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Neuromuscular Training & ACL Injury Prevention: A Systematic Review Bialercowski, Christine; Campbell, Sean; Falkner, Sara; Owen, Jessica; Ward, Alex; MacIntyre, Donna; Dumont, Tyler 2006-10-05

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Neuromuscular Training & Neuromuscular Training & ACL Injury Prevention: A ACL Injury Prevention: A Systematic ReviewSystematic ReviewPresented by:Christine Bialkowski, Sean Campbell, Sara Falkner, Jessica Owen & Alexander WardSupervisors:Donna MacIntyre& Tyler DumontOutlineOutlinezzIntroduction to ACL injurieszzPurpose of our reviewzzMethodzzResultszzDiscussionzzConclusionszzQuestionsAn Introduction to ACL InjuriesAn Introduction to ACL Injuries?~70% are non-contact (Arendtet al., 1995)?Common mechanism = rapid deceleration (I.e. planting/cutting maneuvers or landing from a jump)?Females at higher risk than males (4-6x higher in soccer) (Mihataet al., 2006)Risk FactorsRisk FactorszzINTRINSIC:?Hormonal?Anatomical?Biomechanical?NeuromuscularzzEXTRINSIC:?Bracing?Physical/visual perturbations?Shoe-surface interactions (Hewett et al., 2006)Neuromuscular MechanismsNeuromuscular MechanismszzUnbalanced medial to lateral quadriceps ratio (Myer et al., 2005, Rozziet al., 1999)zzPre-planned vs. unanticipated movements?Increased varus-valgusand internal-external rotation moments (Besieret al., 2001)zzQuadriceps-hamstrings antagonist-agonist relationship?Deficits in strength and activation of hamstrings (Solomonowet al., 1987)?Decreased co-activation (F > M) (Hewett et al., 2006)(PetrusC, 2006)The Need For PreventionThe Need For Preventionzz~95,000 new ACL injuries/yearzzIf surgery is required ?6 to 24 months of rehab = $17,000/injury (Beynnonet al., 2005, Hewett et al., 1999)zzACL reconstruction does not ensure a return to previous activity levels (Fithianet al., 2002) zzIf left untreated ??chronic knee instability, secondary joint damage and early OA (Andriacchiet al., 2006)Purpose of Our ReviewPurpose of Our ReviewzzIdentify the effectiveness of neuromuscular training programs in the prevention of ACL injury in athletes participating in high risk sportsMETHODMETHODLiterature SearchLiterature Search?English language?1996 ?August 2006?MEDLINE, CINAHL, EMBASE, Web of Science, PubMed, SPORT Discus, CENTRAL and PEDroCommon Search StrategyCommon Search Strategy1.Anterior cruciate ligament injur$ or ACL injur$ OR knee injur$2.Prevention3.1 AND 24.Neuromuscular OR exercise OR training OR balance OR proprioception OR agility OR plyometric$5.3 AND 4The Search continuesThe Search continues??zzGrey literature search (ProQuestDissertations & Theses database)zzHand search (J. of Orthopedic and Sports Physical Therapy)zzReference list search of included articleszzContacted expertsStudy Selection CriteriaStudy Selection Criteria1)Subjects were male or female athletes participating in one or more of the identified high risk sports2)The intervention was a neuromuscular training program aimed at preventing knee injury3)An experimental design was used4)Outcome measure was ACL injury incidenceExclusion CriteriaExclusion CriteriaRehabilitation intervention post-ACL injurySPORTDiscus(n=208)EMBASE(n=46)CINAHL(n=96)PubMed(n=137)Cochrane Central Register of Controlled Trials (n=11)PEDro(n=179)Web of Science(n=59)Potentially relevant citations identified through electronic searches (n=736)Citations excluded after title screening (n=582)Abstracts retrieved for review (n=154)Studies excluded after abstract screening (n=109)Full articles retrieved for detailed review (n=45)Studies excluded after full text review (n=38)Relevant studies included in systematic review (n=7)Search Flow DiagramSearch Flow DiagramReview CriteriaReview Criteria?Sackett?s levels of evidence as updated by Phillips et al. in the Oxford Centre for Evidence-based Medicine Levels of Evidence (Sackett, 1986, Phillips et al., 2001)Methodological Quality CriteriaMethodological Quality Criteria?Megens and Harris as modified by Medlicottand Harris (Megens et al., 1998, Medlicottet al, 2006)?10 criteria?Strong (8-10); moderate (6 or 7); weak (5 or less)RESULTSRESULTSLevels of EvidenceLevels of Evidence?5 non-randomized cohort studies?2 randomized cohort studies?All studies used prospective data collection methods?All identified as level IIbMethodological RigorMethodological Rigor?Range 3 to 7 (out of 10)?Mean score = 6?Median score = 7?5 studies scored as ?moderate?and 2 as ?weak?Methodological RigorMethodological RigorAuthorsMandelbaum et al (2005)Hewett et al. (1999)Myklebust et al. (2003)Soderman et al. (2000)Petersen et al. (2005)Caraffa et al. (1996)Heidt et al. (2000)RandomizationNNNYNNYInclusion/ Exclusion criteriaYYYYYYYSimilarity of groups at baselineYNYYYYNReplicabilityYYNYNNNReliabilityYYYNYYNValidityYYYNYYNBlindingNNNNNNNDropoutsNYYYYNNLong-term resultsYYYYYYYAdherenceYYYYNNNTotal score /107777653Rigor ratingModerateModerateModerateModerateModerateWeakWeak10 Criteria for Methodological Rigor10 Criteria for Methodological Rigor1) Randomization: ?2 of the 7 studies randomly assigned subjects to an intervention or control group2) Subject Inclusion and Exclusion Criteria:?High school to semi-professional athletes?Exclusions: Poor compliance; previous knee injury; geography?6 studies targeted females; 1 study targeted males3) Similarity of Groups at Baseline: ?5 studies reported similarities (I.e. height, weight, age, muscle flexibility, balance/ postural sway of lower extremities, sport experience)4) Replicability of the Treatment Protocols: ?Must have been stated within the article or have had an accessible reference?Mandelbaum et al., Hewett et al., and Soderman et al. provided this5) Outcome Measure Reliability: ?MRI or arthroscopy for diagnosis?5 studies met this criteria6) Outcome Measure Validity: ?Valid if used MRI or arthroscopy for diagnosis?Therefore, 5 studies also met this criteria7) Blinding Assessment: ?Must have blinded the subjects, treatment provider AND assessor?No study met this criteria8) Reporting of Dropouts: ?Peterson et al., Hewett et al., Mykelbust et al., and Soderman et al provided sufficient detail9) Long Term Follow-Up: ?All studies were carried out over at least one season (> 6 months)10) Adherence to Intervention Program: ?Unreported in Caraffa et al. and Heidt et al.THE STUDIESTHE STUDIESCaraffa et al. (1996)Caraffa et al. (1996)Study DesignProspective cohortRigor & Level of Evidence5 (?weak?) & IIbDuration3 seasonsTarget PopulationSemi professional and amateur male soccer players Sample Size300 Intervention; 300 Control Caraffa et al. (1996)Caraffa et al. (1996)Intervention?Progressive balance board training, stepping exercises, and ?neuromuscular techniques??20 min/day every day during preseason, 3x/week during active season Supervision?CoachesComplianceNot reportedIncidence?10 Intervention (0.15/team/year)?70 Control (1.15/team/year) Program Recommended?Yes -Significant difference was found between intervention and control groupsHeidt et al. (2000)Heidt et al. (2000)Study DesignRandomized CohortRigor & Level of Evidence3 (?weak?) & IIbDuration1 seasonTarget PopulationFemale high school soccer players (ages 14-18yrs) Sample Size42 Intervention; 258 Control Heidt et al. (2000)Heidt et al. (2000)Intervention?7 week preseason  program including cardiovascular, plyometrics, strength, and flexibility training (20 sessions)?2x/week speed training treadmill sessions where grade was elevated?1x/week plyometric session that progressed throughout 7 weeks from unidirectional to multidirectional to floor obstacles Supervision?Not reportedComplianceNot reportedIncidence?1 Intervention (2.4%); 8 Control (3.1%) Program Recommended??Yes -Significant decrease in lower extremity injuries found between intervention and control groups?No significant difference in incidence of ACL injuries ?authors attribute this to small sample size Hewett et al. (1999)Hewett et al. (1999)Study DesignProspective cohortRigor & Level of Evidence7 (?moderate?) & IIbDuration1 seasonTarget PopulationFemale high school soccer, volleyball, and basketball players Sample Size366 Intervention (female); 897 Control (434 males; 463 females) Hewett et al. (1999)Hewett et al. (1999)Intervention?6 week preseason jump training program; flexibility, plyometrics, and weight training?3x/week, 60-90 min/day, total of 18 sessions Supervision?Athletic trainer, coaches, physical therapist Compliance70% completed 6 week program Incidence?2 Intervention; 6 Control (1 male, 5 female) incidence of allknee injuries?0.43 female control, 0.12 female intervention, 0.09 male control Program Recommended?Yes -The untrained group had a kneeinjury rate 3.6 times higher than the female intervention group and 4.8 times higher than the male control group. Mandelbaum et al. (2003)Mandelbaum et al. (2003)Study DesignProspective cohortRigor & Level of Evidence7 (?moderate?) & IIbDuration2 yearsTarget PopulationAmateur female soccer players (ages 14-18 yrs) Sample Size?2000: 1041 Intervention; 1905 control?2001: 844 Intervention; 1913 Control Mandelbaum et al. (2003)Mandelbaum et al. (2003)Intervention20 min warm up prior to practices and games: 3 warm-up techniques, 5 stretches, 3 strengthening ex?s, 5 plyometric ex?s, 3 soccer specific agility drills Supervision?CoachesCompliance?2000: 96.15%; 2001: 100% Incidence?2000: 2 Intervention  (0.05/athlete/1000 exposures); 32 Control (0.47/athlete/1000 exposures)?2001: 4 Intervention (0.13/athlete/1000 exposures); 35 Control (0.51/athlete/1000 exposures)Mandelbaum et al. (2003)Mandelbaum et al. (2003)Program Recommended?Yes -Significant difference was found between intervention and control groups with 88% reduction/athlete in 2000 season and 74% reduction/athlete in 2001 season Myklebust et al. (2003)Myklebust et al. (2003)Study DesignProspective cohortRigor & Level of Evidence7 (?moderate?) & IIbDuration3 seasons (1 control; 2 intervention seasons)Target PopulationFemale handball players Sample Size?1998/99: Control Season 942?1999/2000: Intervention Season 855?2000/01: Intervention Season 850 Myklebust et al. (2003)Myklebust et al. (2003)Intervention?15 min circuit of floor ex?s, wobble board ex?s, balance mat ex?s?3x/week during 5-7 week training period then 1x/week during season Supervision?Coaches in first season, physiotherapists in second season Compliance?1999/2000: 26% of teams fulfilled compliance criteria (42% elite division)?2000/01: 29% of teams fulfilled compliance criteria (50% elite division) Myklebust et al. (2003)Myklebust et al. (2003)Incidence?Control season: 29 (0.14/1000 player-hours) entire cohort, 13 elite division?First Intervention season: 23 (0.13/1000 player-hours) entire cohort,6 elite division?Second intervention season: 17 (0.09/1000 player -hours) entire cohort, 5 elite division Program Recommended?Yes -Although no significant difference was found between intervention and control seasons across the entire cohort, there was a significant difference between those who completed the program and those who didn?t in the elite division Petersen et al. (2005)Petersen et al. (2005)Study DesignProspective cohortRigor & Level of Evidence6 (?moderate?) & IIbDuration1 seasonTarget PopulationSemi-professional and amateur female handball players Sample Size134 Intervention; 142 Control Petersen et al. (2005)Petersen et al. (2005)Intervention?Six phase balance board and jump exercise program?3x/week preseason (8 weeks), 1 x week competitive season 10 min/ session Supervision?CoachesComplianceNot reportedIncidence1 Intervention (0.04/1000 hours exposure*); 5 Control (0.21/1000 hour exposure)Program Recommended?Yes -Although no significant difference was found between intervention and control groups Soderman et al. (2000)Soderman et al. (2000)Study DesignRandomized cohortRigor & Level of Evidence7 (?moderate?) & IIbDuration1 seasonTarget PopulationFemale soccer players (2nd and 3rd Swedish Divisions) Sample Size62 Intervention; 78 Control Soderman et al. (2000)Soderman et al. (2000)Intervention?Balance board exercises each day for 30 days, then 3x/week for remainder of season?10-15 min/ session Supervision?Self ?home program Compliance70%Incidence4 Intervention; 1 Control Program Recommended??No -Significantly higher incidence rate of major injuries found in intervention group?No significant difference in minor and moderate injuries was found between intervention and control groupsDISCUSSION & DISCUSSION & IMPLICATIONSIMPLICATIONSMethodological Rigor & Methodological Rigor & Levels of EvidenceLevels of EvidencezzRigor and levels of evidence were moderatezzMajor contributors to low quality:?Randomization?BlindingzzNature of study designs makes these difficultIntervention CharacteristicsIntervention CharacteristicszzPhase of implementation:?Pre-season ?Competitive seasonzzType of intervention:?Balance/proprioception ?Strength ?Agility ?Flexibility ?Plyometrics ?CombinationzzOther training parameters (i.e. frequency, duration, progression, etc.)SignificanceSignificancezzAll studies except 1 found a decrease in incidence of ACL injury ?Soderman et al. showed a trendtowards an increase in ACL injury in the intervention groupzzCaraffa et al., Hewett et al., and Mandelbaum et al. found statisticallysignificantdifferenceszzMyklebust et al. found a significant difference between intervention and control groups only in the elite handball division Implications for Clinical PracticeImplications for Clinical Practice1) There is moderate evidence to support the use balance/proprioceptive training in ACL injury prevention. Implications for Clinical PracticeImplications for Clinical Practice2)There is moderate evidence to support the use of plyometric training in combination with other training components injury prevention of ACL injury. Implications for Clinical PracticeImplications for Clinical Practice3)There is promising evidence that balance/proprioception training, strength training and plyometric training when incorporated into a comprehensive training protocol may be effective in reducing the incidence of ACL injury.   -Details insufficientImplications for Clinical PracticeImplications for Clinical Practice4)There is moderate evidence that training implemented in the preseason and/or competitive season is effective for ACL injury prevention. Challenges in Drawing Challenges in Drawing ConclusionsConclusionszzQuality of studieszzLack of program detailszzCompliancezzHeterogeneity:?Intervention parameters?Subjects?DurationImplications for Future ResearchImplications for Future ResearchzzIsolation of program componentszzMore rigorous studieszzCareful documentation to allow replicabilityof training programszzMonitoring and reporting compliancezzIntervention parameters need to be establishedzzEffect of interventions on age and genderLimitations of Our ReviewLimitations of Our ReviewzzOnly used publications in EnglishzzLack of correspondence from expertszzOnly used articles accessible free of charge to UBC studentsQUESTION PERIODQUESTION PERIODThank you for your attention!REFERENCESREFERENCESAndriacchiTP, BriantPL, BevillSL, Koo S. Rotational changes at the knee after ACL injury cause cartilage thinning. Clinical Orthopaedics& Related Research 2006;442:39-44. Arendt E, Dick R. Knee Injury Patterns among Men and Women in Collegiate Basketball and Soccer. NCAA Data and Review of Literature. Am J Sports Med 1995;23:694-701.  BesierTF, Lloyd DG, AcklandTR, Cochrane JL. Anticipatory effects on knee joint loading during running and cutting maneuvers. Med SciSports Exerc2001;33:1176-1181.  Caraffa A, CerulliG, ProjettiM, AisaG, Rizzo A. Prevention of anterior crucuateligament injuries in soccer; A prospective controlled study of proprioceptive training. Knee Surg, Sports Traumatol, Arthrosc1996;4:19-21. FithianDC, Paxton LW, GoltzDH. Fate of the anterior cruciate ligament-injured knee. Orthopedic Clinics of North America 2002;33. Heidt RS, SweetermanLM, CarlonasRL, TraubJA, TekulveFX. Avoidance of Soccer Injuries with Preseason Conditioning. American Orthopaedic Society for Sports Medicine 2000;28:659-662.  Hewett T, Myer G, Ford F. Anterior cruciate ligament injuries infemale athletes. Part 1, Mechanisms and Risk Factors.  Am J Sports Med 2006;34:299-311.  Hewett TE, LindenfeldTN, RiccobeneJV, Noyes FR. The effect of neuromuscular traiingon the incidence of knee injury in female athletes. A prospective study.  Am J Sports Med 1999;27:699-706.  Mandelbaum BR, Silvers HJ, Watanabe DS, KnarrJF, Thomas SD, Griffin, LY, KirkendallDT, Garrett W. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med 2005;33:1003-1010.  MedlicottMS, Harris SR. A systematic review of the effectiveness of exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of temporomandibulardisorder. Phys Ther2006;86:955-975. Megens A, Harris SR. Physical therapy management of lymphedemafollowing treatment for breast cancer: a critical review of its effectiveness. Phys Ther1998;78:1302-1311.  MihataL, BeutlerA, BodenB. Comparing the incidence of anterior cruciate ligament injuryin collegiate lacrosse, soccer and basketball players.  Implications for anterior cruciate ligament mechanism and prevention.  Am J Sports Med 2006;34:899-904. Myer GD, Ford KR, Hewett TE. The effects of gender on quadricepsmuscle activation strategies during a maneuver that mimics a high risk ACL injury position. JElectromyogrKinesiol2005;15:181-189.  Myklebust G, EngebretsenL, BraekkenIH, SkjolbergA, Olsen OE, BahlR.  Prevention of Anterior Cruciate Ligament Injuries in Female Team Handball players: A Prospective Intervention Study Over Three Seasons. Clinical Journal of Sports Med 2003: 13;71-78.  Petersen W, Braun C, WiebkeB, Schmidt K, WeimannA, DrescherW, EilingE, StangeR, Fuchs T, HedderichJ, ZantopT. A controlled prospective case control study of a prevention training program in female team handball players: the German experience. Arch OrthopTrauma Surg2005;125:614-621.  Phillips B, Ball C, Sackett D, BadenochD, Straus S, Haynes B, Dawes M. 2001. Levels of Evidence and grades of recommendation. Centre for Evidence Based Medicine. 2006 June-August [cited 2006 September 12]. Available from: URL:, LephartSM, Gear WS, Fu FH. Knee joint laxity and neuromuscular characteristics of male and female soccer and basketball players. Am J Sports Med 1999;27:312-319.  Sackett DL. Rules of evidence and clinical recommendations on use of antithromboticagents. Chest 1986;89:2S-3S. Soderman K, Werner S, PietilaT, EngstromB, AlfredsonH. Balance board training: prevention of traumatic injuries of the lower extremities in female soccer players? A prospective randomized intervention study. Knee Surg, Sports Traumatol, Arthrosc2000;8:356-363.  SolomonowM, BarattaR, Zhou BH, Shoji H, Bose W, Beck C, D'AmbrosiaR. The synergistic action of the anterior cruciate ligament and thigh muscles in maintaining joint stability. Am J Sports Med 1987;15:207-213.


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