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A Systematic Review of the Effectiveness of Eccentric Strength Training in Prevention of Hamstring Strains.. Beers, Amanda; Cheong, Krystina; Grant, Andrew; Hibbert, Osita; Moizumi, Trevor; Redenbach, Darlene 2007

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Is eccentric strength training effective in the prevention of hamstring strains in otherwise healthy individuals?  Amanda Beers, Krystie Cheong, Andrew Grant, Osita Hibbert & Trevor Moizumi Supervisor: Dr. Darlene Redenbach  Outline Introduction „ Methods „ Results „ Discussion „  „  Limitations  Future Research „ Conclusion „  INTRODUCTION  Hamstring Strains: Prevalence „  1o soft-tissue injury in recreation & sports (Arnason, 2007) „ „  29% of injuries in sprinting 16-23% of injuries in Australian Rules football  „  Activities: sprinting, jumping and kicking  „  High recurrence rates: 12-31% (Petersen, 2005)  Hamstring Strains: Concerns „  High recurrence rate  „  Loss of function  „  Long period of recovery Petersen et al. (2005)  Hamstring Strains: Anatomy „  Posterior thigh triad  „  Bi-articular arrangement: Hip & Knee  „  Common site: Biceps femoris musculotendinous junction  Petersen et al. (2005) & Thelen et al. (2006)  Hamstring Strains: Risk Factors Intrinsic: „ Age „ Sex „ Ethnicity „ Previous injury „ Lumbopelvic instability „ Hamstring flexibility „ Hamstring strength „ Muscle imbalance  Extrinsic: „ Fatigue „ Lack of warm-up „ Inadequate preseason training Most significant predictor of strain Petersen et al. (2005)  Hamstring Strains: Biomechanics Proposed mechanism for hamstring strains: Rapid phase change eccentric to concentric „ Hamstrings = maximally loaded & lengthened „  (Hoskins et al., 2005)  E.g. Hamstring muscle action during gait: Late swing: eccentric contraction „ Heel strike: concentric contraction „  (Proske et al., 2004)  Eccentric Training Subsequent bouts of training: „ „ „  Shift in the length-tension curve Peak tension generated at longer muscle lengths Protective effect against exercise-induced damage (Clarkson et al., 1988)  Proposed mechanism: „ „ „  Sarcomeres added in series Optimize angle of peak torque Reduce risk of potential injury (Brockett et al., 2001)  Rationale „  Lack of consensus with respect to the appropriate management of hamstring strains  „  Role of eccentric training in 1° & 2° prevention of hamstring strains not clearly defined  Research Question  Is eccentric strength training effective in the prevention of hamstring strains in otherwise healthy individuals?  METHODS  Electronic Databases MEDLINE „ PubMed „ EMBASE „ CINAHL „ Cochrane Central Register of Controlled Trials „ Cochrane Database of Systematic Reviews „ SPORTDiscus „ PEDro „ Web of Science „  Hand Searching „  Reference lists  „  Articles published by leading authors  „  Pertinent academic journals  „  Grey literature CIRRIE „ NARIC’S REHABDATA „ CATs „  Search Terms ‘athletic injuries’ OR ‘sprains and strains’ OR ‘leg injuries’ AND ‘hamstring’ OR ‘semimembranosus’ OR ‘semitendinosus’ OR ‘biceps femoris’ AND ‘eccentric’  Inclusion Criteria Population Otherwise healthy individuals  Intervention Eccentric strength training  Comparison Eccentric vs. other or no training  Outcome Incidence or recurrence of hamstring strain  Data Extraction „  Two independent reviewers  „  Custom form  „  Consensus? „ „  Yes: accept or decline No: 3rd reviewer made final decision  Quality Assessment „  Two independent reviewers  „  PEDro Scale  „  Oxford Levels of Evidence  The Search Electronic databases (N=508) Duplicates removed (N=354)  Title screening (N=95) Abstract screening (N=21)  Full text screening (N=5)  Hand searching (N=2)  Total Studies (N=7)  RESULTS  Results „  7 studies met inclusion criteria  „  PEDro: ranged from 2 to 7  „  Oxford Levels: ranged from 2b to 4  „  Grouped into 3 eccentric protocols: 1. “Hamstring lowers” (n=3) 2. Isokinetic strengthening (n=2) 3. Other strengthening (n=2)  Effect of Eccentric Exercise  “Hamstring Lowers”  Arnason et al. (2007) „  Oxford Level = 4 (cohort study)  „  PEDro = 2  „  1° & 2° prevention  „  Elite male soccer players (n=17 teams)  „  Interventions: A. Warm-up Stretching & Flexibility B. Warm-up Stretching & “Hamstring Lowers” C. Warm-up Stretching, Flexibility & “Hamstring Lowers” D. Controls  Arnason et al. (2007) Iceland Baseline Incidence  1999  Iceland & Norway Baseline Incidence  2000  Iceland C  Norway A 2001  Iceland & Norway B  2002  A. Warm-up Stretching & Flexibility B. Warm-up Stretching & “Hamstring Lowers” C. Warm-up Stretching, Flexibility & “Hamstring Lowers” D. Controls  Arnason et al. (2007) Outcomes: Incidence = # of hamstring strains per 1000 player hrs Severity = duration of absence from play  Results: Incidence „ “Hamstring Lowers” < baseline amongst all interventions „ “Hamstring Lowers” 65% < controls Severity „ No sig. difference in injury & re-injury severity rates All interventions vs. baseline “Hamstring lowers” vs. controls  Brooks et al. (2006) „  Oxford Level = 4 (cohort study)  „  PEDro = 5  „  1° & 2° prevention  „  Elite male rugby players (n=546)  „  Interventions: A. Strengthening B. Strengthening & Stretching C. Strengthening, Stretching & “Hamstring Lowers”  Brooks et al. (2006) Outcomes: Incidence = # of injuries per 1000 player hours Severity = # of days lost per injury Results: Incidence „ “Hamstring lowers” sig. < strengthening „ “Hamstring lowers” sig. < strengthening & stretching Severity „ No sig. difference across groups  Gabbe et al. (2006) „  Oxford Level = 2b (RCT)  „  PEDro = 7  „  1° & 2° prevention  „  Competitive male football players (n=220)  „  Interventions: A. “Hamstring Lowers” B. Stretching & ROM  Gabbe et al. (2006) Outcomes: Incidence = # of hamstring strains Results: Incidence „ „  “Hamstring Lowers” group not at decreased risk for strains Players who completed at least 2 training sessions: „  “Hamstring Lowers” < Strengthening & Stretching (4%)  „  +++ drop out rate  (13.2%)  Effect of Eccentric Exercise  Isokinetic Strengthening  Croisier et al. (2002) „  Oxford Level = 4 (cohort study)  „  PEDro = 2  „  2° prevention  „  Elite male athletes (n=26) „  „  Soccer, track & field, martial arts  Intervention: „ „  Individualized rehab program Kintrex 500® dynamometer  Croisier et al. (2002) Outcomes: Incidence = # of hamstring strains Pain (VAS) Results: Incidence „  No recurrent hamstring strains @ 12 months  Pain „ „  VAS sig. decreased Remained constant for 12 months  Queiros Da Silva et al. (2005) „  Oxford Level = 4 (cohort study)  „  PEDro = 2  „  2° prevention  „  Male athletes (n=8)  „  Intervention: „ „  Cybex® isokinetic dynamometer “Classical kinesitherapy”  Queiros Da Silva et al. (2005) Outcome: Incidence = # of hamstring strains Results: Incidence „  No recurrent hamstring strains @ 8-months  Effect of Eccentric Exercise  Other Strengthening  Askling et al. (2003) „  Oxford Level = 2b (RCT)  „  PEDro = 6  „  1° & 2° prevention  „  Elite male soccer players (n=30)  „  Intervention: A. General training & YoYoTM Flywheel ergometer (Trained) B. General training (Control)  Askling et al. (2003) Outcomes: Incidence = # of hamstring strains Results: Incidence „ Trained (n=3) < control (n=10) 6 in Trained had previous hamstring injury 4 in Controls had previous hamstring injury 2/6 in Trained sustained recurrent strain 4/4 in Controls sustained recurrent strain  Sherry & Best (2004) „  Oxford Level = 2b (RCT)  „  PEDro = 7  „  2° prevention  „  Male & female athletes (n=24)  „  Interventions: A. Stretching & Strengthening (STST): “Standing foot catches” B. Progressive Agility & Trunk Stability (PATS)  Sherry & Best (2004) Outcomes: Incidence = # of hamstring strains Results: Incidence „ PATS (n=0) sig. < STST (n=6) @ 16 days after return to sport „ 1+ hamstring strain in each group @ 12-month follow-up  Summary of Results AUTHOR (YEAR)  PREVENTION  INCIDENCE  SEVERITY  “Hamstring Lowers” Arnason et al. (2007)  1˚ & 2˚  Gabbe et al. (2006)  1˚ & 2˚  Brooks et al. (2006)  1˚ & 2˚  No difference  No difference  Isokinetic Strengthening Croisier et al. (2002)  2˚  Ø  Queiros Da Silva et al. (2005)  2˚  Ø  Other Strengthening Askling et al. (2003) Sherry & Best (2004)  1˚ & 2˚ 2˚  DISCUSSION  Discussion „  Protective effect of eccentric training  „  No apparent relationship between study quality & findings  „  No apparent relationship between eccentric exercise protocols & findings  Limitations „  Small # of studies  „  Lack of high level research  „  Poor study design  „  Small sample size  Limitations „  Heterogeneous diagnosis of hamstring strains  „  Heterogeneous eccentric interventions „ „ „  „  Prescription Not in isolation Concurrent training  Heterogeneous operational definitions „ „  Incidence Severity  Limitations „  Participants Sex „ Level of competition „  „  Adverse effects: DOMS  „  Dropouts  FUTURE RESEARCH  Future Research „  Additional high level research  „  Larger sample sizes  „  Better controls Eccentric strengthening in isolation „ Avoid concurrent training „  Future Research Suggestions: „ Comparison of eccentric protocols (e.g. type, prescription) „  Comparison between athletic levels of competition  „  Male vs. female response to eccentric training  CONCLUSION  Conclusion „  Numerous studies suggest a protective effect. However, generalization of findings is limited due to a lack of high level trials.  „  Until more evidence becomes available, concrete recommendations to support or counter the application of eccentric training protocols for the 1° & 2° prevention of hamstring strains cannot be made.  Acknowledgements We would like to thank: Dr. Darlene Redenbach Dr. Donna MacIntyre Ms. Charlotte Beck Dr. Angela Busch Dr. Susan Harris … for their mentorship during the preparation of this systematic review  References Proske U, Morgan DL, Brockett CL, Percival P. Identifying athletes at risk of hamstring strains and how to protect them. Clin Exp Pharmacol Physiol. 2004 Aug; 31:546-550. Croisier JL, Forthomme B, Namurois MH, Vanderthommen M, Crielaard JM. Hamstring muscle strain recurrence and strength performance disorders. Am J Sports Med. 2002; 30:199-203. Brooks JH, Fuller CW, Kemp SP, Reddin DB. Incidence, risk, and prevention of hamstring muscle injuries in professional rugby union. Am J Sports Med. 2006; 34:1297-1306. Petersen J, Holmich P. Evidence based prevention of hamstring injuries in sport. Br J Sports Med. 2005; 39:319-323. Hoskins W, Pollard H. The management of hamstring injury--part 1: Issues in diagnosis. Man Ther. 2005; 10:96-107. Hoskins W, Pollard H. Hamstring injury management--part 2: Treatment. Man Ther. 2005; 10:180-190. Thelen DG, Chumanov ES, Sherry MA, Heiderscheit BC. Neuromusculoskeletal models provide insights into the mechanisms and rehabilitation of hamstring strains. Exerc Sport Sci Rev. 2006; 34:135-141.  References Sherry MA, Best TM. A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains. J Orthop Sports Phys Ther. 2004; 34:116-125. Brockett CL, Morgan DL, Proske U. Human hamstring muscles adapt to eccentric exercise by changing optimum length. Med Sci Sports Exerc. 2001; 33:783-790. Clarkson PM, Tremblay I. Exercise-induced muscle damage, repair, and adaptation in humans. J Appl Physiol. 1988; 65:1-6. Arnason A, Andersen TE, Holme I, Engebretsen L, Bahr R. Prevention of hamstring strains in elite soccer: An intervention study. Scand J Med Sci Sports. 2007. Gabbe BJ, Branson R, Bennell KL. A pilot randomised controlled trial of eccentric exercise to prevent hamstring injuries in community-level australian football. J Sci Med Sport. 2006 May; 9:103-109. Askling C, Karlsson J, Thorstensson A. Hamstring injury occurrence in elite soccer players after preseason strength training with eccentric overload. Scand J Med Sci Sports. 2003; 13:244-250. Queiros Da Silva C, Cotte T, Vicard L, Chantelot L, Ferret J. Interest of eccentric isokinetic exercises in cases of calcanean tendinosis and thigh muscular injuries: Prospective study results. Isokinetics Exerc Sci. 2005; 13:39-44.  Picture References Sherry MA, Best TM. A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains. J Orthop Sports Phys Ther. 2004; 34:116-125. Gabbe BJ, Branson R, Bennell KL. A pilot randomised controlled trial of eccentric exercise to prevent hamstring injuries in community-level australian football. J Sci Med Sport. 2006 May; 9:103-109. Askling C, Karlsson J, Thorstensson A. Hamstring injury occurrence in elite soccer players after preseason strength training with eccentric overload. Scand J Med Sci Sports. 2003; 13:244-250. Buckinghamshire Chilterns University College. The human performance laboratory. Available at: http://www.bcuc.ac.uk/images/IMG_2317.JPG. Accessed July, 2007. http://www.bu.edu/athletics/news/photos/Lee_Story31.jpg http://www.yamakai.org/profile/side-kick-face.jpg http://www.zonkbonk.com/media/hamstring.gif http://bigchase.files.wordpress.com/2007/02/soccer.jpg http://www.chinadaily.com.cn/english/doc/2006-01/30/xin_390103300954164144598.jpg http://www.kidcyber.com.au/IMAGES/footyaussie.jpg httpwww.pt.ntu.edu.twhmchaiKines04KINmotionMusculature.filesForceVelocityCurve.jpg http://www.fitstep.com/Advanced/Anatomy/Graphics/hamstrings-anatomy.jpg http://www.tacoma.k12.wa.us/schools/es/sherman/teamwork%20pic.jpg  QUESTIONS?  

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