evidence-based acl injury prevention strategies ......health condition, disorder, disease: acl tear...
TRANSCRIPT
Evidence-based ACL Injury Prevention Strategies: Translation of Research Findings into Clinical Practices
Dai Sugimoto, PhD, ATC, CSCS The Micheli Center for Sports Injury Prevention Boston Children’s Hospital - Sports Medicine
I. Effect of ACL injury
ICF Model
Health condition, disorder, disease: ACL tear
Body function & structures impairment: Constant pain, noticeable effusion, a lack of ROMs, and atrophy.
Activities limitation: Inability to walk and difficulties in ADL including taking shower, driving a car, and yard work.
Participation restriction: Incapability of participating in sporting activities. May miss a work or class duties.
Environmental factor Personal factor
Impact of Injury: Career
Return to play
- High School: 63%
- College: 69% (McCullough et al, AJSM 2012)
- Early adults: 73% (Brophy et al, AJSM 2012)
Impact of Injury: At 2 years
Return to sports
- Same level: 41%
- Lower level: 11%
- Different sport(s): 14% (Ardern et al, AJSM 2015)
Subsequent ACL Injury Risk
Second ACL injury in ACL-R: 23 - 29% (Paterno et al, AJSM 2010, Webster et al, AJSM 2014)
Second ACL injury risk in ACL-R: 15 times greater. (Paterno et al, CJSM 2012)
20010)
Effect of Previous Knee Surgery
Knee injury risk in college: 7 - 20 times greater. (Rugg et al, AJSM 2014) 20010)
Pre-mature Osteoarthritis Risk
Radiographic
osteoarthritis signs:
74% within 10 - 15
years (Øiestad et al, AJSM 2011)
Negative impact
on quality of life: 75% (Lohmander et al, Arth Rheum 2004)
II. Evidence-based ACL Injury
Prevention Strategies
Mechanism of ACL Injury
Direct or Indirect contact: 30%
Noncontact: 70% (Arendt et al, AJSM, 1995; Boden et al, Orthopedics, 2000; Agel et al, AJSM, 2005; Walden et
al, KSSTA, 2007)
Literature Search
Time: 1995 - May, 2012
Databases: PubMed and EBSCO (CINAHL, MEDLINE, SPORTDiscus)
Key words search
Meta-Analysis
Prophylactic Effectiveness
74% risk reduction for noncontact ACL injury
46% risk reduction for overall ACL injury
(Sugimoto et al, Curr Phys Med Rehabil Rep 2015)
Variable Odds ratio and 95% CI
Odds
ratio
p-Value
Early Adults 1.001
0.997
Late Teens 0.476
0.073
Mid Teens 0.265
0.001
0.01 0.1 1 10 100
Favors to
Preventive
Training
Favors to
Control
Age Influence of
Neuromuscular Training on
ACL Injury Reduction
• The earlier they start, the greater prophylactic effectiveness (Myer et al, AJSM 2013)
Studies: Biomechanics
205 female high school athletes
Laboratory assessment before a season
18 months Noncontact ACL
injury: 9 (Hewett et al, AJSM 2005)
8.4° greater knee abduction angles
- Sensitivity: 78%
- Specificity: 73% (Hewett et al, AJSM 2005)
ACL Injury Biomechanical Risk Factors
10.5° less knee flexion angle
Greater ground reaction force
Asymmetrical
landing pattern (Hewett et al, AJSM 2005)
ACL Injury Biomechanical Risk Factors
ACL injured:
Greater lateral
trunk flexion and
less trunk flexion
angles (Hewett et al, BJSM 2009)
ACL Injury Biomechanical Risk Factors
Variable Odds ratio and 95% CI
Odds
ratio
p-Value
Low Volume 0.655
0.045
Moderate Volume 0.461
0.059
High Volume 0.315
0.001
0.01 0.1 1 10 100
Favors to
Preventive
Training
Favors to
Control
Dosage Influence of
Neuromuscular Training on
ACL Injury Reduction
• The higher volume, the greater prophylactic effectiveness
(Sugimoto et al, Sports Med 2014)
Sub-group Analysis: Exercise
Exercise Categorizations:
Balance
Plyometrics
Strength
Proximal Control
Single vs. Multiple Exercise(s)
Effect of Strength on
ACL Injury Reduction
Steffen et al.
No strength
increases
Risk
reduction:
29%
(Steffen et al, Scand J Med Sci Sports 2008)
Effect of Strength on
ACL Injury Reduction
Mandelbaum et al. and Gilchrist et al.
Strength increases:
- +11.7% in hip abductor
- +9.8% in hamstrings
Risk reduction:
74 - 88%
(Mandelbaum et al, AJSM 2005;
Gilchristetal, et al, AJSM 2008)
Decreased hamstrings strength
Decreased hamstrings: quadriceps ratio
(Myer et al, CJSM 2009)
ACL Injury Neuromuscular Risk Factors
Poor trunk reposition
sense and history of
low back pain
- Sensitivity: 91%
- Specificity: 68%
(Zazulak et al, AJSM 2007)
ACL Injury Neuromuscular Risk Factors
Effect of Hip Abductor Strength
Decreased hip
abductor strength:
Increased knee
abduction angles. (Jacobs et al, JAT 2007; Heinert et al,,
JSR 2008)
Comparison of Hip Abductor and
Adductor Peak Torque and Ratio
(Sugimoto et al, CJSM 2014)
Study: Effect of Hip Strength
501 young athletes
Isometric hip strength tests before a season
One season Noncontact ACL
injury: 15 (Khayambashi et al, AJSM 2015)
Effect of Hip Strength: Results
(Khayambashi et al, AJSM 2015)
Conclusion: Exercise
Include a variety of exercises, especially strengthening and proximal control exercises.
Plyometrics on
Ground Reaction Force
Ground reaction force reduction in landing:
- 22.0% - 26.4% - 7.4%
(Vescovi et al, Phys Ther Sport 2008)
(Irmischer et al, JSCR 2004)
(Hewett et al, AJSM 1996)
Effect of Feedback on
Biomechanics
Spike jump landing:
- Verbal and video feedback
- 18.7° greater knee flexion angles
(Parson et al, JSCR 2012)
Neuromuscular Training with
vs. without Feedback
- Training with and without verbal feedback
Biofeedback Training on
Biomechanical Alteration
- Training with verbal feedback
- 6.9° and 6.5° less knee abduction angles
- Training without
verbal feedback
- 2.9° and 2.6° less
knee abduction
angles
(Myer et al, AJSM 2013)
An inverse dose-
response relationship
- High
compliance: 82%
- Moderate
compliance: 44%
- Low
compliance: 12% 0.01 0.1 0.2 0.5 1 2 5
Low
Compliance 0.88 (0.53, 1.47)
Moderate
Compliance 0.56 (0.05, 3.41)
High
Compliance 0.18 (0.02, 0.77)*
(Sugimoto et al, JAT 2012)
Sub-group Analysis: Compliance
Translation from research study to clinical practices
(Myklebust et al, BJSM 2013)
Access to Qualified Healthcare
HS soccer coaches (N=756): 20% - Length of coaching experiences (>7 years) - Additional support personnel (AT,CSCS) Barriers: - Lack of knowledge: 64% - Time restrictions: 43% - Lack of understanding & support: 43%
(Joy et al, JSCR 2013)