a concentric-eccentric heavy slow loading programme performed three times per week and eccentric only exercises performed twice daily, 7 days/week, have achieved similar results.4 While within-group mean severity scores improve, individual responses are wide ranging for the same exercise programme4 and success rates vary from 44% failing to improve5 to 100% success6 for a similar exercise intervention. Here we discuss a novel consideration to explain such phenomena—cognitive and contextual factors that affect each individual therapeutic encounter. We acknowledge that heterogeneity in the research cohorts (eg, age, sex, chronicity, comorbidities) or variations in how the exercise programme was delivered and progressed likely play a role, but we focus on factors we feel have received little attention