| Literature DB >> 35457516 |
Anmol T Mattu1, Brianna Ghali2, Vanessa Linton3, Alex Zheng3, Ian Pike3,4.
Abstract
Anterior cruciate ligament (ACL) injuries account for a large percentage of knee injuries, disproportionately affecting female athletes. To help health professionals stay current, we performed an umbrella review to evaluate the effectiveness of ACL injury prevention programs in reducing non-contact ACL injury rates, determine the effective components within interventions, and provide clinical recommendations. Twelve databases (Medline, Embase, Cochrane Database of Systematic Reviews, SPORTDiscus, Cumulative Index to Nursing and Allied Health Literature, PEDro, Web of Science Core Collection, Epistemonikos, TRIP, BC Guidelines and Protocols, CPG Infobase, ProQuest Dissertations and Theses Global) were searched in May 2021 to identify relevant systematic reviews and meta-analyses. Four databases were searched again in September 2021 to identify recent primary literature. Non-contact ACL injury data were extracted to calculate incidence rate ratios (IRRs) and these were combined using an inverse variance random-effects model. A qualitative assessment of included reviews was performed. The methodological quality of the studies was assessed using a Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2) or Cochrane Risk-of-Bias Tool for Randomized Trials (RoB 2). Sixteen reviews and two primary studies met the inclusion criteria. Across 11 primary studies, prevention programs were effective in reducing non-contact ACL injuries by 64% (IRR = 0.36 (95% CI: 0.18-0.70)). A multi-faceted exercise program, beginning in the pre-season and containing at least three exercise types, may be beneficial in reducing ACL injury risk.Entities:
Keywords: anterior cruciate ligament (ACL); female athlete; injury prevention; meta-analysis; neuromuscular training; prevention program; youth
Mesh:
Year: 2022 PMID: 35457516 PMCID: PMC9027388 DOI: 10.3390/ijerph19084648
Source DB: PubMed Journal: Int J Environ Res Public Health ISSN: 1660-4601 Impact factor: 4.614
Figure 1PRISMA flow diagram of the literature search for review articles.
The reasons for the exclusion of all studies that were excluded after a full-text review are listed below.
| Study | Main Reason for Exclusion |
|---|---|
| Chiaro [ | Adult population |
| Albaugh et al. [ | Could not find full-text |
| Herman et al. [ | Duplicate |
| Rishiraj et al. [ | Narrative review without a search algorithm |
| Taylor et al. [ | No differentiation between mechanisms of ACL injury in results and/or analyses |
| Zheng et al. [ | Not in English |
| Herzberg et al. [ | Wrong intervention |
| Willadsen et al. [ | Wrong outcomes |
| Paszkewicz et al. [ | Wrong study design |
Figure 2PRISMA flow diagram of the literature search for primary articles.
The reasons for the exclusion of all studies that were excluded after a full-text review of primary literature are listed below.
| Study | Main Reason for Exclusion |
|---|---|
| Lewis et al. [ | Wrong outcomes |
| Paulson et al. [ | Wrong study design |
| Foss et al. [ | No differentiation between mechanisms of ACL injury |
| Omi et al. [ | Adult population |
| Achenbach et al. [ | Duplicate |
Characteristics of the included systematic reviews.
| Study ID | Databases Searched | Date of Last Search | Total Number of Studies * (Non-Contact) | Total Number of Participants * (Non-Contact) | Study Funding |
|---|---|---|---|---|---|
| Hewett et al. [ | Medline, CINAHL | NR | 5 (3) | 8764 (8324) | NIH |
| Padua et al. [ | PubMed | NR | 5 (2) | 8850 (6532) | NR |
| Noyes et al. [ | PubMed, CINAHL, Science Direct | August 2011 | 6 (4) | 13,067 (8400) | NR |
| Stojanovic et al. [ | Medline | June 2011 | 9 (5) | 13,884 † (NR) | NR |
| Herman et al. [ | PubMed, Embase, SPORTDiscus, PEDro, Google Scholar, ISI Web of Knowledge, Scirus | January 2012 | 6 (3) | 8999 (4034) | NR |
| Noyes et al. [ | Medline, CCRCT | May 2013 | 9 # (9) | 19,493 | NR |
| Michaelidis et al. [ | PubMed, CINAHL, CCRCT, Science Direct, SPORTDiscus, PEDro, SCOPUS | September 2012 | 13 (11) | 22,052 (21,612) | None |
| Stevenson et al. [ | Medline, CINAHL, CCRCT | 2011 | 10 (5) | 15,512 (5771) | NR |
CINAHL: Cumulative Index to Nursing and Allied Health Literature; CCRCT: Cochrane Central Register of Controlled Trials; NR: Not reported; NIH: National Institutes of Health grant; *: related to all ACL injuries; #: includes one unpublished update; †: included male participants.
Characteristics of the included systematic reviews and meta-analyses.
| Study ID | Databases Searched | Date of Last Search | Total Number of Primary Studies * (Non-Contact) | Total Number of Participants (Non-Contact) | Meta-Analysis Results † | Reduction in Non-Contact ACL Risk | Study Funding Sources |
|---|---|---|---|---|---|---|---|
| Hewett et al. [ | Medline, CINAHL | 2004 | 6 (3) | 9040 (8324) | Not conducted | - | NIH |
| Grindstaff et al. [ | PubMed, Medline, CINAHL, SPORTDiscus, Web of Science | October 2005 | 5 (5) | 11,026 | Not conducted | - | NR |
| Yoo et al. [ | Medline, CCRCT | June 2007 | 7 (4) | 10,618 (8247) | OR = 0.36 (0.23–0.54) | 64% | NR |
| Sadoghi et al. [ | PubMed, Medline, CINAHL, CCRCT, Embase | December 2010 | 8 (6) | 10,618 (9982) | RR = 0.48 (0.26–0.89) | 62% | None |
| Sugimoto et al. [ | PubMed, Medline, CINAHL, SPORTDiscus | January 2012 | 12 (10) | 18,523 (18,083) | RRR = 73.4% (63–81) | 73.4% | NIH |
| NNT = 108 (86–150) | |||||||
| Gagnier et al. [ | Medline, CINAHL, CCRCT, Embase, SPORTDiscus, HTA | July 2011 | 14 (NR) | ~27,136 (NR) | Not conducted | - | U of M Bone & Joint Injury Prevention & Rehabilitation Center |
| Taylor et al. [ | PubMed, Medline, CINAHL, CCRCT, SPORTDiscus | July 2012 | 13 (9) | 24,188 (19,891) | OR = 0.38 (0.22–0.64) | 62% | None |
| Donnell-Fink et al. [ | PubMed, Medline, CINAHL, CCRCT, Embase, Web of Science | December 2014 | 14 (9) | 20,132 (15,235) # | IRR = 0.51 (0.30–0.88) | 48.7% | NIH, NIAMSD |
CCRCT: Cochrane Central Register of Controlled Trials; CINAHL: Cumulative Index to Nursing and Allied Health Literature; HTA: Health Technology Assessment; OR: odds ratio; RR: risk ratio; RRR: relative risk reduction; NNT: number needed to treat; IRR: incidence rate ratio; NR: not reported; NIH: National Institutes of Health grant; U of M: University of Michigan; NIAMSD: National Institute of Arthritis and Musculoskeletal and Skin Diseases grant; *: meta-analysis only; #: not all studies included in the meta-analysis and included male participants; †: pooled results for non-contact ACL injury only, not restricted to youth; ^: removed from the final analysis due to failure to differentiate the mechanism of ACL injury.
Primary studies included in the systematic reviews and meta-analyses.
| Systematic Review and/or Meta-Analysis | Primary Study | |||||||
|---|---|---|---|---|---|---|---|---|
| Hewett et al. [ | Mandelbaum et al. [ | Olsen et al. [ | Pfeiffer et al. [ | Steffen et al. [ | Kiani et al. [ | LaBella et al. [ | Walden et al. [ | |
| Hewett et al. [ | X | X | ||||||
| Padua et al. [ | X | X | X | |||||
| Hewett et al. [ | X | X | ||||||
| Grindstaff et al. [ | X | X | X | |||||
| Yoo et al. [ | X | X | X | |||||
| Noyes et al. [ | X | X | X | X | ||||
| Sadoghi et al. [ | X | X | X | |||||
| Stojanovic et al. [ | X | X | X | |||||
| Herman et al. [ | X | X | X | X | X | |||
| Sugimoto et al. [ | X | X | X | X | X | X | X | |
| Noyes et al. [ | X | X | X | X | X | X | X | X |
| Michaelidis et al. [ | X | X | X | X | X | X | X | |
| Taylor et al. [ | X | X | X | X | X | X | X | X |
| Stevenson et al. [ | X | X | X | X | X | |||
| Donnell-Fink et al. [ | X | X | X | X | X | X | X | X |
*: systematic review only; #: meta-analysis only.
Characteristics and injury results of all primary studies.
| Study ID | Study Design | Number of Participants | Age (Years) | Sports | Number of Injuries | ACL Injury Incidence * |
|---|---|---|---|---|---|---|
| Hewett et al. [ | Prospective cohort study | C: 463 | 14–18 | Soccer, basketball, volleyball | C: 5 | 0.22 |
| I: 366 | I: 0 | 0.00 | ||||
| Mandelbaum et al. [ | Prospective cohort study | C: 3818 | 14–18 | Soccer | C: 67 | 0.49 |
| I: 1885 | I: 6 | 0.09 | ||||
| Olsen et al. [ | Randomized controlled trial | C: 778 | 15–17 | Handball | C: 5 | 0.11 |
| I: 808 | I: 1 | 0.02 | ||||
| Pfeiffer et al. [ | Prospective cohort study | C: 862 | 14–18 | Soccer, basketball, volleyball | C: 3 | 0.08 |
| I: 577 | I: 3 | 0.17 | ||||
| Steffen et al. [ | Randomized controlled trial | C: 947 | 13–17 | Soccer | C: 2 | 0.06 |
| I: 1073 | I: 3 | 0.09 | ||||
| Kiani et al. [ | Prospective cohort study | C: 729 | 13–19 | Soccer | C: 5 | 0.15 |
| I: 777 | I: 0 | 0.00 | ||||
| LaBella et al. [ | Randomized controlled trial | C: 755 | 16.2 ± 1.1 | Soccer, basketball | C: 6 | 0.48 |
| I: 737 | 16.2 ± 1.5 | I: 2 | 0.10 | |||
| Walden et al. [ | Randomized controlled trial | C: 2085 | 12–17 | Soccer | C: 8 | 0.12 |
| I: 2479 | I: 5 | 0.07 | ||||
| Achenbach et al. [ | Randomized controlled trial | C: 215 | 15.1 ± 1.0 | Handball | C: 2 | 0.32 |
| I: 259 | 14.9 ± 0.9 | I: 0 | 0.00 | |||
| Yarsiasat et al. [ | Randomized controlled trial | C: 26 | 14–19 | Sepak takraw | C: 3 | 0.05 |
| I: 26 | I: 1 | 0.02 |
*: ACL injury incidence per 1000 athlete-exposure events.
Summary of intervention details for the primary studies.
| Study ID | Program Name | Exercise Types Included | Feedback | Duration (min.) | Frequency (d/wk.) | Length of Program | Training Season | Equipment | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Warm-Up | Plyometrics | Strength | Agility | Balance | Stretching | ||||||||
| Hewett et al. [ | Sportsmetrics | X * | X | X | 60–90 | 3 | 6 weeks | PS | Gymnastic mat, cones | ||||
| Mandelbaum et al. [ | PEP | X | X * | X | X | X | 20 | 2–3 | 12 weeks for 3 seasons | S | Cones | ||
| Olsen et al. [ | OLSEN | X | X * | X | X | X | X | 15–20 | 15 sessions then 1 | 8 months | S | Wobble board, | |
| Pfeiffer et al. [ | KLIPP | X | X * | 20 | 2 | 2 seasons | S | None | |||||
| Steffen et al. [ | The “11” | X | X | X | X | X | X | 20 | 15 sessions then 1 | 8 months | PS, S | Balance mat | |
| Kiani et al. [ | HPT | X | X * | X | X | 20–25 | 2 (PS), 1 (S) | 9 months | PS, S | None | |||
| LaBella et al. [ | KIPP | X | X | X | X | X | X | 20 | 2–5 # | 13 ± 2.5 weeks | S | None | |
| Walden et al. [ | Walden | X | X | X | X | 15 | 2 | 7 months | S | None | |||
| Achenbach et al. [ | HSIPP | X | X | X | 15 | 2–3 (PS), 1 (S) | 10–12 weeks + season | PS, S | None | ||||
| Yarsiasat et al. [ | PEP | X | X | X | X | X | 20 | 3 | 8 weeks | Unsure | Cones | ||
PEP: Prevent Injury and Enhance Performance; KLIPP: Knee Ligament Injury Preventive Program; HPT: HarmoKnee Preventative Training Program; KIPP: Knee Injury Prevention program; HSIPP: Handball-Specific Injury Prevention Program; PS: pre-season; S: in-season; *: emphasis on technique; #: before team practices and an abbreviated version with dynamic motion exercises only before games.
Figure 3Quality assessment of the reviews using the AMSTAR 2 tool. RCT: randomized control trial; NSRI: non-randomized studies of interventions.
Figure 4Main effect meta-analysis: random-effects, inverse variance weighted model. IRR: incidence rate ratio; CI: confidence interval.
Figure 5Funnel plot for the random-effect estimate.