ChiroACCESS Article

Preventing Sports Injuries through Proprioceptive Neuromuscular Training

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March 17, 2010

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SoccerA March 2010 systematic review conducted in Germany underscores the value of neuromuscular training in preventing sports injuries.  They concluded that "On the basis of the results of seven high-quality studies, this review showed evidence for the effectiveness of proprioceptive/neuromuscular training in reducing the incidence of certain types of sports injuries among adolescent and young adult athletes during pivoting sports."  The pivoting sports included basketball, hockey, handball, volleyball, soccer and floorball.  Multiple high quality studies now support the use of training programs to improve proprioception and the research further supports that this proprioceptive improvement translates to reduced risk of sports associated injuries.  The benefit is even greater for those with a history of sports injury.

The proprioception neuromuscular training programs varied but included strategies using balance platform devices, wobble boards, single leg stance, stretching, core stability exercises, plyometrics, strength training, and agility training.  Most of the studies were aimed at assessing all sports injuries but several focused on just injuries of the lower extremity.  Chiropractors engaged in sports medicine and/or including primary prevention in their wellness programs should consider the addition of a strong evidence-based proprioceptive-neuromuscular training program in their practice.

Neuromuscular training for sports injury prevention: a systematic review.

Med Sci Sports Exerc. 2010 Mar;42(3):413-21.

Hübscher M, Zech A, Pfeifer K, Hänsel F, Vogt L, Banzer W.
Department of Sports Medicine, Goethe-University Frankfurt, Frankfurt, Germany.

PURPOSE: The aim of this systematic review was to assess the effectiveness of proprioceptive/neuromuscular training in preventing sports injuries by using the best available evidence from methodologically well-conducted randomized controlled trials and controlled clinical trials without randomization.

METHODS: Two independent researchers performed a literature search in various electronic databases and reference lists. The reviewers independently assessed trials for inclusion criteria and methodological quality and extracted the data. Focusing on studies of high methodological quality, relative risks (RR) and 95% confidence intervals (CI) were used to estimate treatment effects.

RESULTS: From a total of 32 relevant studies, 7 methodologically well-conducted studies were considered for this review. Pooled analysis revealed that multi-intervention training was effective in reducing the risk of lower limb injuries (RR = 0.61, 95% CI = 0.49-0.77, P < 0.01), acute knee injuries (RR = 0.46, 95% CI = 0.28-0.76, P < 0.01), and ankle sprain injuries (RR = 0.50, 95% CI = 0.31-0.79, P < 0.01). Balance training alone resulted in a significant risk reduction of ankle sprain injuries (RR = 0.64, 95% CI = 0.46-0.9, P < 0.01) and a nonsignificant risk reduction for injuries overall (RR = 0.49, 95% CI = 0.13-1.8, P = 0.28). Exercise interventions were more effective in athletes with a history of sports injury than in those without.

CONCLUSION: On the basis of the results of seven high-quality studies, this review showed evidence for the effectiveness of proprioceptive/neuromuscular training in reducing the incidence of certain types of sports injuries among adolescent and young adult athletes during pivoting sports. Future research should focus on the conduct of comparative trials to identify the most appropriate and effective training components for preventing injuries in specific sports and populations.

Balance improvements in female high school basketball players after a 6-week neuromuscular-training program.

J Sport Rehabil. 2009 Nov;18(4):465-81.

McLeod TC, Armstrong T, Miller M, Sauers JL.
Athletic Training Program, A.T. Still University, Mesa, AZ, USA.

CONTEXT: Poor balance has been associated with increased injury risk among athletes. Neuromuscular-training programs have been advocated as a means of injury prevention, but little is known about the benefits of these programs on balance in high school athletes.

OBJECTIVE: To determine whether there are balance gains after participation in a neuromuscular-training program in high school athletes.

DESIGN: Nonrandomized controlled trial.

SETTING: All data were collected at each participating high school before and after a 6-wk intervention or control period.

PARTICIPANTS: 62 female high school basketball players recruited from the local high school community and assigned to a training (n = 37) or control (n = 25) group.

INTERVENTION: Training-group subjects participated in a 6-wk neuromuscular-training program that included plyometric, functional-strengthening, balance, and stability-ball exercises.

MAIN OUTCOME MEASURES: Data were collected for the Balance Error Scoring System (BESS) and Star Excursion Balance Test (SEBT) before and after the 6-wk intervention or control period.

RESULTS: The authors found a significant decrease in total BESS errors in the trained group at the posttest compared with their pretest and the control group (P = .003). Trained subjects also scored significantly fewer BESS errors on the single-foam and tandem-foam conditions at the posttest than the control group and demonstrated improvements on the single-foam compared with their pretest (P = .033). The authors found improvements in reach in the lateral, anteromedial, medial, and posterior directions in the trained group at the posttest compared with the control group (P < .05) using the SEBT.

CONCLUSION: The study demonstrates that a neuromuscular-training program can increase the balance and proprioceptive capabilities of female high school basketball players and that clinical balance measures are sensitive to detect these differences.

Effect of proprioception training on knee joint position sense in female team handball players.

Br J Sports Med. 2008 Jun;42(6):472-6. Epub 2008 Apr 7.

Pánics G, Tállay A, Pavlik A, Berkes I.
Faculty of Physical Education and Sports Science, Semmelweis University, Budapest, Hungary.

BACKGROUND: A number of studies have shown that proprioception training can reduce the risk of injuries in pivoting sports, but the mechanism is not clearly understood.

AIM: To determine the contributing effects of propioception on knee joint position sense among team handball players.

STUDY DESIGN: Prospective cohort study.

METHODS: Two professional female handball teams were followed prospectively for the 2005-6 season. 20 players in the intervention team followed a prescribed proprioceptive training programme while 19 players in the control team did not have a specific propioceptive training programme. The coaches recorded all exposures of the individual players. The location and nature of injuries were recorded. Joint position sense (JPS) was measured by a goniometer on both knees in three angle intervals, testing each angle five times. Assessments were performed before and after the season by the same examiner for both teams. In the intervention team a third assessment was also performed during the season. Complete data were obtained for 15 subjects in the intervention team and 16 in the control team. Absolute error score, error of variation score and SEM were calculated and the results of the intervention and control teams were compared.

RESULTS: The proprioception sensory function of the players in the intervention team was significantly improved between the assessments made at the start and the end of the season (mean (SD) absolute error 9.78-8.21 degrees (7.19-6.08 degrees ) vs 3.61-4.04 degrees (3.71-3.20 degrees ), p<0.05). No improvement was seen in the sensory function in the control team between the start and the end of the season (mean (SD) absolute error 6.31-6.22 degrees (6.12-3.59 degrees ) vs 6.13-6.69 degrees (7.46-6.49 degrees ), p>0.05).

CONCLUSION: This is the first study to show that proprioception training improves the joint position sense in elite female handball players. This may explain the effect of neuromuscular training in reducing the injury rate.

Neuromuscular control of trunk stability: clinical implications for sports injury prevention.

J Am Acad Orthop Surg. 2008 Sep;16(9):497-505.

Zazulak B, Cholewicki J, Reeves NP.
Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA.

Recent prospective evidence supports the hypothesis that impaired trunk control is a contributing factor to sports injuries of the spine as well as to segments of the kinetic chain. The current concepts regarding neuromuscular control of trunk stability are best described from a systems engineering perspective. In the analysis of current neuromuscular training protocols for sports injury prevention, these principles are applied to identify components that optimize neuromuscular control of trunk stability. Current perspectives of neuromuscular learning can be applied clinically to aid in the formulation of injury prevention strategies.

Proprioception and ankle injuries in soccer.

Clin Sports Med. 2008 Jan;27(1):195-217, x.

Ergen E, Ulkar B.
Sports Medicine Department, Ankara University School of Medicine, Cebeci 06590, Ankara, Turkey.

Because soccer attracts many participants and leads to a substantial number of injuries, especially of the lower extremities, it is important to study possibilities for injury prevention and proper rehabilitation to return safely to activities. Ankle sprains can be prevented by external ankle supports and proprioceptive-coordination training, especially in athletes with previous ankle sprains. Proprioception is a broad concept that includes balance and postural control with visual and vestibular contributions, joint kinesthesia, position sense, and muscle reaction time. Proprioceptive feedback is crucial in the conscious and unconscious awareness of a joint or limb in motion. Enhancement of functional joint stability by proprioceptive (or neuromuscular) training is important both in prevention and rehabilitation of athletic injuries.

The importance of sensory-motor control in providing core stability: implications for measurement and training.

Sports Med. 2008;38(11):893-916. doi: 10.2165/00007256-200838110-00002.

Borghuis J, Hof AL, Lemmink KA.
Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.

Although the hip musculature is found to be very important in connecting the core to the lower extremities and in transferring forces from and to the core, it is proposed to leave the hip musculature out of consideration when talking about the concept of core stability. A low level of co-contraction of the trunk muscles is important for core stability. It provides a level of stiffness, which gives sufficient stability against minor perturbations. Next to this stiffness, direction-specific muscle reflex responses are also important in providing core stability, particularly when encountering sudden perturbations. It appears that most trunk muscles, both the local and global stabilization system, must work coherently to achieve core stability. The contributions of the various trunk muscles depend on the task being performed. In the search for a precise balance between the amount of stability and mobility, the role of sensory-motor control is much more important than the role of strength or endurance of the trunk muscles. The CNS creates a stable foundation for movement of the extremities through co-contraction of particular muscles. Appropriate muscle recruitment and timing is extremely important in providing core stability. No clear evidence has been found for a positive relationship between core stability and physical performance and more research in this area is needed. On the other hand, with respect to the relationship between core stability and injury, several studies have found an association between a decreased stability and a higher risk of sustaining a low back or knee injury. Subjects with such injuries have been shown to demonstrate impaired postural control, delayed muscle reflex responses following sudden trunk unloading and abnormal trunk muscle recruitment patterns. In addition, various relationships have been demonstrated between core stability, balance performance and activation characteristics of the trunk muscles. Most importantly, a significant correlation was found between poor balance performance in a sitting balance task and delayed firing of the trunk muscles during sudden perturbation. It was suggested that both phenomena are caused by proprioceptive deficits. The importance of sensory-motor control has implications for the development of measurement and training protocols. It has been shown that challenging propriocepsis during training activities, for example, by making use of unstable surfaces, leads to increased demands on trunk muscles, thereby improving core stability and balance. Various tests to directly or indirectly measure neuromuscular control and coordination have been developed and are discussed in the present article. Sitting balance performance and trunk muscle response times may be good indicators of core stability. In light of this, it would be interesting to quantify core stability using a sitting balance task, for example by making use of accelerometry. Further research is required to develop training programmes and evaluation methods that are suitable for various target groups.

Neuromuscular training and injury prevention in sports.

Clin Orthop Relat Res. 2003 Apr;(409):53-60.

Etty Griffin LY.
Peachtree Orthopaedic Clinic, 2045 Peachtree Road, N.E., Suite 700, Atlanta, GA 30309, USA.

Exercises that help develop neuromuscular control and increase functional joint stability are critical in conditioning and rehabilitation programs designed for injury prevention in sports. Information regarding joint movement and joint position provided by mechanoreceptors in the skin, muscles, tendons, ligaments, and joints combine with input from the vestibular and visual systems to maintain balance. Insufficient neurologic input or improperly processing that input at the spinal, brain stem, or cognitive centers can lead to an inadequate response by the motor system resulting in an injury. Therefore, it is important to include drills that enhance neuromuscular control into traditional training, conditioning, and rehabilitation programs for sports.

Balance index score as a predictive factor for lower sports results or anterior cruciate ligament knee injuries in Croatian female athletes--preliminary study.

Coll Antropol. 2007 Mar;31(1):253-8.

Vrbanic TS, Ravlic-Gulan J, Gulan G, Matovinovic D.
Orthopaedic Clinic Lovran, Medical Faculty, University of Rijeka, Rijeka, Croatia.

Female athletes participating in high-risk sports suffer anterior cruciate ligament (ACL) knee injury at a 4- to 6-fold greater rate than do male athletes. ACL injuries result either from contact mechanisms or from certain unexplained non-contact mechanisms occurring during daily professional sports activities. The occurrence of non-contact injuries points to the existence of certain factors intrinsic to the knee that can lead to ACL rupture. When knee joint movement overcomes the static and the dynamic constraint systems, non-contact ACL injury may occur. Certain recent results suggest that balance and neuromuscular control play a central role in knee joint stability, protection and prevention of ACL injuries. The purpose of this study is to evaluate balance neuromuscular skills in healthy Croatian female athletes by measuring their balance index score, as well as to estimate a possible correlation between their balance index score and balance effectiveness. This study is conducted in an effort to reduce the risk of future injuries and thus prevent female athletes from withdrawing from sports prematurely. We analysed fifty-two female athletes in the high-risk sports of handball and volleyball, measuring for their static and dynamic balance index scores, using the Sport KAT 2000 testing system. This method may be used to monitor balance and coordination systems and may help to develop simpler measurements of neuromuscular control, which can be used to estimate risk predictors in athletes who withdraw from sports due to lower sports results or ruptured anterior cruciate ligament and to direct female athletes to more effective, targeted preventive interventions. The tested Croatian female athletes with lower sports results and ACL knee injury incurred after the testing were found to have a higher balance index score compared to healthy athletes. We therefore suggest that a higher balance index score can be used as an effective risk predictor for lower sports results and lesser sports motivation, anterior cruciate ligament injury and the ultimate decision to withdraw from active participation in sports. If the balance testing results prove to be effective in predicting the occurrence of ligament injuries during future sports activities, we suggest that prophylactic training programs be introduced during athlete training, since the prevention of an initial injury will be more effective than prevention of injury recurrence.


Phys Med Rehabil Clin N Am. 2000 May;11(2):323-40, vi.

Laskowski ER, Newcomer-Aney K, Smith J.
Department of Physical Medicine and Rehabilitation, Mayo Sports Medicine Center, Rochester, Minnesota, USA.

Although definitions of proprioception may vary, its importance in preventing and rehabilitating athletic injuries remains constant. Proprioception plays a significant role in the afferent-efferent neuromuscular control arc. This control arc is disrupted with joint and soft tissue injury. Restoring proprioception after injury allows the body to maintain stability and orientation during static and dynamic activities. By focusing on aspects of neuromuscular function, such as dynamic joint stability, practitioners can design and study interventions to maximize sport and daily life neuromuscular function. Further research is necessary to elucidate how proprioceptive deficits can be remedied or compensated to improve function and prevent reinjury.
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