Development of a preliminary evidence-based neuromusculoskeletal exercise guideline to reduce injury risk in the lower limb

Highlights

• A summary of the literature is presented as it applies to intrinisic modifiable risk factors.

• Based on these findings, a preliminary neuromusculoskeleatal exercise guideline is proposed for the interprofessional sports medicine team to consider during the management of the athlete.

Abstract

Athletic participation growth has resulted in increased exposures and neuromusculoskeletal (NMSK) non-contact injuries. Based on current evidence, the primary objective of this literature review is to create a preliminary evidence-based NMSK exercise guideline, addressing these intrinsic modifiable risk factors. Systematic searches were conducted September 2014 prior to data extraction utilizing CINAHL Plus (1995 to September 2014), MEDLINE (1995 to September 2014), and Academic Search Premier (1995 to September 2014). A priori defined inclusion criteria were applied and included the following: (i) full text, (ii) published in English, (iii) peer-reviewed articles addressing injury risk of non-contact lower extremity injury, (iv) identified specific exercises aimed at reducing injury risk of non-contact lower extremity injury, were the key data extraction points of interest. 3163 potential articles were identified from the initial search, 3120 excluded with reason based on the exclusion criteria. Exclusion criteria was applied in the form of an eight item list summarized in table 2, 43 articles remained after search criteria were applied. Novel to the current body of knowledge, this review identified nine intrinsic modifiable risk factors of the NMSK system that were used as a foundation to create the exercise guideline consisting of 30 exercise techniques.

Introduction

In today's society, there has been significant growth in athletic participation at the competitive level, to the extent of nearly doubling over the last four decades (Centers for Disease Control and Prevention, 2006). In 2013, thirty-five million children between the ages of 15–18 years old played organized sports, with 52% being female (Youth Sports Statistics, 2013). The increase in participation at the competitive levels, while representing a positive trend, unfortunately has resulted in increased exposures to sports-related injuries (Hootman, Dick, & Agel, 2007). The NCAA Injury Surveillance System (ISS) defines injury based on three criteria: (1) injury occurred during participation in an organized practice or contest, (2) injury required medical attention by a certified athletic trainer or physician, and (3) athlete was unable to participate or perform due to injury for one or more days beyond the day of injury (Hootman et al., 2007). Anterior cruciate ligament injury rates have been reported to be as high as “2.8 to3.1 injuries” per 10,000 exposures in women's collegiate basketball and soccer (Smith et al., 2012 ACL risk Factors). The incidence rate for ankle sprains has been reported as 2.5 per 1000 person-years in the general population, with the highest incidence occurring between the ages of 15–19 years old, and 49% of these injuries occurring during athletics (Martin et al., 2013, Tyler et al., 2006). Therefore, the increased exposure rates and volume of injuries create a challenge in the management of these injuries within the healthcare system.

As healthcare professionals, a key priority of focus is to effectively and efficiently manage these injuries, with the goal of returning the athlete to their respective sport in a safe and functional manner, while simultaneously minimizing the risk of re-injury. Previous injury continues to be the most robust injury risk factor (Kiesel et al., 2007, Martin et al., 2013, Lehr et al., 2013). Despite advances in surgical techniques and rehabilitation protocols, it has been shown that only 40% of athletes who underwent anterior cruciate ligament reconstruction returned to their respective sport and 25% sustained a second ACL tear (Ardern et al., 2011, Hui et al., 2011). Value-based management of sports-related injuries may help meet this challenge by critically reviewing evidence-based screening, assessment, and intervention “injury prevention” models applied to these athletes. Injury prevention models encompass a battery of screening, testing, and assessment procedures, which identify the higher risk athletes, allowing limited resources to be prioritized. The literature consistently acknowledges that neuromusculoskeletal (NMSK) injuries are multifactorial in nature (Lehr et al., 2013, Kiesel et al., 2007). Conceptually, in terms of interventions, specific neuromuscular programs that aim to decrease “injury risk” by addressing the intrinsic modifiable risk factors are a possible means to potentially prevent and/or minimize NMSK non-contact injuries (Sheerin et al., 2012, Benjaminse et al., 2015, p. 182; Di Stasi, Myer, & Hewett, 2013).

In summary, efficient screening, testing, and assessment tools capturing the intrinsic modifiable risk factors may be most valuable to healthcare professionals involved with pre-participation physicals and return to sport decision-making. The utilization of these tools can assist in identifying the high risk versus low risk athletes, which creates an opportunity to direct limited resources to these high risk athletes (Plisky et al., 2006, Kiesel et al., 2007, Kiesel et al., 2014, Kiesel et al., 2014, Kiesel et al., 2007, Lehr et al., 2013). From an intervention and programming standpoint, the program needs to also address the intrinsic modifiable risk factors for NMSK injury (Sheerin et al. 2012). To this end, program development focusing on not only capturing, but also addressing specific risk factors, could potentially prove useful to the healthcare professional managing these conditions (Gilchrist, Mandelbaum, & Melancon, 2008).

To date, the professional gap between researchers and clinicians in this area has arguably led to clinical variability amongst clinical practices and mixed outcomes as a result. To this end, the purpose of this literature review is to take a novel approach, by not only investigating the best available literature on injury risk factors, but to also develop a preliminary evidenced-based NMSK exercise progression guideline. This novel approach creates a concise resource for both the researcher and clinician, with the ultimate goal of moving the science of injury prevention forward to promote consistency and positive outcomes.