ChiroACCESS Article

Chiropractic in the Treatment and Prevention of Sports Injuries

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ChiroACCESS Editorial Staff



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April 15, 2010

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RugbyChiropractors have a longstanding history of treating musculoskeletal sports injuries.  There have been few research studies that document the value of chiropractic treatment for sports injuries and nearly no research that has looked at providing evidence that chiropractic care can play a role in preventing those injuries.  The void and need for research supporting the role of chiropractic in sports injury prevention makes a randomized clinical trial (RCT) published last week (8 April, 2010) an important contribution to the literature.  Hoskins and Pollard used two groups of male semi elite Australian Rules football athletes, matched them in several ways and randomly placed them in one of two arms of the study.  All received the usual and customary management and medical care.  Half also received chiropractic care which consisted of both soft tissue and high velocity spinal manipulation.   There research evaluated several outcomes.  When chiropractic care was added to conventional management, there was a significant reduction in lower limb strain injuries, time missed as a result of knee injuries, lower low back pain, and there was improvement in health status.  “In addition, although not statistically significant, there was a trend towards prevention of hamstring and primary non-contact knee injuries and there were no reported adverse outcomes from the intervention.”  The authors do acknowledge the several limitations to their work including the small sample size.  The work is nonetheless an important piece and one of the few where the focus is prevention.  Free full text here.

This RCT was published only a few months after a Cochrane Systematic Review (please see second abstract below) that found insufficient evidence that manual procedures prevent hamstring injuries.

The effect of a sports chiropractic manual therapy intervention on the prevention of back pain, hamstring and lower limb injuries in semi-elite Australian Rules footballers: a randomized controlled trial.

BMC Musculoskelet Disord. 2010 Apr 8;11(1):64. [Epub ahead of print]

Hoskins W, Pollard H.

BACKGROUND: Hamstring injuries are the most common injury in Australian Rules football. It was the aims to investigate whether a sports chiropractic manual therapy intervention protocol provided in addition to the current best practice management could prevent the occurrence of and weeks missed due to hamstring and other lower-limb injuries at the semi-elite level of Australian football.

METHODS: Sixty male subjects were assessed for eligibility with 59 meeting entry requirements and randomly allocated to an intervention (n=29) or control group (n=30), being matched for age and hamstring injury history. Twenty-eight intervention and 29 control group participants completed the trial. Both groups received the current best practice medical and sports science management, which acted as the control. Additionally, the intervention group received a sports chiropractic intervention. Treatment for the intervention group was individually determined and could involve manipulation/mobilization and/or soft tissue therapies to the spine and extremity. Minimum scheduling was: 1 treatment per week for 6 weeks, 1 treatment per fortnight for 3 months, 1 treatment per month for the remainder of the season (3 months). The main outcome measure was an injury surveillance with a missed match injury definition.

RESULTS: After 24 matches there was no statistical significant difference between the groups for the incidence of hamstring injury (OR:0.116, 95% CI:0.013-1.019, p=0.051) and primary non-contact knee injury (OR:0.116, 95% CI:0.013-1.019, p=0.051). The difference for primary lower-limb muscle strains was significant (OR:0.097, 95%CI:0.011-0.839, p=0.025). There was no significant difference for weeks missed due to hamstring injury (4 v14, chi2:1.12, p=0.29) and lower-limb muscle strains (4 v 21, chi2:2.66, p=0.10). A significant difference in weeks missed due to non-contact knee injury was noted (1 v 24, chi2:6.70, p=0.01).

CONCLUSIONS: This study demonstrated a trend towards lower limb injury prevention with a significant reduction in primary lower limb muscle strains and weeks missed due to non-contact knee injuries through the addition of a sports chiropractic intervention to the current best practice management. Trial registration The study was registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12608000533392).

Interventions for preventing hamstring injuries.

Cochrane Database Syst Rev. 2010 Jan 20;(1):CD006782.

Goldman EF, Jones DE.
Synergy Healthcare, 1-4 Stokers Buildings, Front Street East, Bedlington, Northumberland, UK, NE22 5DS.

BACKGROUND: Some sports, such as football, have a high incidence of hamstring injuries. Various interventions targeting the prevention of such injuries are in common use.

OBJECTIVES: To assess the effects (primarily, on the incidence of hamstring injuries) of interventions used for preventing hamstring injuries in physically active individuals. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to December 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2008, Issue 4), MEDLINE and other databases (to December 2008), reference lists and clinical trials registers.

SELECTION CRITERIA: Randomised or quasi-randomised trials of interventions for preventing hamstring injuries were included; as were trials testing interventions for the prevention of lower-limb injuries, provided that hamstring injuries were reported. Secondary outcomes included compliance, severity and the occurrence of other leg injuries.

DATA COLLECTION AND ANALYSIS: Two authors independently screened search results, assessed methodological quality and extracted data. Risk ratios (RR) and 95% confidence intervals (95% CI) were calculated for dichotomous variables and are reported for individual and pooled data.

MAIN RESULTS: Seven randomised controlled trials involving 1919 participants were included. All trials involved people, predominantly young adults, participating in regular sporting activities. Some trials were compromised by poor methodology, including lack of blinding and incomplete outcome data.Four trials, including 287 participants, examined interventions directly targeted at preventing hamstring injuries. Three of these trials, which tested hamstring strengthening protocols, had contradictory findings, with one small trial showing benefit (although the control rate of mainly minor hamstring injury was unusually high). The other two trials found no benefit, with a greater incidence of hamstring injury in the intervention group. One unpublished and underpowered trial provided some evidence that manual therapy may prevent lower-limb muscle strain (RR 0.13, 95% CI 0.02 to 0.97), although the finding for hamstring injury did not reach statistical significance (RR 0.21, 95% CI 0.03 to 1.66).Three trials testing interventions for preventing lower limb injuries for which data for hamstring injury were available found no statistically significant effect for hamstring injury for either proprioceptive protocols (two cluster randomised trials) or a warm up/cool down and stretching protocol (one trial).

AUTHORS' CONCLUSIONS: There is insufficient evidence from randomised controlled trials to draw conclusions on the effectiveness of interventions used to prevent hamstring injuries in people participating in football or other high risk activities for these injuries. The findings for manual therapy need confirmation.

Strength imbalances and prevention of hamstring injury in professional soccer players: a prospective study.
Croisier, J.L.;  Ganteaume, S.;  Binet, J.;  Genty, M.;  Ferret, J.M.; 

American Journal of Sports Medicine 2008 AUG Vol. 36(8) pp. 1469 - 75

BACKGROUND: The relationship between muscle injury and strength disorders remains a matter of controversy. PURPOSE: Professional soccer players performed a preseason isokinetic testing aimed at determining whether (1) strength variables could be predictors of subsequent hamstring strain and (2) normalization of strength imbalances could reduce the incidence of hamstring injury. STUDY DESIGN: Cohort study (prognosis); Level of evidence, 1. METHODS: A standardized concentric and eccentric isokinetic assessment was used to identify soccer players with strength imbalances. Subjects were classified among 4 subsets according to the imbalance management content. Recording subsequent hamstring injuries allowed us to define injury frequencies and relative risks between groups. RESULTS: Of 687 players isokinetically tested in preseason, a complete follow-up was obtained in 462 players, for whom 35 hamstring injuries were recorded. The rate of muscle injury was significantly increased in subjects with untreated strength imbalances in comparison with players showing no imbalance in preseason (relative risk = 4.66; 95% confidence interval: 2.01-10.8). The risk of injury remained significantly higher in players with strength imbalances who had subsequent compensating training but no final isokinetic control test than in players without imbalances (relative risk = 2.89; 95% confidence interval: 1.00-8.32). Conversely, normalizing the isokinetic parameters reduced the risk factor for injury to that observed in players without imbalances (relative risk = 1.43; 95% confidence interval: 0.44-4.71). CONCLUSION: The outcomes showed that isokinetic intervention gives rise to the preseason detection of strength imbalances, a factor that increases the risk of hamstring injury. Restoring a normal strength profile decreases the muscle injury incidence.
Predictors of hamstring injury at the elite level of Australian football.
Gabbe, B.J.;  Bennell, K.L.;  Finch, C.F.;  Wajswelner, H.;  Orchard, J.W.; 

Scandinavian Journal of Medicine & Science in Sports 2006 FEB Vol. 16(1) pp. 7 - 13

BACKGROUND: Hamstring injuries are the most common injury sustained by elite Australian football players and result in substantial costs because of missed training time, unavailability for matches and lost player payments. Evidence to support proposed risk factors for hamstring injury is generally lacking, limiting the development of appropriate prevention strategies. AIM: To identify intrinsic risk factors for hamstring injury at the elite level of Australian football. METHODS: A prospective cohort of 222 players underwent baseline measurement in the form of a self-report questionnaire and a musculo-skeletal screen during the pre-season period of the 2002 Australian football season. Injury surveillance and exposure data were collected for the full season. Logistic regression analyses were used to identify independent predictors of hamstring injury in this group of players. RESULTS: Thirty-one players sustained a hamstring injury. A past history (previous 12 months) of hamstring injury and increasing age were found to be independent predictors of hamstring injury. CONCLUSIONS: Older players and those with a previous history of hamstring injury are target groups for further research and implementation of injury prevention strategies. Restricted ankle dorsiflexion range of movement warrants consideration in the development of prevention programs for hamstring injury.

Recurrent posterior thigh symptoms detrimental to performance in rugby union: predisposing factors.

Devlin, L.; 

Sports Medicine 2000 APR Vol. 29(4) pp. 273 - 87

Recurrent hamstring injury is a very common problem in rugby union, but has been largely ignored in the literature. It is concluded that a multifactorial aetiology may be present, and that these symptoms may be part of a continuum of symptoms that may lead to more serious injuries. Effective management needs to focus not just locally, but include proximal issues such as lumbo-pelvic stability and correcting lumbar spine dysfunction. The factors addressed in a prevention programme are likely to contribute to performance gains.

Factors associated with hamstring injuries. An approach to treatment and preventative measures.

Worrell, T.W.; 

Sports Medicine 1994 MAY Vol. 17(5) pp. 338 - 45

Following hamstring strain, rehabilitation is often prolonged and frustrating for the athlete and for the sports medicine clinician. Though the initial treatment of rest, ice, compression and elevation is accepted for muscle strains, no consensus exists for rehabilitation of hamstring muscle strains. This lack of agreement concerning rehabilitation of hamstring injury represents our lack of understanding of the mechanism of injury and the factors that contribute to hamstring strain. A hamstring rehabilitation model is proposed that is based on our current understanding of the aetiological factors that contribute to hamstring muscle strain. The influence and interaction of hamstring strength, flexibility, warm-up and fatigue are aetiological factors that should be addressed in the rehabilitation and prevention of hamstring strains. The rehabilitation model is, however, not without limitations and speculations. Further research is needed to clarify the etiological factors of hamstring strain and the efficacy of different rehabilitation protocols.
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