The effect of a sports chiropractic manual therapy intervention on the prevention of back pain, hamstring and lower limb injuries in semi-elite Australian Rules footballers: a randomized controlled trial

Australian Rules football is a unique body contact sport. It is played on a natural grass, oval shaped field, with the size varying between 135 - 185 meters in length and 110 - 155 meters in width. Teams consist of 18 players per side plus four on an unlimited interchange bench. Each game is played over four 20 minute quarters plus stoppage time. Physical requirements of players include: repeated rapid acceleration and deceleration efforts often involving change of direction, agility, jumping, bending to pick up the oval shaped ball, tackling and other collisions [1]. There is a continuous nature of play requiring high aerobic capacity, although the speed of the game has increased and now involves a greater number of shorter high intensity play periods and longer stop periods [2]. The most important means of ball progression is by punt kicking. Australian Rules football has the highest rates of non-contact soft tissue injuries when compared with other body contact football codes such as rugby league and rugby union [3], with the incidence of lower limb muscle strains at the elite national competition, the Australian Football League (AFL), being 35% per season [4].

Hamstring injuries are the most prevalent injury in Australian Rules football at the AFL [4] and feature prominently at other levels of play [5]. Per season in the AFL hamstring injuries afflict 16% of players, cause 3.4 missed matches per injury, account for the most time missed due to injury and have the highest rates of injury recurrence, with one in three injuries recurring on return to play [4]. On return to play, player performance is significantly lower [6]. Hamstring injuries are also the most common muscle injury in running based sports [7]. Knowledge surrounding optimal preventative measures is therefore critical.

The prevention of hamstring injuries has long been recognized as a priority effort. By contrast, Bahr and Holme [8] have opined that well designed prospective hamstring injury prevention studies are lacking. Recent literature reviews have been universal in their depiction of the lack of evidence for the prevention of hamstring injuries and the requisite for evidence based approaches to be determined through randomized controlled trials (RCTs) [7, 9, 10]. Prevention of injury becomes more crucial as the most established predictors for hamstring injury in Australian Rules football are immutable in nature, namely a current or recent history of a hamstring injury and age [11].

Conventional injury prevention has focused on local hamstring factors. Orchard [11] has said that sports medicine dogma advises that poor flexibility, fatigue, lack of warm up and weakness are risk factors for injury. The evidence to support this tenet for hamstring injury is lacking [7]. However, a growing body of literature, largely of an indirect nature, suggests that several non-local hamstring factors may have an association with injury [12‐16], whilst a Cochrane systematic review of the literature has stated that consideration should be given to the lumbar spine, sacroiliac and pelvic alignment and postural control mechanisms when managing hamstring injuries [17]. Despite the knowledge that non-local factors may exist, the literature appears almost devoid of research investigating their possible identification and documenting the effects, if any, of addressing non-local factors in hamstring injury management [12, 16, 18]. A recent review of the literature stated that newer approaches that incorporate manipulation in multi-modal management approaches for hamstring injury prevention should be further investigated [9]. Thus it was the objective of this RCT to investigate whether a sports chiropractic intervention consisting of pragmatically and individually determined high-velocity low-amplitude (HVLA) manipulation, mobilization and/or supporting soft tissue therapies to the spine, pelvis and extremity could reduce local and non-local hamstring injury risk factors to prevent the occurrence of hamstring and other non-contact lower limb injuries and decrease low back pain (LBP) and alter health outcomes in semi-elite Australian Rules footballers.

This RCT demonstrated that a sports chiropractic manual therapy intervention provided at the semi-elite level of Australian Rules football in addition to the current best practice multi-disciplinary medical, paramedical and sports science management resulted in the prevention of primary lower limb muscle strain injuries, although no statistical significance was noted for hamstring injury and primary non-contact knee injury. The addition of the intervention was associated with a reduced number of matches missed due primary non-contact knee injury, although no statistical significance was noted for hamstring injury and primary lower limb muscle strains. In addition, reduction in LBP was observed along with improvements in some aspects of the physical components of health status as measured by the SF-39. Treatment was predominantly directed at non-local to hamstring areas, which supports the view that several non-local factors may potentially contribute to hamstring and lower limb injury occurrence [7, 9], which may be addressed through multimodal and multidisciplinary management [16]. These findings are important due to their potential for injury reduction, performance benefit and cost saving practices for a relatively low cost intervention.

There are limitations in the presented study. Because the required subject numbers as determined by the power analysis was not achieved, care is needed in the interpretation of the results. The late withdrawal of two clubs reduced the subject numbers recruited and meant that the required target of subject numbers would not be reached. Due to the late withdrawal it was decided to continue with the study. However, the number of subjects determined by the power analysis is based on an arbitrary determined effect size, and the numbers required would have been different if another effect size had been chosen. Moreover, the results that are presented report statistical significance and it is difficult to determine what difference in the raw figures would be clinically significant. As the level of significance for prevention of hamstring injuries and primary non-contact knee injuries was p = 0.051, given that the study was short of the number of subjects required by the power analysis, there is a strong likelihood of a type 2 error, especially considering how close each of these results were to p < 0.05. With regards to the fact that lower limb muscle strain injury incidence was significantly lower while the missed weeks was not, this implies that many minor grade strain injuries may have been prevented, but the one injury causing 4 missed matches skewed the results and meant the comparison would not be statistically significant. This is important in a small sample study such as the prevention of one serious injury (or not) can significantly alter the weeks lost profile of a particular treatment approach. Only studies with much larger sample sizes can really effectively confirm this important research observation.

Furthermore, a question could be raised regarding control group selection. It was felt that using the club based best practice medical, paramedical and sports science management as the control was valid because no change in hamstring injury rates using this same approach have been documented in the AFL's long running injury surveillance [4]. Corroborating this viewpoint, the hamstring injury incidence reported for the control group (17%) was very similar to that reported in AFL players (16%) using the same methodology. Difficulty arises in attempting to perform research on high-level professional or semi-professional athletes due to clubs not being overly enthusiastic for researchers to perform interventions on their contracted and paid players, particularly if the intervention to be performed is purely for control purposes. To counter this dilemma a pragmatic approach to research design was taken which created a further limitation in that subjects were not blinded to group allocation, meaning it cannot be ruled out that the intervention effect was due purely to placebo or Hawthorne effects, particularly as there was no blinding of the therapist. However, more modern research design often requires new interventions to be compared with the existing best practice approach [22], which was done in this study.

The injury surveillance for adverse reactions to treatment may be limited due to the subjectivity of aspects of the injury definition. Players may not have self-reported injury. If injury was delayed or transient, players may not have attributed injury to the intervention, instead attributing it to training/competition activities or other medical, paramedical or sports science management. Such a problem exists in any multi-modal management scenario. Conversely, given the reliability of the missed match injury definition [20], it is highly unlikely that a more severe injury resulting in loss of competition match play was missed.

The diagnosis of hamstring strains is usually made on clinical grounds [23]. Hamstring strains are commonly diagnosed through history (acute onset, non-contact mechanism) and examination (local tenderness, reproducible pain on straight leg raise testing and/or resisted knee flexion) [24]. In professional sport, MRI assessment is often used to support the clinical diagnosis and provide further assessment of the extent and severity of the injury. However, costs and availability preclude the use of this modality for routine assessment outside of professional sport. Additionally, both clinical examination and MRI findings are strongly correlated with the time required to return to competition, suggesting MRI is not required for estimating the duration of rehabilitation of an acute minor or moderate hamstring injury [25]. MRI imaging to confirm diagnosis of hamstring strains was not routinely performed in this study. There are limitations in relying on both clinical methods of diagnosis and MRI as hamstring injuries can appear clinically but not on MRI and they also may appear on MRI but not clinically [25]. As MRI was not routinely used, there is a possibility that some of the hamstring injuries in this study may have been MRI negative which are often considered "back related". There is some controversy regarding "back related" hamstring injuries as to whether a muscle strain is the cause, particularly for minor strains where causes for the pain may include referred pain from neuromeningeal or myofascial structures such as the lumbar spine and sciatic nerve or from nearby muscles such as the gluteal and pirifomis [23]. However, "back related" hamstring injury is an undefined term generally signifying both local hamstring signs and positive lumbar signs [23]. It should be noted that none of the hamstring injuries in the study had positive lumbar signs present at the time of diagnosis, but the lack of MRI diagnosis remains as a limitation of the study.

The intervention applied in this study was based largely on indirect evidence and speculative reasoning that local and non-local factors could potentially contribute to hamstring injury, which have been suggested to act as a guide to a complete prevention program [9]. Similar hypotheses could be made regarding other lower limb muscle strain injuries and non-contact knee injuries. As a uni-modal approach was not adopted to address a single risk factor, it is unclear as to what the specific mechanism of improvement was or what component of the protocol resulted in injury prevention. The multi-modal intervention was decided upon on the basis that it more accurately represents sports chiropractic clinical practice [26‐28], and because sports injuries, including hamstring injuries, result from a complex interaction of multiple risk factors and events, of which only a fraction have been identified [8]. For the reversible risk factors that exist for hamstring injury, no definitive evidence exists to support them [7]. It has been suggested that waiting for a substantial body of evidence to exist to support a risk factor in its role in injury before conducting a RCT may be considered unethical [8].

Whilst a multi-modal approach was adopted, we speculate that the most significant difference between the control and the intervention groups was the inclusion of a significant amount of HVLA manipulation, as soft tissue therapies were habitually administered to the athletes in this cohort. Although data were not recorded in this study, manipulation if used by manipulative physiotherapists (as in the control group) has a tendency to be slow velocity or mobilization in nature and if HVLA techniques are rendered they are characteristically done so sparingly [29]. In the paper by Flynn et al. [29] they state that in the previously reported low back pain literature high velocity spinal manipulation utilization rates for low back pain to be between 2.8% and 8.9%, with rates in a heavily evidence based education system to be 36.2%. Alternatively, in the cited studies low velocity mobilization is used between 27.2% and 72.0% of the time. Despite these figures being the most up to date yet published, these figures represent United States, Ireland and United Kingdom physiotherapists and the figures may not be representative of current practice in those geographical locations or in Australian physiotherapists in particular. In contrast, the sports chiropractic intervention provided to the intervention group had a greater emphasis on performing HVLA manipulative techniques to both spinal and extremity joints, with 92% of total joint based treatment involving some form of HVLA manipulation technique. Future research would benefit from recording the nature of the control interventions in order to clarify the differences between interventions or to specifically address the role of HVLA based manipulative techniques. Future studies could specifically document the scope of the manual treatment delivered by all treating practitioners in both groups, which would assist in comparing outcomes. A criticism of manual therapy interventions is that its effects are short term in nature. Because of this, it was decided that an ongoing treatment approach with adequate spacing of treatments during the season would be applied. This would also best manage ongoing injury and sub-clinical micro-trauma or gradual onset injury that could occur to players over the course of the season. The decision on the minimum scheduling of treatment decided upon for the intervention group was made such that there would be a likely treatment effect. Treatment scheduling in this pragmatic arrangement was then based upon current and previous player medical history, examination findings, practicality, player preference and practitioner experience. As the intervention was provided by a single practitioner, this removed issues associated with inter-practitioner reliability. As mentioned in the results there was an average of 17 treatment consultations administered per player in the intervention group, but due to the pragmatic nature of the design, not all players received the same amount of treatment.

Sherry and Best [18] have suggested that neuromuscular control of the lumbopelvic region is needed to create optimal function of the hamstrings. They further suggest that changes in neuromuscular control could lead to changes in length tension relationships or force-velocity relationships of the hamstrings, predisposing injury. This hypothesis could extend to other muscle groups including quadriceps and groin muscles. Other authors have also hypothesized that dysfunction of the axial skeleton may predispose abnormal hamstring functioning that may relate to a greater incidence of injuries [7, 9, 16], which is supported by evidence documenting lumbopelvic factors as risk factors for hamstring injury [12‐15]. Supporting this mechanism of injury is the large body of literature showing that LBP is associated with changes in lumbopelvic muscle activation and recruitment [30, 31], including early activation of biceps femoris and alteration in neuromuscular control strategies [32], all of which could contribute to injury. In athletes, changes in lumbopelvic stabilization exist following clinical recovery of LBP [33]. Noteworthy is the high prevalence, frequency and severity of LBP occurring in the subjects recruited for this study [34].

Although the neurophysiological mechanisms underlying HVLA manipulation are not fully known or understood [35], evidence exists showing it is capable of stimulating muscle spindles, pacinian corpuscles and golgi tendon organs greater than that achieved by slow velocity mobilization [36]. Panjabi [37] has hypothesized that injured spinal mechanoreceptors may alter afferent input, effecting motor unit recruitment. Alterations in the recruitment of motor units of the deep lumbopelvic muscles may result in altered lumbopelvic stabilization strategies and insufficient force generated by the hamstrings and other muscles attached to the pelvis, or may result in excessive force production, causing subsequent injury. Alterations in hamstring motor units may also occur. Stimulation of mechanoreceptors by HVLA manipulation may improve afferent feedback required to update and modify motor functions. This may improve neuromuscular control of the lumbopelvic region and/or the coordination of hamstring and pelvic muscle function, preventing injury. In support of such a view, Solomonow et al. [38] have demonstrated that discharge of spinal proprioception can produce change in multifidus activation. Additionally, HVLA spinal manipulation has been shown to produce significant improvements in feed forward activation times of deep abdominal musculature [39], whilst case reports have shown it may improve the ability to perform transversus abdominus [40] and multifidus contraction [41]. Collectively these deficiencies have been found to be associated with LBP, with transverses abdominus and multifidus being key stabilizers in lumbopelvic stabilization [30, 42]. Studies have also indicated that HVLA manipulation may improve muscle function through either facilitation or disinhibition of neural pathways [35]. These effects, combined with spinal manipulation improving hamstring strength [12], and increased joint mobility through mechanical stretching and neurophysiological mechanisms [35], may have lead to improvements in hamstring and other lower limb muscle functioning and subsequent injury prevention noted in this study. Due to the complex multi-factorial etiology underlying hamstring and lower limb muscle injury, it is probable that more than one possibly interacting mechanism occurred to prevent injury. Additionally, the targeted inclusion of soft tissue therapies and extremity joint mobilization and manipulation stretching soft tissues and improving joint mobility may have potentially contributed to injury prevention.

The trend towards reduction in primary non-contact knee injuries and significant improvements in weeks missed due to these injuries may appear surprising. However, recent literature has documented the more precise details of the biceps femoris anatomy, which have not previously been appreciated [43]. The authors hypothesized that there may be a synergistic effect between biceps femoris and popliteus, signifying bicep femoris' important role in knee joint stabilization [43]. This may highlight the important bidirectional inter-play between hamstring and knee function. Thus, soft tissue treatments delivered to the popliteus and knee region and HVLA manipulation to the knee may have assisted with knee function and therefore led to prevention of knee injury. Lastly, research has shown that HVLA spinal manipulation can reduce knee extensor inhibition associated with anterior knee pain [44], which could lead to improvements in knee function and injury prevention. Of interest, LBP has also been associated with inhibition of the knee extensor muscles [45], which could imply a link between lumbopelvic and knee function. The potential role of the knee in hamstring injury has been discussed elsewhere in further detail [7].

Due to constraints in manuscript size, we are unable to describe the entire treatment provided in this study or to speculate on all proposed mechanisms of improvement, which will be the subject of a subsequent publication. It should be noted that treatment provided was patient specific and addressed both kinetic and kinematic chain variables. The treatment was representative of the 'modern multimodal' (MMM) chiropractic approach that has been described in the sports chiropractic literature [26, 27], and recommended in selecting a chiropractor for the management of athletic injuries [28].

Based on the limitations of this study which includes a low sample size, this RCT demonstrated that a sports chiropractic intervention comprising significant amounts of HVLA manipulation and soft tissue therapies provided in addition to the current best practice medical, paramedical and sports science management appears to be beneficial for the prevention of lower limb muscle strain injuries, weeks missed due to primary non-contact knee injuries and reduction of LBP and improvement in physical components of health status. In addition, although not statistically significant, there was a trend towards prevention of hamstring and primary non-contact knee injuries and there were no reported adverse outcomes from the intervention. The interesting trend in results but non-statistically significance should be replicated using a larger sample size to remove the short comings of this study. Based on the findings of this study due consideration should be given for the inclusion of sports chiropractic in the management options of elite athletes.