Sports Medicine Research: In the Lab & In the Field: Compliance with Neuromuscular Warm-Up Programs as Another Key Factor in Injury Prevention (Sports Med Res)
Tuesday, October 22, 2013

Compliance with Neuromuscular Warm-Up Programs as Another Key Factor in Injury Prevention

Superior compliance with a neuromuscular training programme is associated with fewer ACL injuries and fewer acute knee injuries in female adolescent football players: secondary analysis of an RCT

Martin Hagglund, Isam Atroshi, Philippe Wagner, Markus Walden. Published Br J Sport Medicine: 2013 Oct; 47(15):974-9. doi: 10.1136/bjsports-2013-092644. Epub 2013 Aug 20

Take Home Message: Neuromuscular training programs have shown to significantly reduce the number of ACL injuries. Previous literature identified that a young starting age has the greatest protective benefit for ACL injuries. This study added to the existing evidence that high compliance with NMT programs is another key factor in reducing ACL injuries.

Neuromuscular training (NMT) has established its role in injury prevention, especially at the knee. It is known that the initiation of NMT at a young age leads to more effective injury prevention; however other factors such as compliance have not had such support in the literature. Therefore, Hagglund et al. investigated compliance with NMT programs as another key element in successful knee injury prevention. Hagglund performed a sub-study of a previously published randomized control trial, which examined the use of NMT programs for the prevention of acute knee injuries in adolescent female soccer players. The end points for Hagglund’s analysis were anterior cruciate ligament (ACL) injury rate for the primary outcome, acute knee injury, and severe knee injury (caused a greater then four week absence). The study population consisted of 2471 athletes in the intervention group and 2085 athletes in the control group. The intervention group was further subdivided into low, intermediate, and high compliance groups based on their completion of NMT sessions per week. Decreasing compliance was observed for the individual player (~ -5% per month) over the course of the season, as well as attendance of practice sessions (~ -2% per month). The decrease in practice attendance rates was most noticed in the intermediate compliance tertile (decrease by 12%) and low compliance tertiles (decrease by 29%), while the high compliance tertile only showed a decrease of 5%. Injury rates showed a significant reduction (88%) in ACL injury between the high compliance and low compliance tertiles of the individual athlete group. The rate reduction of severe or acute knee injuries in the high and intermediate compliance tertiles was between 72% and 90% when compared to the low compliance tertile.

Findings of this study suggest that compliance is another key limiting factor of NMT programs in the prevention of knee injuries. One advantage of such warm-up programs is that it can be implemented and monitored by the coaching staff, which in turn can also pose a problem. The coaching staff at times is only interested in short term success and may place the potential of significant knee injuries second. Adolescent athletes or ones that do not compete on the highest level may not recognize the importance of warm-up programs, and as a result, may not perform them correctly or at all. Hagglund provides a feasible solution to maximizing the exposure to NMT programs, by implementing it for every practice, which guarantees that each athlete is exposed to such warm-up programs. A previous study by Myer concluded that implementation of NMT programs for adolescent female athletes ages 14 to 18 years shows the greatest benefit in ACL injury prevention. Judging by those two studies, age and compliance are important factors for a successful NMT program, however questions for the durability of NMT benefits remains.

Questions for Discussion: How can compliance with NMT programs be increased and maintained over the course of a season? How many NMT sessions per week are necessary to obtain the greatest benefit? How can exposure to NMT programs be increased?

Reviewed by: Stephen Thomas

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Hägglund M, Atroshi I, Wagner P, & Waldén M (2013). Superior compliance with a neuromuscular training programme is associated with fewer ACL injuries and fewer acute knee injuries in female adolescent football players: secondary analysis of an RCT. British Journal of Sports Medicine, 47 (15), 974-9 PMID: 23962878

7 comments:

Colby Mangum said...

I think with compliance in any situation, even outside of these particular programs, there must be buy-in. The participants and supervisors must all "buy-in" and commit to performing the prevention program, rehab exercises, reporting to treatments when asked, etc. This is not a surprising finding, but is something that I think is not given enough attention. We can spend a lot of time creating these programs and going back and forth over which aspects should be included or focused more heavily upon, but at the end of the day...the athletes must participate and buy in. The athletic trainers, coaches, or whoever may be supervising these programs must also buy in and stay committed to completing the full program. All parties have to be on board throughout the duration of the program. The timing of completion may vary depending on the age group and setting. A high school team that practices every weekday could work it into their warm up or pre-practice regimen much easier than a recreational league that does not meet as frequently. When a team only has a certain allotment for practice time, they usually want to focus on the sport, not a prevention program. The results of this study can help sway, but the evidence necessary to have all parties commit may differ depending on the audience. Exposure can be increased by getting the word out and by starting with one team or group that is fully committed and using them as the example to spread these programs to other teams and potentially schools.

Christian Glaser said...

Colby, thank you very much for your comment. You did touch on some very important aspects of prevention programs and their implementation. I completely agree with you that implementing such programs in recreational leagues is more difficult then i.e. with high school teams. This will need convincing of the coaching staff, athletes and parents all alike to fully commit to prevention programs. At the same time, incorporating NMT programs will only take up 15 minutes of practice time. While the competitive sports programs are more exposed to the latest training methods and prevention programs, the obstacle lies with the less competitive programs and their exposure to preventive effects of NMT programs, as well as recognizing the need for such.

Jason Shermer said...

I think this is where good communication and teamwork play an important role. ATCs CSCSs and Coaches can all work together to come up with a good NMT program and incorporate it into the warm up of each practice, especially at the HS/MS levels. ATCs should monitor and make sure the coach is complying with the program and also reach out to parents/coaches and explain/educate the importance of this program and the proven results of these studies.

Gabriella Basile said...

I agree with the fact that involving the coaching staff with the NMT program will be beneficial. They are already doing a warm up they can easily include the NMT program during that. I agree with Jason that we need to educate parents, athletic directors and coaches on these programs, their importance and how to do them properly and safely.

Sylvia Thelemaque said...

I feel as if in order to have the best NMT program not only does it need to be discussed with the athlete but also emphasize to about NMT coaches.Simply because like you mentioned most coaches only care about short progress and do not look far ahead. Stress to the coaches what and how neuromuscular control in general plays into the rehab/ injury process and how it plays role in progression. Even though no matter how good of an athlete you are, your balance will never be spot on perfect. You can perform these types of task everyday, and there are a ton of ways to make these types of task fun and challenging.

I feel like to encourage a coach to incorporate these types of warm ups you should challenge him to see if he can perform the task. Change up the difficulty and like mentioned earlier then give benefits to how it can positively effect athletes in both short and long term.

Will Bradley said...

Because female athetes are more susceptible to ACL injuries than men, would you try to focus more efforts on applying an ACL prevention program to womens sports? Or equally between men and women?

Jeffrey Driban said...

Will, I personally would advocate for prevention programs among males and females. Both sex seem to receive benefits from the programs and I think there are ways to minimize the costs to make it a cost-effective strategy.

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