Dosage Effects of Neuromuscular Training Intervention to Reduce Anterior Cruciate Ligament Injuries in Female Athletes: Meta- and Sub-Group Analyses
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.Get Access
Although a series of meta-analyses demonstrated neuromuscular training (NMT) is an effective intervention to reduce anterior cruciate ligament (ACL) injury in female athletes, the potential existence of a dosage effect remains unknown.
Our objective was to systematically review previously published clinical trials and evaluate potential dosage effects of NMT for ACL injury reduction in female athletes.
This study took the form of a meta- and sub-group analysis.
The keywords ‘knee’, ‘anterior cruciate ligament’, ‘ACL’, ‘prospective’, ‘neuromuscular’, ‘training’, ‘female’, and ‘prevention’ were utilized in PubMed and EBSCO host for studies published between 1995 and May 2012.
Inclusion criteria set for studies in the current analysis were (i) recruited female athletes as subjects, (ii) documented the number of ACL injuries, (iii) employed an NMT intervention aimed to reduce ACL injuries, (iv) had a control group, (v) used a prospective control trial design, and (vi) provided NMT session duration and frequency information.
Main outcome measures
The number of ACL injuries and female athletes in each group (control and intervention) were compared based on duration, frequency, and volume of NMT via odds ratios (ORs).
A total of 14 studies were reviewed. Analyses that compared the number of ACL injuries with short versus long NMT duration showed greater ACL injury reduction in female athletes who were in the long NMT duration group (OR 0.35, 95 % CI 0.23–0.53, p = 0.001) than in those in the short NMT duration group (OR 0.61, 95 % CI 0.41–0.90, p = 0.013). Analyses that compared single versus multi NMT frequency indicated greater ACL injury reduction in multi NMT frequency (OR 0.35, 95 % CI 0.23–0.53, p = 0.001) compared with single NMT frequency (OR 0.62, 95 % CI 0.41–0.94, p = 0.024). Combining the duration and frequency of NMT programs, an inverse dose-response association emerged among low (OR 0.66, 95 % CI 0.43–0.99, p = 0.045), moderate (OR 0.46, 95 % CI 0.21–1.03, p = 0.059), and high (OR 0.32, 95 % CI 0.19–0.52, p = 0.001) NMT volume categories.
The inverse dose-response association observed in the subgroup analysis suggests that the higher the NMT volume, the greater the prophylactic effectiveness of the NMT program and increased benefit in ACL injury reduction among female athletes.
- National Federation of State High School Associations. 2010 High School Participation Survey. Indianapolis, Ind: National Federation of State High School Associations; 2002.
- Messina DF, Farney WC, DeLee JC. The incidence of injury in Texas high school basketball. A prospective study among male and female athletes. Am J Sports Med. 1999;27:294–9.
- Gomez E, DeLee JC, Farney WC. Incidence of injury in Texas girls’ high school basketball. Am J Sports Med. 1996;24:684–7. CrossRef
- Toth AP, Cordasco FA. Anterior cruciate ligament injuries in the female athlete. J Gend Specif Med. 2001;4:25–34.
- Arendt EA, Agel J, Dick R. Anterior cruciate ligament injury patterns among collegiate men and women. J Athl Train. 1999;34:86–92.
- Griffin LY, Albohm MJ, Arendt EA, et al. Understanding and preventing noncontact anterior cruciate ligament injuries: a review of the Hunt Valley II meeting, January 2005. Am J Sports Med. 2006;34:1512–32. CrossRef
- Hewett TE, Ford KR, Myer GD. Anterior cruciate ligament injuries in female athletes: Part 2, a meta-analysis of neuromuscular interventions aimed at injury prevention. Am J Sports Med. 2006;34:490–8. CrossRef
- Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med. 2005;33:492–501. CrossRef
- Hewett TE, Torg JS, Boden BP. Video analysis of trunk and knee motion during non-contact anterior cruciate ligament injury in female athletes: lateral trunk and knee abduction motion are combined components of the injury mechanism. Br J Sports Med. 2009;43:417–22. CrossRef
- Zazulak BT, Hewett TE, Reeves NP, et al. Deficits in neuromuscular control of the trunk predict knee injury risk: a prospective biomechanical-epidemiologic study. Am J Sports Med. 2007;35:1123–30. CrossRef
- de Marche Baldon R, Lobato DF, Carvalho LP, et al. Effect of functional stabilization training on lower limb biomechanics in women. Med Sci Sports Exerc. 2012;44:135–142.
- Lephart SM, Abt JP, Ferris CM, et al. Neuromuscular and biomechanical characteristic changes in high school athletes: a plyometric versus basic resistance program. Br J Sports Med. 2005;39:932–8. CrossRef
- Myer GD, Ford KR, Brent JL, et al. Differential neuromuscular training effects on ACL injury risk factors in “high-risk” versus “low-risk” athletes. BMC Musculoskelet Disord. 2007;8:39. CrossRef
- Myer GD, Brent JL, Ford KR, et al. A pilot study to determine the effect of trunk and hip focused neuromuscular training on hip and knee isokinetic strength. Br J Sports Med. 2008;42:614–9. CrossRef
- Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train. 2007;42:311–9.
- Hewett TE, Lindenfeld TN, Riccobene JV, et al. The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study. Am J Sports Med. 1999;27:699–706.
- Kiani A, Hellquist E, Ahlqvist K, et al. Prevention of soccer-related knee injuries in teenaged girls. Arch Intern Med. 2010;170:43–9. CrossRef
- Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med. 2005;33:1003–10. CrossRef
- Soderman K, Werner S, Pietila T, et al. Balance board training: prevention of traumatic injuries of the lower extremities in female soccer players? A prospective randomized intervention study. Knee Surg Sports Traumatol Arthrosc off J ESSKA. 2000;8:356–63. CrossRef
- Pfeiffer RP, Shea KG, Roberts D, et al. Lack of effect of a knee ligament injury prevention program on the incidence of noncontact anterior cruciate ligament injury. J Bone Joint Surg Am. 2006;88:1769–74. CrossRef
- Myer GD, Sugimoto D, Thomas S, et al. The influence of age on the effectiveness of neuromuscular training to reduce anterior cruciate ligament injury in female athletes: a meta-analysis. Am J Sports Med. 2012;41:216–24.
- Gagnier JJ, Morgenstern H, Chess L. Interventions designed to prevent anterior cruciate ligament injuries in adolescents and adults: a systematic review and meta-analysis. Am J Sports Med. 2013;41:1952–62. CrossRef
- Sadoghi P, von Keudell A, Vavken P. Effectiveness of anterior cruciate ligament injury prevention training programs. J Bone Joint Surg Am. 2012;94:769–76. CrossRef
- Nikander R, Malkia E, Parkkari J, et al. Dose-response relationship of specific training to reduce chronic neck pain and disability. Med Sci Sports Exerc. 2006;38:2068–74. CrossRef
- LaBella CR, Huxford MR, Grissom J, et al. Effect of neuromuscular warm-up on injuries in female soccer and basketball athletes in urban public high schools: cluster randomized controlled trial. Arch Pediatr Adolesc Med. 2011;165:1033–40. CrossRef
- Myklebust G, Engebretsen L, Braekken IH, et al. Prevention of anterior cruciate ligament injuries in female team handball players: a prospective intervention study over three seasons. Clin J Sport Med. 2003;13:71–8. CrossRef
- Steffen K, Myklebust G, Olsen OE, et al. Preventing injuries in female youth football—a cluster-randomized controlled trial. Scand J Med Sci Sports. 2008;18:605–14. CrossRef
- Ebell MH, Siwek J, Weiss BD, et al. Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. J Am Board Fam Pract. 2004;17:59–67. CrossRef
- Heidt RS Jr, Sweeterman LM, Carlonas RL, et al. Avoidance of soccer injuries with preseason conditioning. Am J Sports Med. 2000;28:659–62.
- Olsen OE, Myklebust G, Engebretsen L, et al. Exercises to prevent lower limb injuries in youth sports: cluster randomised controlled trial. BMJ (Clin Res Ed). 2005;330(7489):449. CrossRef
- Petersen W, Braun C, Bock W, et al. A controlled prospective case control study of a prevention training program in female team handball players: the German experience. Arch Orthop Trauma Surg. 2005;125:614–21. CrossRef
- Gilchrist J, Mandelbaum BR, Melancon H, et al. A randomized controlled trial to prevent noncontact anterior cruciate ligament injury in female collegiate soccer players. Am J Sports Med. 2008;36:1476–83. CrossRef
- Pasanen K, Parkkari J, Pasanen M, et al. Effect of a neuromuscular warm-up programme on muscle power, balance, speed and agility: a randomised controlled study. Br J Sports Med. 2009;43:1073–8. CrossRef
- Walden M, Atroshi I, Magnusson H, et al. Prevention of acute knee injuries in adolescent female football players: cluster randomised controlled trial. BMJ (Clin Res Ed). 2012;344:e3042.
- Yoo JH, Lim BO, Ha M, et al. A meta-analysis of the effect of neuromuscular training on the prevention of the anterior cruciate ligament injury in female athletes. Knee Surg Sports Traumatol Arthr. 2010;18:824–30. CrossRef
- Vila-Cha C, Falla D, Farina D. Motor unit behavior during submaximal contractions following six weeks of either endurance or strength training. J Appl Physiol. 2010;109:1455–66. CrossRef
- Chilibeck PD, Calder AW, Sale DG, et al. A comparison of strength and muscle mass increases during resistance training in young women. Eur J Appl Physiol Occup Physiol. 1998;77:170–5. CrossRef
- Agel J, Arendt EA, Bershadsky B. Anterior cruciate ligament injury in national collegiate athletic association basketball and soccer: a 13-year review. Am J Sports Med. 2005;33:524–30. CrossRef
- Arendt E, Dick R. Knee injury patterns among men and women in collegiate basketball and soccer. NCAA data and review of literature. Am J Sports Med. 1995;23:694–701. CrossRef
- Boden BP, Dean GS, Feagin JA Jr, et al. Mechanisms of anterior cruciate ligament injury. Orthopedics. 2000;23:573–8.
- Myklebust G, Maehlum S, Engebretsen L, et al. Registration of cruciate ligament injuries in Norwegian top level team handball. A prospective study covering two seasons. Scand J Med Sci Sports. 1997;7:289–92. CrossRef
- Walden M, Hagglund M, Werner J, et al. The epidemiology of anterior cruciate ligament injury in football (soccer): a review of the literature from a gender-related perspective. Knee Surg Sports Traumatol Arthrosc. 2011;19:3–10. CrossRef
- Li RT, Lorenz S, Xu Y, et al. Predictors of radiographic knee osteoarthritis after anterior cruciate ligament reconstruction. Am J Sports Med. 2011;39:2595–603. CrossRef
- Lohmander LS, Ostenberg A, Englund M, et al. High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players twelve years after anterior cruciate ligament injury. Arthr Rheum. 2004;50:3145–52. CrossRef
- Oiestad BE, Holm I, Aune AK, et al. Knee function and prevalence of knee osteoarthritis after anterior cruciate ligament reconstruction: a prospective study with 10 to 15 years of follow-up. Am J Sports Med. 2010;38:2201–10. CrossRef
- Oiestad BE, Holm I, Engebretsen L, et al. The association between radiographic knee osteoarthritis and knee symptoms, function and quality of life 10–15 years after anterior cruciate ligament reconstruction. Br J Sports Med. 2011;45:583–8. CrossRef
- Soligard T, Nilstad A, Steffen K, et al. Compliance with a comprehensive warm-up programme to prevent injuries in youth football. Br J Sports Med. 2010;44:787–93. CrossRef
- Sugimoto D, Myer GD, Bush HM, et al. Compliance with neuromuscular training and anterior cruciate ligament injury risk reduction in female athletes: a meta-analysis. J Athl Train. 2012;47:714–23. CrossRef
- Dosage Effects of Neuromuscular Training Intervention to Reduce Anterior Cruciate Ligament Injuries in Female Athletes: Meta- and Sub-Group Analyses
Volume 44, Issue 4 , pp 551-562
- Cover Date
- Print ISSN
- Online ISSN
- Springer International Publishing
- Additional Links
- Author Affiliations
- 1. The Micheli Center for Sports Injury Prevention, Waltham, MA, USA
- 2. Division of Sports Medicine, Department of Orthopedics, Boston Children’s Hospital, Boston, MA, USA
- 3. Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, MLC 10001, Cincinnati, OH, 45229, USA
- 4. Sports Medicine Biodynamics Center and Human Performance Laboratory, Cincinnati, OH, USA
- 5. College of Health Science, University of Kentucky, Lexington, KY, USA
- 6. Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
- 7. Athletic Training Division, School of Allied Medical Professions, The Ohio State University, Columbus, OH, USA
- 8. Departments of Orthopaedic Surgery, Biomedical Engineering and Rehabilitation Sciences, University of Cincinnati, Cincinnati, OH, USA
- 9. Sports Health & Performance Institute, The Ohio State University, Columbus, OH, USA