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Guus Reurink - Therapeutic interventions
The document is a systematic review analyzing the effectiveness of therapeutic interventions for acute hamstring injuries, updating previous findings from 2012. It examines various treatment methods, quality of studies based on the PEDro score, and highlights the need for improved research methodologies in the future. The review concludes that while some interventions show strong to moderate evidence, conflicting results are observed for PRP treatments.
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Guus Reurink - Therapeutic interventions
- 1. Therapeu5c interven5ons in acute hamstring injuries A systema5c review Gustaaf Reurink Human Movement Scien5st Sports Medicine Registrar
- 2.
- 3. Study Design N Interven5on PEDro score Effect Cibulka et al. (1986) RCT 20 SI manipula5on 5/10 = Kornberg et al. (1989) CCT 28 Slump stretch 3/10 + Lee et al. (2011) CCT 11 Actovegin injec5ons 4/10 + Malliaropoulos et al. (2004) RCT 80 Stretching 4/10 + Reynolds et al. (1995) RCT 44 NSAID’s 7/10 = Sherry & Best (2004) RCT 24 Core stability + agility 7/10 + 207
- 4. Study Design N Interven5on PEDro score Effect Cibulka et al. (1986) RCT 20 SI manipula5on 5/10 = Kornberg et al. (1989) CCT 28 Slump stretch 3/10 + Lee et al. (2011) CCT 11 Actovegin injec5ons 4/10 + Malliaropoulos et al. (2004) RCT 80 Stretching 4/10 + Reynolds et al. (1995) RCT 44 NSAID’s 7/10 = Sherry & Best (2004) RCT 24 Core stability + agility 7/10 + 207
- 5. Purpose Update of the 2012 review 1) Effec5veness of therapeu5c interven5ons in acute hamstring injuries 2) What should we do (be_er) in future research?
- 6. • Search Methods strategy (September 2014) – Search terms: ‘hamstring…’ AND ‘therapy…’ – Database: PubMed • Inclusion criteria • Subjects with acute hamstring injuries • Therapeu5c interven5on • Design: RCT (different from 2012)
- 7. Risk of bias analysis (PEDro score1,2) 1. Randomisa5on 2. Alloca5on concealed 3. Baseline differences 4. Blinding of subjects 5. Blinding of therapists 6. Blinding of outcome assessor 7. >85% of pa5ents available for analysis 8. ‘Inten5on-‐to-‐treat’ 9. Sta5s5cal comparison of key outcome reported 10. Point measures and measures of variability provided 1. Maher et al. Phys Ther 2003; 2. de Morton et al. ≥ 6/10 high quality study < 6/10 low quality study Aust J Physiother 2009
- 8. Best evidence synthesis1 Level of evidence: 1. Strong >1 high quality study 2. Moderate 1 high quality study 3. Limited low quality study 4. Conflic5ng conflic5ng results 5. No evidence no studies 1. Van Tulder et al. Spine 2003
- 9. Results Study N Interven5on Control PEDro score Effect Cibulka (1986) 20 SI manipula5on No 5/10 = Reynolds (1995) 44 NSAID’s Placebo 7/10 = Malliaropoulos (2004) 80 ‘Intensive’ stretching ‘Normal’ stretching 4/10 + Sherry & Best (2004) 24 Core stability + agility Stretching+ strength 7/10 + Silder et al. (2013) 31 Core stability + agility Running + eccentric 5/10 = Askling et al. (2013) 75 Lengthening exercises Conven5onal 6/10 + Askling et al. (2014) 65 6/10 + Reurink et al. (2014) 80 PRP Placebo 9/10 = Hamid et al. (2014) 28 PRP No 7/10 + 447
- 10. Results Study N Interven5on Control PEDro score Effect Cibulka (1986) 20 SI manipulaDon No 5/10 = Reynolds (1995) 44 NSAID’s Placebo effect 7/10 = Malliaropoulos (2004) 80 ‘Intensive’ stretching for ‘Normal’ NO stretching 4/10 + Sherry & Best (2004) 24 evidence Core stability + agility Stretching+ strength 7/10 + Silder et al. (2013) 31 Core stability + agility Running + eccentric 5/10 = Askling et al. (2013) 75 LIMITED Lengthening exercises Conven5onal 6/10 + Askling et al. (2014) 65 6/10 + Reurink et al. (2014) 80 PRP Placebo 9/10 = Hamid et al. (2014) 28 PRP No 7/10 +
- 11. Results Study N Interven5on Control PEDro score Effect Cibulka (1986) 20 SI manipula5on No 5/10 = Reynolds (1995) 44 NSAID’s Placebo 7/10 = Malliaropoulos (2004) 80 ‘Intensive’ stretching ‘Normal’ stretching 4/10 + Sherry & Best (2004) 24 Core stability + agility Stretching+ strength 7/10 + Silder et al. (2013) 31 Core stability + agility Running + eccentric 5/10 = Askling et al. (2013) 75 effect NO for evidence MODERATE Lengthening exercises Conven5onal 6/10 + Askling et al. (2014) 65 6/10 + Reurink et al. (2014) 80 PRP Placebo 9/10 = Hamid et al. (2014) 28 PRP No 7/10 +
- 12. Results Study N Interven5on Control PEDro score Effect Cibulka (1986) 20 SI manipula5on No 5/10 = Reynolds (1995) 44 NSAID’s Placebo 7/10 = Malliaropoulos (2004) 80 ‘Intensive’ stretching ‘Normal’ stretching 4/10 + Sherry & Best (2004) 24 Core stability + agility Stretching+ strength 7/10 + Silder et al. (2013) 31 Core stability + agility Running + eccentric 5/10 = Askling et al. (2013) 75 evidence posiDve Lengthening exercises Conven5onal 6/10 + Askling et al. (2014) 65 6/10 + Reurink et al. (2014) 80 PRP Placebo 9/10 = Hamid et al. (2014) 28 PRP No 7/10 + LIMITED for effect
- 13. Results Study N Interven5on Control PEDro score Effect Cibulka (1986) 20 SI manipula5on No 5/10 = Reynolds (1995) 44 NSAID’s Placebo 7/10 = Malliaropoulos (2004) 80 ‘Intensive’ stretching ‘Normal’ stretching 4/10 + Sherry & Best (2004) 24 Core stability + agility Stretching+ strength 7/10 + effect Silder et al. (2013) 31 Core stability + agility Running + eccentric 5/10 = Askling et al. (2013) 75 posiDve Lengthening exercises Conven5onal 6/10 + for evidence Askling et al. (2014) 65 6/10 + Reurink et al. (2014) 80 PRP Placebo 9/10 = Hamid et al. (2014) 28 PRP No 7/10 + MODERATE
- 14. Results Study N Interven5on Control PEDro score Effect Cibulka (1986) 20 SI manipula5on No 5/10 = Reynolds (1995) 44 NSAID’s Placebo 7/10 = Malliaropoulos (2004) 80 ‘Intensive’ stretching ‘Normal’ stretching 4/10 + Sherry & Best (2004) 24 Core stability + agility Stretching+ strength 7/10 + Silder et al. (2013) 31 Core stability + agility Running + eccentric 5/10 = Askling et al. (2013) 75 difference Lengthening exercises Conven5onal 6/10 + Askling et al. (2014) 65 6/10 + Reurink et al. (2014) LIMITED evidence 80 PRP for Placebo 9/10 = Hamid et al. (2014) 28 PRP No 7/10 + no
- 15. Results effect posiDve Study N Interven5on Control PEDro score Effect for Cibulka (1986) Reynolds (1995) evidence 20 SI manipula5on No 5/10 = 44 NSAID’s Placebo 7/10 = Malliaropoulos (2004) 80 ‘Intensive’ stretching ‘Normal’ stretching 4/10 + Sherry & Best (2004) 24 Core stability + agility Stretching+ strength 7/10 + Silder et al. (2013) 31 Core stability + agility Running + eccentric 5/10 = Askling et al. (2013) 75 Lengthening exercises ConvenDonal 6/10 + STRONG Askling et al. (2014) 65 6/10 + Reurink et al. (2014) 80 PRP Placebo 9/10 = Hamid et al. (2014) 28 PRP No 7/10 +
- 16. Results Study N Interven5on Control PEDro score Effect Cibulka (1986) 20 SI manipula5on No 5/10 = Reynolds Malliaropoulos CONFLICTING (1995) 44 NSAID’s evidence Placebo 7/10 = (2004) 80 ‘Intensive’ stretching ‘Normal’ stretching 4/10 + Sherry & Best (2004) 24 Core stability + agility Stretching+ strength 7/10 + Silder et al. (2013) 31 Core stability + agility Running + eccentric 5/10 = Askling et al. (2013) 75 Lengthening exercises Conven5onal 6/10 + Askling et al. (2014) 65 6/10 + Reurink et al. (2014) 80 PRP Placebo 9/10 = Hamid et al. (2014) 28 PRP No 7/10 +
- 17. • Double blind placebo controlled trial • PRP vs Placebo • 80 subjects with hamMsetdriainn 4g2 dinayjsu ries in both groups Reurink et al. NEJM 2014
- 18. Hazard raDo 0.96 (95% CI, 0.61 to 1.51) p=0.66 No benefit of PRP Reurink et al. NEJM 2014
- 19. 100% 80% 60% 40% 20% 0% Re-‐injury rate 16% 14% PRP-‐group Placebo-‐group Reurink et al. NEJM 2014
- 20. Strengths and limita5ons • Robust methodology – Randomised – Alloca5on concealment – Blinding – No lost to follow-‐up • Generalisa5on to – Other PRP products – Other injec5on protocols – Professional athlete seong
- 21. PRP: Hamid et al. 2014 • Single blind • PRP vs no injec5on • N = 28 • Other PRP system • Mean RTP: – PRP: 27 days – Control: 43 days HR 4.8 (95% CI, 1.3-‐19.3) Hamid et al. AJSM 2014
- 22. PRP: Hamid et al. 2014 • Limita5ons – Single blinded: placebo effect? – No re-‐injuries reported – RTP criteria? • Pain free on palpa5on • ROM < 10° side to side difference • Isometric strength (60, 180 and 300 deg/s) side to side difference < 10% à Tol et al. 20142: at RTP 67% has >10% side-‐to-‐side defecit! 1. Hamid et al. AJSM 2014; 2. Tol et al. BJSM 2014
- 23. Discussion: Outcome measures Most clinically relevant: • Time to RTP – No validated test to asses readiness – RTP criteria osen involve subjec5ve measures (e.g. pain) à Blinding à Well defined/described progression and RTP criteria à Monitoring re-‐injuries
- 24. 1 2 3 4 5 6 7 8 9 10 total score Cibulka et al. 1986 + ? -‐ -‐ -‐ -‐ + + + + 5/10 Reynolds et al. 1995 + + + + + + -‐ -‐ -‐ + 7/10 Malliaropoulos et al. 2004 + ? + ? ? ? ? ? + + 4/10 Sherry & Best 2004 + + + -‐ -‐ -‐ + + + + 7/10 Silder et al. 2013 + ? + -‐ -‐ -‐ -‐ + + + 5/10 Askling et al. 2013 + ? + -‐ -‐ -‐ + + + + 6/10 Askling et al. 2014 + -‐ + -‐ -‐ -‐ + + + + 6/10 Reurink et al. 2014 + + -‐ + + + + + + + 9/10 Hamid et al. 2014 + ? + -‐ -‐ + + + + + 7/10 Discussion: PEDro score ≥ 6/10 high quality < 6/10 low quality
- 25. Challenges for future research It is 5me to set the bar high! • High quality RCTs – Blinding – Alloca5on concealment – Well defined progression and RTP criteria – Re-‐injury monitoring
- 26. Take home message • Increased number of RCT’s – But….. s5ll <450 subjects studied • Strong-‐moderate evidence – Lengthening exercises – Core stability + agility – NSAIDs no effect • Conflic5ng evidence for PRP • Future research: high quality RCTs
- 27.