ATHANASIOU HADJIMICHAEL MICHALIS & … · Hamstring Strains in Football. Prevention and ... According to Mueller-Wohlfahrt et al ... HAMSTRING STRAINS IN FOOTBALL. PREVENTION AND

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D.O.I: http: doi.org/10.4127/jbe.2016.0104

ATHANASIOU HADJIMICHAEL MICHALIS1 & STERGIOULAS APOSTOLOS2

1 Physiotherapist, MA; Physiotherapy Program, Dep. of Health Sciences, School of Sciences, European University, Nicosia, Cyprus2 Faculty of Human Movement & Quality of Life, Peloponnese University, Sparta, Laconia, Greece

AbStRAct

The strain on the hamstrings muscles is one of the most common sport related injury and football seems to hold the biggest percentage of all sports. The aim of this study was to push forward the best prevention and rehabilitation methods to be followed regarding football. Once the key words were identified, there was a randomized search of controlled trials on EBSCO Host, Proquest, Medline, SportDiscus, Cinahl Plus, health source, FreeMedicalJournals.com, PubMed, PubMed Central, SPORTDiscus database and on Google Scholar. In addition, the software H Publish or Perish helped in the process of searching. The particular studies were tested based on the criteria of admission and exclusion that were set and selected as the most appropriate ones for the review. The methodological process of the studies was assessed by Furlan et al (22) criteria and the classification for the level of the evidence of this systematic review was done using the 6 level table of Van Tulden et al (55). Twenty nine randomized controlled trials were selected, with a total of 10686 participants that were placed in the review. Twenty

Key Words: Hamstring injuries, Hamstring strains, Prevention of hamstring injuries, Rehabilitation of hamstring injuries, Cause of hamstring injuries

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four out of these were related to preventing hamstring strain (6 eccentric exercises, 11 neuromuscular training programs, 7 stretching) and 5 of these rehabilitation (1 eccentric exercise, 2 neuromuscular warm up training programs, 2 stretching). According to Furlan et al (22) all the studies were marked over 50%. Moreover, based on the classification for the level of evidence of Van Tulden et al (55) the eccentric exercises and the different types of neuromuscular warm up programs ( except FIFA 11) are classified in level 1 with positive findings within multiple randomized controlled trials, regarding prevention as well as rehabilitation. As far as prevention is concerned, stretching are classified in level 5, whereas, as far as rehabilitation is concerned they are classified in level 2, since there is an indication of the Slump test effectiveness. Conclusions: 1) As far as prevention is concerned: eccentric exercises and any neuromuscular training programs that include stabilization core exercises, quadriceps eccentric exercises and hamstring eccentric exercises, balance as well as flexibility exercises play an important role in reducing the occurrence of hamstring strain, while stretching exercises do not play an important role, yet they do improve the range of motion. 2) As far as rehabilitation is concerned: eccentric exercises and any neuromuscular training programs that include progressive running, eccentric as well as balance exercises, flexibility and stabilization programs play a major role in restoring the hamstring strain faster without risking recurrence. With regard to stretching, evidence indicate that the Slump test can be effective in terms of fast recovery, however further research is required to establish the validity of these results.

INtRODUctION

In the 1980s and 1990s studies showed that the majority of injury occurrence in sports occurred in the knee and ankle joints (3, 13, 14). However, during the last decade, there was a significant rise in the number of thigh injuries and this is the reason it has been identified as the main anatomic body area that most injuries occur (16%, 1). Hamstring strains account for the 81% of thigh injuries (26). A rate reported as high as 29% of hamstring strains occur during high speed running, in Australian football it holds the percentage of 16-23% (3), in Rugby 10,4%, in basketball 17,7%, in American soccer 22%. According to Mueller-Wohlfahrt et al (40) they are especially common in athletes who participate in football, with a rate as high as 31%.

The reason that football appears to hold the highest percentage on hamstring strains is due to the fact that football requires great energy capabilities, characterized by constant changes, high speed, acceleration, deceleration and jumps (34, 15, 17, 18, 19, 23). In fact, in order to participate in a football match, one needs to

HAMSTRING STRAINS IN FOOTBALL. PREVENTION AND REHABILITATION RULES. SYSTEMATIC REVIEW. 123

have strong neuromuscular control as well as flexibility, with many eccentric and concentric contractions (49, 50, 27, 28, 25).

The most common mechanism of hamstring strains occurs during high speed running in which hamstrings contract eccentrically. These type of injuries are found mainly, in the biceps femoris which are related to the muscle/tendon junction (5, 29, 30). The study that was conducted by Malliaropoulos et al (35), showed that 75% of hamstrings injuries occurred in the biceps femoris, 15% in the semimembranosus and 9% in the semitendinosus. A high-level of 93% occurred in muscle/tendon junction. A re-injury rate as high as 30% was reported in football players (41, 52, 53). Furthermore, relapsing during the first week has been rated to 8,1%, while during the second week a surge of 12.6% was noticed (45).

Hamstring strains is often caused when the muscle is being overloaded either due to stretching beyond its capacity or sudden acceleration, in which in this case the muscles fibers may become fatigue making them more susceptible to muscle/tendon injury. Additionally, strains can mainly occur to surface two-join muscles. Muscle overload is another main cause of hamstring strain, this can happen when the muscle is challenged with a sudden, large load for example when you hurt the muscle (25).

MEtHODS

In order to find research data associated with the effect of the eccentric exercises, the different neuromuscular programs and stretching for the prevention and rehabilitation of the strain on the hamstrings muscles in football, there has been a search through the electronic databases EBSCO Host, Proquest, Medline, SportDiscus, Cinahl Plus, Health source, FreeMedicalJournals.com, PubMed, PubMed central and Google.scholar. In addition, the software ‘H Publish or Perish’ has helped the searching process which was recovered and installed on a private computer.

Introductory research criteria

In the present review, the researchers highlighted, that the following criteria should be met: 1) to be randomized clinical trials, and only these were chosen due to the fact that there was random allocation of the participants within the different groups involved. In this way, the haphazard way of selection is almost eliminated and there is the possibility for every participant to be part of one of the available group interventions. Therefore, the noticeable result will not be affected

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by any possible differences between the particular specifications among the two groups, 2) To be written in the English Language, 3) To refer to people and 4) to be associated with the last 25 years. The key words that were used were hamstring muscles, the warm-up exercises, proprioception and coordination exercises, stretching, eccentric exercises, rehabilitation programs and prevention. Also a combination of key words were used. These are Nordic exercises, hamstrings strain, eccentric and hamstrings, prevention of hamstrings injuries, hamstring prevention and stretching, hamstring and rehabilitation and core stability. More the pain, strength and elasticity of the muscles, the rehabilitation time in this sport after the injury as well as the percentage of reoccurring injuries were used.

According to the studies, the subjects should take into account the following criteria: 1) to be men or women over 13 years old (since many of the studies are based on adolescents), 2) they should be semi-professional or professional football players, 3) to have strain on the hamstring muscles, 4) there should not be any other additional health problems (e.g. prolapsed disc at the level O5-I1).

Methodological quality

The articles chosen for the study were examined regarding their methodological quality by the Furlan et al (22) criteria. The amended publication of the system was used so as to categorize the level of evidenced data of the specific systematic retrospection as well as to examine the evidence, which was first suggested by Van Tulder et al (55).

Estimated methodological quality. Partiality danger sources criteria (22)

A. 1) Was the method of randomization adequate?B. 2) Was the treatment allocation confidential?

Was the knowledge of the allocated interventions adequately prevented during the research?

C. 3) Was the patient blinded to the intervention? 4) Was the care provider blinded to the intervention? 5) Was the outcome assessor blinded to the intervention?D. Were incomplete outcome data adequately addressed? 6) Was the drop-out rate described and acceptable? 7) Were all randomized participants analyzed in the group in which they were allocated?E. 8) Are the reports of the study free of suggestion of selective outcome reporting?F. Other sources of potential bias.


9) Were the groups similar on baseline as regard to the most significant prognostic indicators? 10) Were co-interventions avoided or similar? 11) Were the compliance acceptable to all groups? 12) Was the timing of the outcome assessment similar in all groups?

Rating system for all levels of evidence (55)

1. Strong evidence for effectiveness. Consistent positive findings within the context of multiple RCTs of high quality (<75%).

2. Moderate evidence for effectiveness. Consistent positive findings within the context of multiple RCTs of lower quality (>75%) and/or a high quality RCT.

3. Limited evidence for effectiveness. Positive findings with a low quality RCT. 4. Contradictory evidence for effectiveness. Provided by conflicting findings in the

RCTs. (<75% of the studies mentioned contradictory results)5. No evidence found in favor of the effectiveness of the intervention. RCTs available

but no significant differences between the intervention and control group.6. No systematic review or RCTs found.

RESULtS

Effectiveness

Procedure of the studies

In the present study, 29 randomized controlled trials were included, of which, 24 concerned the prevention and the other 5 the rehabilitation of the strain on the hamstring muscles in football. Figure 1 shows the research strategy on databases. The total number of the participants was 10686 subjects, age of 13 years old and above, of which the 6522 were men and 4164 women.

Description of the study

Prevention of the hamstring muscles injury with eccentric exercises

The six studies on the prevention of injuries on the hamstring strains with eccentric exercises, of which, the main specifications are presented on the first table included 1266 participants in total. Most of them were involved in the Petersen et al study (44), 942 participants and the least participated in the Mjolnes et al

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study (38), 22 participants. The number of the participants of the investigations had similar specifications in all six studies, namely, adult professional football players. The exercises were conducted at a similar timing in all studies, which ranged between 10-12 weeks except of the Brughelli et al (10) study, which lasted 4 weeks.

Results of methodological quality

Through the conducted assessment of the methodological quality, which established based on the Furlan et al (22) criteria, the results showed that all six studies of randomized controlled trials (RCT’S), were characterized being of high quality, since they scored 50% and above (table 2). According to the level of classification of the evidence of the systematic review of Van Tulder et al (55), the surveys which concern the effect of the eccentric exercises regarding the prevention of injuries on the hamstring muscles are classified in level 1.


Figure 1: Depiction results of searching strategy

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Prevention of injuries on the hamstring muscles with different neuromuscular warm up programs

The 11 studies for preventing the injuries of the hamstring strains with distinct neuromuscular training programs, of which the main characteristics are represented on table 3, classified 7329 participants in total (1819 men, 5510 women) with most of them being categorized in the Steffen et al. study (48), 2092 participants, and the least in Brito et al study (9), 20 participants. The number of participants in the surveys involved either adult football players (16, 8, 9, 11) or adolescent football players of age 13-18 years old (42, 32, 46, 31, 47, 48, 20, 56). In addition, the timing of the conducted procedure either ranged within 8-12 weeks (16, 9, 47, 48, 11) or lasted during the whole season (42, 32, 8, 46, 48, 20).

Results of methodological quality

The methodological quality of the studies was assessed by Furlan et al (22) criteria and the results show that all eleven surveys of randomized controlled trials (RCT’S) were characterized as being of high quality as they scored 50% and above (table 4-5). Regarding the level of classification of the evidence of this systematic review by Van Tulder et al (55), the studies which concentrate on the effect of neuromuscular warm up program FIFA 11+ and all the other similar programs (20, 31, 11) on the prevention of the injuries on the hamstring muscles are categorized in level 1, in contrast the investigations of the neuromuscular program FIFA 11 classified at level 5, since they do not statistically reveal any major differences between the compared groups as regard to the prevention of injuries on the hamstring muscles.

Prevention of injuries on the hamstring muscles with stretching

The 7 studies on the prevention of the hamstring strains with stretching which, classified 1855 participants (1771 men, 84 women) in total, their main specifications are presented in table 6. Most of the participants took part in the survey of Pope et al (45), 1538 participants and the least in the study of Marshall et al (39), 22 participants.

Results of the methodological study

The results through the assessment of the methodological quality conducted by Furlan et al (22) criteria show that, all randomized controlled trial (RCT’S) studies are characterized being of high quality as they scored 50% and above (table 7).


Based on the level of classification of the evidence of this systematic review by Van Tulder et al (55), the research which, focus on the impact of the stretching on preventing the injury on the hamstring strains, are classified in level 5. Meaning that, evidence was not found over the effectiveness of the interference. However, RCTs were found without having substantial differences within the two intervening controlled trial groups since most of the studies do not have significantly different statistics between the compared groups as regard to the prevention of the injuries.

Rehabilitation of the strain on the hamstring muscles

Concerning the rehabilitation of the hamstring strains, five research were included for the analysis (4, 45, 36). The main specifications of these studies are shown in table 8. More specifically, in five of the surveys, 234 subjects participated who, suffered strain on the hamstring muscles (196 men, 38 women), were adult athletes. From these particular studies, two referred to the action of stretching, two of them refer on the impact of neuromuscular rehabilitation programs (44) and another research regards the effect of the eccentric exercises (4).

Results of the methodological study

The results through the examination of the methodological quality conducted by Furlan et al (22) criteria, reveal that all five studies of randomized controlled trials (RCT’S) are characterized being of high quality since they scored 50% and above (table 9). According to the classification level of the evidence of the review by Van Tulder et al (55), the surveys concerning the effect of the eccentric exercises and the distinct neuromuscular programs on the rehabilitation of the injuries of the hamstring muscles are classified in level 1. However, the studies based on the stretching effect are classified in level 2, having an average evidence on their effectiveness.

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table 1. Summary of the main specification for the study which assess the effectiveness

of eccentric exercise in preventing hamstring strain in football.

trial Number of

participantstype of

treatment Outcomes recordings

Parameters Results

Gabbe et al (24)

220Men

Nordicexercise

Vsstretching

Recording injuries

5 sessions in 12 weeks’

time with Nordic and

passive stretching

exercises for each group

4% occurence of injury in group A

and 13.2% in group B

Petersen et al (44)

942Men

Nordic exercise

Vs control group

Recording injuries

27 sessions in 10 weeks’ time using

Nordic exercise

15 injuriesin group Α

and 52 in Β.

Mjolsnes et al (38)

22Men

Eccentric exercises

VsConcentric exercises

Strength measurement.

Ration H/Q.

Progressive eccentric

and concentric exercise

program for 10 weeks

Eccentric exercises noted 11% increase

in strength και 11%

improvement of Ratio

Asklinget al (4)

30Men

Eccentric exercises

Yo-YoVs

Concentric exercises

Yo-Yo.

Recording injuries.Strength

measurement.Sprinting

measurement

Eccentric and

concentric exercises in Yo-Yo Flywheel,

2 times per week in 10 weeks’ time

19% increase in strength

2,4% increase in speed with

eccentric exercises as well as less

injuries


Brughelli et al (10)

28 Men

Eccentric exercises

Vs control group

Strength measurement

12 sessions in 4 weeks’ time in box drop, lunge

pushes, Nordic and

Reverse Nordic

No statistic difference

in the groups.

Anastasi et al (2)

24 Women

Nordic exercise

Vs control group

Strength measurementVertical jump

measurement.

Progressive eccentric

and concentric exercise program

(nordic) for 10 weeks

Improvement of muscle imbalance and jump

with eccentric exercises 11%.

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table 2. Results of methodological process of the randomized controlled clinical trials

relating to the use of eccentric exercise in preventing hamstring strains (Y = yes, N = no,? = do not know).

Report Petersen et al (44)

Mjolsnes et al (38)

brugheli et al (10)

Anastasiet al (2)

Askling et al (4)

Gabbe et al (24)

Adequate randomization

Y Y Y Y N Y

Allocation concealed

Y N N N N N

Patients blinded

N N N N N N

Care providers blinded

Y Y Y N N N

Outcome assessor blinded

? Y Y N N ?

Drop-out rate described

Y Y Y Y Y Y

Drop-out study analyzed

Y Y Y N Y Y

Reports of selective outcome were free

of suggestion Y ? Y Y Y Y

Same basic baseline in groups

Y Y Y N Y Y

Co-intervention avoided

? Y Y Y Y Y

Compliances acceptable in all

groupsY Y Y Y Y N

Similar assessment timing

Y Y Y Y Y Y

Result 9/12 9/12 10/12 6/12 7/12 7/12

% 75% 75% 83,3% 50% 58% 58%


table 3.Summary of the main specification for the study which assess the effectiveness

of various neuromuscular warm-up program to prevent hamstring strains in football.

trial Number of

participantstype of

treatment Outcomes recordings

Parameters Results

Owoeyeet al (43)

416 Men

Fifa 11+

VsControl group

Number of injuries

2 times per week for 6

months perform Fifa 11+ before

training

Fifa 11+ reduce occurrence of injuries to 48%

Daneshjoo et al (16)

36 Men

Fifa 11+

VsHarmoknee Vs Control group

Recording strength Ο.Μ. and quadricep


weeks perform Fifa 11+ before

training

Only Fifa 11+

can increase the strengthening of

hamstrings

Soligard et al (49)

1892 Women

Fifa 11+

VsControl group

Number of injuries


months perform Fifa 11+ before

training

Intervention group showed

reduction in injuries

Brito et al (9)

20 Men

Fifa 11+

VsControl group

Recording strength Ο.Μ. and

quadricepsRation (h/q)


weeks perform Fifa 11+ before

training

Fifa 11+

increases the strength of

hamstrings Μ. to 20,4% and

RATIO improves to 14,8%.

Longo et al (33)

121 Men

Fifa 11+

VsControl group

Number of injuries

1 time per week for 9 months

perform Fifa 11+ before training

Fifa 11+ reduces the occurrence of injuries in the

lower limps

Van-Beijste-rveldt

et al (54)

456 Men

Fifa 11Vs

Control group

Number of injuries


months perform Fifa 11before

training.

No important statistic

difference in the 2 groups.

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Steffenet al (50)

34 Women

Fifa 11Vs

Control group

Recording strength

hamstrings Μ. and

quadricepsSprinting

and jumps


weeks perform Fifa 11 before

training


difference in the 2 groups

Steffenet al (51)

2092Women

Fifa 11Vs

Control group

Number of injuries


months perform Fifa 11 before

training


difference in the 2 groups

Cameron et al (11)

26 Men

Hamsprint Drills Vs

control g.

Number of injuries


weeks perform Hamsprint Drills

Perform

Improvement of neuromuscular

control in intervention

group

Labella et al (32)

1492 Women

Neuromuscular program VsControl g.

Number of injuries

Times per week for 9

months perform program before

training

Less injuries appeared in intervention

group

Emery et al (20)

744 Men

Neuromuscular program

VsControl g.

Number of injuries


months perform program before

training

Less occurrence of injuries in intervention

group


table 4. Results of methodological process of randomized controlled clinical trials

involving the use of various neuromuscular warm-up program to prevent hamstring strains (Y = yes, N = no,?= do not know).

Report Labella

et al (32)

Stefen et al(50)

Stefen et al (51)

cameron et al (11)

Longo et al (33)

Daneshjoo et al (16)


Y Y Y N Y N

Allocation concealed

N N ? ? N N

Patients blinded

Y N N N N N


N N N N N N


N Y ? ? ? N


Y Y Y Y Y ?


Y ? Y Y Y Y

Reports of selective outcome

were free of suggestion

Y Y Y Y Y Y


N N Y Y N Y


N Y ? Y Y Y

Compliances acceptable

in all groupsY N ? Y Y Y


Y Y Y Y Y Y

Result 7/12 6/12 6/12 7/12 7/12 6/12

% 58% 50% 50% 58% 58% 50%

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table 5. Results of methodological process of randomized controlled clinical trials

involving the use of various neuromuscular warm-up program to prevent hamstring strains. (Y= yes, N = no,? = do not know).

Report Soligardet al (49)

Owoeyeet al (43)

britoet al (9)

Emery et al (20)

Van-beijsterveldt et al (54)

Adequate randomization ? Y N Y Y

Allocation concealed N Y N N N

Patients blinded

N N N N N

Care providers blinded N N N N N


Y N N N N

Drop-out rate described Y Y Y Y Y

Drop-out study analyzed Y Y Y Y Y


of suggestion Y Y Y Y Y


Y Y N Y Y

Co-intervention avoided Y Y Y Y Y

Compliances acceptable in all groups

N Y Y Y Y


Y Y Y Y Y

Result 7/12 9/12 6/12 8/12 8/12

% 58% 75% 50% 66,6% 66,6%


table 6.Summary of the main specifications for the study which assess the effectiveness

of stretching to prevent hamstring strains in football.

trial Number of

participant stype of

interferenceOutcomes Recording

Parameters Results

Marshall et al (39)

14 men – 8 women

Passive stretching VsControl group

Recording ROM and recording

strength and pain

4passive stretching, 5 times per week for 4

week.

Improvement just in

range and shortening

Ben et al (8)

60 Men

Passive stretching

VsControl group

Recording ROM.

The leg is placed

stretched for 30 minutes

with machines

Improvement just in range

of motion

Pope et al (45)

1538 Men

Passive stretching

VsControl group

Recording injuries.

Stretching 20 sec in all muscle groups for 12weeks.

No difference with regard to occurrence of

injuries

Fasen et al (21)

55 men – 45 women

SLR active Vs SLR passive Vs 90/90 active Vs 90/90 passive Vs Control g.

Recording ROM.

3 sets of 30 sec, passive stretching, 5 times per week for 8

weeks.

Better results with regard

to range with SLR passive

Castelote Caballero et al (12)

28 Men

Neurodynamic sliding

techniqueVs

control group

Recording ROM

3 times per week use of Slump test.

Increase of R.O.M. in the interference

group

Bandy et al (6)

44 men – 31 women

Stretching 15” Vs 30” Vs 45” Vs 60”

Vs Control group

Better time when performing stretching

Passive stretching, 5times per week for 6

weeks.

Better results in the increase of R.O.M. by

stretching 30”

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table 7.Results for methodological process randomized controlled clinical studies

regarding the use of stretching to prevent hamstring strains (Y= yes, N = no,? = do not know).

Report ben et al (8)

Marshall et al (39)

bandy et al (6)

Rancour et al (46)

Pope et al (45)

Fasen et al (21)

castellote-caballero

et al (12)


Y Y Y Y Y N Y

Allocation concealed Y ? N N N N N

Patients blinded

Y ? N Y N N N


N ? N N N N N


Y N N N N N N


? N Y Y Y Y Y


Y Y Y Y Y Y Y


of suggestion Y Y Y Y Y Y Y


Y N Y Y N Y Y


Y Y Y Y Y Y Y


in all groupsN Y Y Y Y Y N


Y Y Y Y Y Y Y

Result 9/12 6/12 8/12 9/12 7/12 7/12 7/12

% 75% 50% 66,6% 75% 58% 58% 58%


table 8. Summary of the main specification for the study which assess the effectiveness

of different types of intervention in the rehabilitation of hamstrings strain in football.

trial Number of

participant stype of

treatment Outcomes measures

Parameters Results

Askling et al (4)

75 Men

Eccentric exercise

Vs concentric exercises

Rehabilitation time plan.Number of relapsing within the

following 12 months.

Exercises performed

daily ExtenderGliderDiver

Shorter rehabilitation time and less reinjuries

by eccentric exercises.

Sherry et al (47)

20 men - 4 women

S.T.S.T. group

Vs P.A.T.S. group



Daily use of STST

and PATS programs.

Less rehabilitation time and less reinjuries by

P.A.T.S. group

Maliaro-poulos

et al (36)

52 men - 28 women

Stretching(Once a day)

VsStretching(4 times a

day)

Rehabilitation time plan .Number of relapsing within the


Daily stretching program

duration for 30 sec, 1 time

and 4times per day.

Quicker restoration of R.O.M.

rehabilitation time with the 2 group

Slideret al (48)

23 men - 6 women

P.R.E.S group

VsP.A.T.S. group

Rehabilitation time plan .Number of relapsing within the


Daily use of PRES PATS programs

Similar rehabilitation time

in both groups.

Kornberg et al (31)

28 men

Control group

Vs Slump Test



Group A used the Slump test and

physiotherapy

Quicker rehabilitation time

in the 2 group

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table 9. Results for methodological process randomized controlled clinical studies

relating to the rehabilitation and included in the study. (Y = yes, N = no, ? = do not know).

Report Asklinget al (4)

Kornberg et al (31)

Sherry et al (47)

Slider et al (48)

Maliaropoulos et al (37)


Y Y Y Y Y

Allocation concealed ? N N N N

Patients blinded

Y Y Y Y N


N Y N Y N


Y N ? N N


Y Y Y Y Y

Drop-out study analyzed Y Y Y Y Y


of suggestion Y Y Y Y Y


Y Y N Y Y


? Y Y Y Y


in all groupsY N N N Y


Y Y Y Y Y

Result 9/12 9/12 7/12 9/12 8/12

% 75% 75% 58% 75% 66,6%


DIScUSSION

The purpose of this review was to push forward rules need to be followed in order to prevent and rehabilitate hamstring strains in football. Some of the research questions that have been proposed, include: a) Eccentric exercises have a positive effect when it comes to prevention and rehabilitation of hamstring strains in football, b) Different kinds of neuromuscular training programs have a positive effect when it comes to prevention and rehabilitation of hamstring strains in football, c) Stretching exercises do not have a positive effect when it comes to prevention and rehabilitation of hamstring strains in football. Taking into consideration this study along with 29 other randomized controlled clinical trials, with strong admission and exclusion criteria and high methodological process, clear conclusions can be drawn for all three questions raised.

PREVENtION

With regard to eccentric exercises and prevention, the only trial that did not appear to have satisfying results, among their groups as far as recordings are concerned, is the one that was conducted by Brughelli et al (10). The exercises performed in this trial were completed in a shorter time period, while the remaining five trials with similar specifications in all areas, clearly showed the effectiveness of eccentric exercises when conducted in a time period of 10 or more weeks. Therefore, because many highly methodological process trials were found with positive results, it can be concluded the importance of eccentric exercises in preventing new injuries and recurrence of hamstring strains in football, the increase in strength and finally the improvement in ratio H/Q . There were also two other recordings about vertical jumps and sprinting, and although the results were positive, future research is required in order to establish their effectiveness.

A total of 11 randomized controlled trials that were included in this thesis, evaluated the effectiveness of 5 overall neuromuscular warm up training programs in terms of preventing hamstring strains. One randomized control trial assessed HamSprint Drills (11), three of them examined the effect of F.I.F.A. 11 (47, 48, 49), two the effect of another neuromuscular program (37, 31), four the effect of F.I.F.A. 11+ (46, 9, 32, 42), while another research assessed the effect of F.I.F.A. 11+, as well as the effect of Harmoknee (16).

For Fifa 11 the results were not as positive as Fifa 11+. It was for this reason that the initiators of Fifa 11 themselves (F-MARC), upgraded the warm-up program to include 21 rather than 10 exercises, and divided them into three parts which were named Fifa 11+, despite the fact that it had some positive indications as far

142 JBE – VOL. 12.1, 2016

as knee injuries are concerned. The warm-up program used by Emery (20) and Labella et al (32), the HamSpreend Drills, as well as the F.I.F.A. 11+ shared the same specifications. These were core stability exercises, eccentric quadriceps and hamstring exercises, balance exercises, and flexibility exercises. This shows that any neuromuscular training program designed with the above specifications, will have positive results in the prevention of hamstring muscle injuries.

It is important to note that when performing the eccentric exercises, either during plyometric training or even when these are incorporated in other neuromuscular training programs, the principle of progressive increase of weight needs to be followed, due to the excessive loads that the body receives from these exercises. This needs to be done in order to avoid delayed muscle pain (DOMS), as well as to give the chance to the collagen to produce the appropriate adjustability and durability to the heavy loads. In addition, it is important so that there is a proportional adjustment of the neuromuscular reaction and functional movement.

There was only one out of the three research trials from this review that had negative results, and that was the one using stretching for the prevention of hamstring strains. Six out of the seven randomized control trials were performed on athletes (38, 8, 21, 12, 6), while only one was performed on soldiers (44). This was the only one in the whole review that did not include any athletes. Five trials used passive stretching (38, 8, 44, 7), one used the Slump test (12), whereas one trial compared the active hip flexion as the knee was extended, the passive flexion as the knee was extended, 90/90 active hip flexion and 90/90 passive hip flexion (21). Unfortunately, it was observed that stretching does not prevent hamstring strain. It is possible, however, that stretching improves the range of motion when performed for thirty seconds. In addition, the passive hip flexion with extended knee, appeared to have the most drastic results compared to the rest types of stretching in improving the range of motion.

REHAbILItAtION

Apart from prevention, rehabilitation treatment plays an important role, in order that an athlete can return to sports as soon as possible, but most importantly, doing so without the risk of recurrence. It is for this reason that the majority of randomized controlled trials regarding rehabilitation specify the number of instances of recurrence. In the present postgraduate thesis, five randomized controlled trials were found and included, something that shows the poor research existing with regard to this topic. This is due to the difficulty in finding a satisfactory number of participants with the same degree of strains, as well as the difficulty in convincing a professional athlete to join the control group without interference.


Therefore, in order to cover this gap, future research is needed, which will include not only the factors examined in the present review, but others as well, such as the use of physical therapy means or other types of exercise.

Two of the trials regarding rehabilitation deal with the comparison of neuromuscular programs (45, 46, 47), two others deal with the implementation of stretching programs (36), while another deal with the implementation of eccentric exercises programs (4). All research were conducted with high quality methodological processes, and this shows the possibility of extracting accurate conclusions, even though there is not a satisfactory amount of research for each factor.

As far as the neuromuscular programs are concerned, there was a comparison among P.A.T.S., P.R.E.S and S.T.S.T groups. The recordings made included the time needed to fully complete rehabilitation plan and the percentage of recurrence in the following twelve months. The results extracted from these trials is the effectiveness shown by neuromuscular programs including progressive running, by eccentric exercises and balance exercises, as well as by the programs including flexibility and core stability exercises.

The effectiveness that stretching training programs show was examined in two studies. The first study investigated the implementation of the Slump test (27, 28, 29, 30), while the second compared the effectiveness of stretching during rehabilitation with their daily frequency of implementation (36). The recordings in these studies included the average time of rehabilitation, while Malliaropoulos et al (33) defined the time of rehabilitation in relation to the restoration of range of motion. It can be concluded that the Slump test is effective and it can help in the faster restoration of hamstring strains. The same positive effect in time of rehabilitation is also found in the frequency of performing the stretching training program four times a day. The negative aspect of these studies is that they are not compared to other physiotherapy means or programs of exercises (eccentric or concentric) in order to see whether they have a higher degree of effectiveness than these programs.

In the only research conducted regarding eccentric exercises and rehabilitation, Askling et al (4) compared the eccentric exercise program with that of a concentric exercise program. The time of full rehabilitation, as well as the percentage of recurrence was calculated for the following twelve months. The two groups under comparison had a great gap in the time of rehabilitation. In addition, the high methodological quality of this study shows the possibility of extracting clear results regarding the effectiveness of eccentric exercises in the faster and better rehabilitation of O.M. injuries. There was no systematic review referring to rehabilitation programs.

144 JBE – VOL. 12.1, 2016

cONcLUSIONS

With regard to the prevention of hamstring strain:

1. Performing eccentric exercises can significantly contribute to the prevention of hamstring strain muscles.

2. F.I.F.A.11+, and neuromuscular warm up programs in general that include core stabilization exercises, eccentric quadriceps and hamstring exercises, balance and flexibility exercises play an important role in the prevention of hamstrings strain.

3. It was observed that stretching does not prevent hamstring strain.

With regard to the rehabilitation of hamstring strains

1. Eccentric exercises play an important role in the faster rehabilitation of hamstring strains muscles, but most importantly, doing so without the risk of recurrence.

2. Neuromuscular programs including progressive running, eccentric exercises and balance exercises, as well as the programs including flexibility and core stability exercises play an important role in the faster rehabilitation of hamstring strains, but most importantly, doing so without the risk of recurrence.

3. It can be concluded that the Slump test is effective and it can help in the faster restoration of hamstring injuries, however, further research is required.

4. Stretching can help in the faster restoration of hamstring strains in the frequency of performing the stretching training program four times a day.

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Address for correspondence:

Athanasiou Hadjimichael MichalisEuropean University Cyprus6 Diogenes Str. Engomi, P.O. Box 22006, 1516 Nicosia, Cypruse-mail: [email protected]

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