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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 2007-07-30

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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 MoizumiSupervisor: Dr. Darlene RedenbachOutline??Introduction??Methods??Results ??Discussion??Limitations??Future Research??ConclusionINTRODUCTIONHamstring Strains: Prevalence ??1osoft-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 recoveryPetersen et al.(2005)Hamstring Strains: Anatomy??Posterior thigh triad??Bi-articular arrangement: Hip & Knee??Common site: Biceps femoris  musculotendinous  junctionPetersen et al.(2005) & Thelenet al.(2006)Hamstring Strains: Risk FactorsIntrinsic: ??Age??Sex??Ethnicity??Previous injury??Lumbopelvic instability??Hamstring flexibility??Hamstring strength??Muscle imbalanceExtrinsic:??Fatigue??Lack of warm-up??Inadequate preseason trainingMost significantpredictor of strainPetersen et al. (2005) Hamstring Strains: BiomechanicsProposed 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(Proskeet al.,2004)Eccentric TrainingSubsequent 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 definedResearch QuestionIs eccentric strength training effective in the prevention of hamstring strains in otherwise healthy individuals?METHODSElectronic Databases ??MEDLINE ??PubMed ??EMBASE ??CINAHL ??Cochrane Central Register of Controlled Trials??Cochrane Database of Systematic Reviews??SPORTDiscus??PEDro ??Web of ScienceHand Searching ??Reference lists ??Articles published by leading authors??Pertinent academic journals??Grey literature??CIRRIE ??NARIC?S REHABDATA ??CATsSearch Terms ?athletic injuries?OR?sprains and strains?OR?leg injuries?AND?hamstring?OR?semimembranosus?OR?semitendinosus?OR?biceps femoris?AND ?eccentric?Inclusion CriteriaPopulationOtherwise healthy individualsInterventionEccentric strength trainingComparison Eccentric vs. other or no training OutcomeIncidence or recurrence of hamstring strainData Extraction ??Two independent reviewers ??Custom form??Consensus? ??Yes:accept or decline ??No:3rd reviewer made final decisionQuality 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)Total Studies (N=7)Hand searching (N=2)RESULTSResults??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?Arnasonet 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. ControlsArnasonet al.(2007)Iceland & Norway Baseline IncidenceIcelandBaseline IncidenceNorwayAIcelandCIceland & Norway B1999200220012000A. Warm-up Stretching & Flexibility B. Warm-up Stretching & ?Hamstring Lowers?C. Warm-up Stretching, Flexibility & ?Hamstring Lowers?D. ControlsArnasonet al.(2007)Outcomes:Incidence= # of hamstring strains per 1000 player hrs Severity= duration of absence from playResults:Incidence ???Hamstring Lowers?< baseline amongst all interventions???Hamstring Lowers?65% < controlsSeverity ??No sig. difference in injury & re-injury severity ratesAll interventions vs. baseline ?Hamstring lowers?vs. controlsBrooks 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?Outcomes:Incidence= # of injuries per 1000 player hours Severity= # of days lost per injuryResults:Incidence ???Hamstring lowers?sig. <  strengthening???Hamstring lowers?sig. <  strengthening & stretching Severity??No sig. difference across groupsBrooks et al. (2006)Gabbeet al. (2006) ??Oxford Level = 2b (RCT)??PEDro = 7??1?& 2?prevention??Competitive male football players (n=220)??Interventions: A. ?Hamstring Lowers? B. Stretching & ROMGabbeet al. (2006) Outcomes:Incidence= # of hamstring strainsResults:Incidence???Hamstring Lowers?group not at decreased risk for strains??Players who completed at least 2 training sessions:???Hamstring Lowers?<  Strengthening & Stretching (4%) (13.2%)??+++ drop out rateEffect of Eccentric ExerciseIsokinetic StrengtheningCroisieret 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?dynamometerOutcomes:Incidence= # of hamstring strains Pain(VAS)Results:Incidence??No recurrent hamstring strains @ 12 monthsPain ??VAS sig. decreased ??Remained constant for 12 monthsCroisieret al. (2002)QueirosDaSilva et al.(2005)??Oxford Level = 4 (cohort study)??PEDro = 2??2?prevention??Male athletes (n=8)??Intervention:??Cybex?isokinetic dynamometer???Classical kinesitherapy?QueirosDaSilva et al.(2005) Outcome:Incidence = #of hamstring strainsResults:Incidence??No recurrent hamstring strains @  8-monthsEffect of Eccentric ExerciseOtherStrengtheningAsklinget al.(2003) ??Oxford Level = 2b (RCT)??PEDro = 6??1?& 2?prevention??Elite male soccer players (n=30)??Intervention: A. General training & YoYoTMFlywheel ergometer(Trained)B. General training (Control)Asklinget al.(2003)Outcomes:Incidence= # of hamstring strainsResults: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 strainSherry & 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 strainsResults:Incidence??PATS (n=0) sig. < STST (n=6) @ 16 days after return to sport??1+hamstring strain in each group @ 12-month follow-upSummary of ResultsAUTHOR (YEAR) AUTHOR (YEAR) PREVENTIONPREVENTIONINCIDENCEINCIDENCESEVERITYSEVERITY?Hamstring Lowers?Arnasonet al. (2007)1?& 2?No differenceGabbeet al. (2006)1?& 2?Brooks et al. (2006)1?& 2?No difference Isokinetic StrengtheningCroisieret al. (2002)2??QueirosDaSilva et al.(2005)2?? Other StrengtheningAsklinget al.(2003)1?& 2?Sherry & Best  (2004)2?DISCUSSIONDiscussion ??Protective effect of eccentric training??No apparent relationship between study quality & findings??No apparent relationship between eccentric exercise protocols & findingsLimitations??Small # of studies??Lack of high level research??Poor study design??Small sample sizeLimitations ??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??DropoutsFUTURE RESEARCHFuture Research ??Additional high level research ??Larger sample sizes ??Better controls??Eccentric strengthening in isolation??Avoid concurrent trainingFuture Research Suggestions: ??Comparison of eccentric protocols (e.g. type, prescription)??Comparison between athletic levels of competition??Male vs. female response to eccentric trainingCONCLUSIONConclusion??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.AcknowledgementsWe would like to thank: Dr. Darlene RedenbachDr. Donna MacIntyreMs. Charlotte BeckDr. Angela BuschDr. Susan Harris?for their mentorship during the preparation of this systematic reviewReferences ProskeU, Morgan DL, Brockett CL, Percival P. Identifying athletes at risk of hamstring strains and how to protect them. ClinExp PharmacolPhysiol. 2004 Aug; 31:546-550. Croisier JL, ForthommeB, Namurois MH, VanderthommenM, CrielaardJM. Hamstring muscle strain recurrence and strength performance disorders. Am J Sports Med. 2002; 30:199-203. Brooks JH, Fuller CW, Kemp SP, ReddinDB. Incidence, risk, and prevention of hamstring muscle injuries in professional rugby union. Am J Sports Med. 2006; 34:1297-1306. Petersen J, HolmichP. 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. ThelenDG, ChumanovES, Sherry MA, HeiderscheitBC. Neuromusculoskeletalmodels provide insights into the mechanisms and rehabilitation of hamstring strains. ExercSport SciRev. 2006; 34:135-141.References Sherry MA, Best TM. A comparison of 2 rehabilitation programs inthe treatment of acute hamstring strains. J OrthopSports Phys Ther. 2004; 34:116-125. Brockett CL, Morgan DL, ProskeU. Human hamstring muscles adapt to eccentric exercise by changing optimum length. Med SciSports Exerc. 2001; 33:783-790. Clarkson PM, Tremblay I. Exercise-induced muscle damage, repair, and adaptation in humans. J ApplPhysiol. 1988; 65:1-6. ArnasonA, Andersen TE, HolmeI, EngebretsenL, Bahr R. Prevention of hamstring strains in elite soccer: An intervention study. Scand J Med SciSports. 2007. GabbeBJ, Branson R, BennellKL. A pilot randomised controlled trial of eccentric exercise to prevent hamstring injuries in community-level australianfootball. J SciMed Sport. 2006 May; 9:103-109. AsklingC, KarlssonJ, ThorstenssonA. Hamstring injury occurrence in elite soccer players after preseason strength training with eccentric overload. Scand J Med SciSports. 2003; 13:244-250. QueirosDaSilva C, CotteT, VicardL, ChantelotL, Ferret J. Interest of eccentric isokinetic exercises in cases of calcaneantendinosisand thigh muscular injuries: Prospective study results. IsokineticsExercSci. 2005; 13:39-44.Picture References Sherry MA, Best TM. A comparison of 2 rehabilitation programs inthe treatment of acute hamstring strains. J OrthopSports Phys Ther. 2004; 34:116-125.GabbeBJ, Branson R, BennellKL. A pilot randomised controlled trial of eccentric exercise to prevent hamstring injuries in community-level australianfootball. J SciMed Sport. 2006 May; 9:103-109.AsklingC, KarlssonJ, ThorstenssonA. Hamstring injury occurrence in elite soccer players after preseason strength training with eccentric overload. Scand J Med SciSports. 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.jpgQUESTIONS?

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