Question: What are the effects of interventions designed to prevent sports injuries?
Data sources: MEDLINE, PubMed, the Cochrane Central Register of Controlled Trials, SPORTDiscus, CINAHL, PEDro (to 2005), personal files, and reference lists of retrieved articles and relevant reviews.
Selection criteria: Randomized or quasirandomized controlled studies were selected if they evaluated the effects of any preventive intervention on sports injuries, were fully published in peer-reviewed journals before January 1, 2006, reported injury rates, and described explicitly the intervention protocol and outcome measures. Thirty-two studies (24,931 participants) met the selection criteria. The quality of study methods was assessed with use of an 11-point scoring criteria (score range, 0 = low to 11 = high). Quality scores ranged from 1 to 8 points (mean 3.8 points).
Main outcome measure: Injury.
Main results:Insoles: 5 studies (6 comparisons, n = 2446) compared the use of custom-made or prefabricated insoles with the use of no insoles to reduce lower extremity injuries. Five of the 6 comparisons showed a benefit for insoles (odds ratio [OR] range, 0.10 to 0.70). One study (n = 874) compared different types of orthoses and found no difference among groups.
External joint supports: Seven studies (n = 10,300) evaluated the use of external joint supports. Three of 4 studies showed that ankle orthoses or ankle stabilizers reduced injury (OR range, 0.16 to 0.60). One study of outside-the-boot braces showed no statistical difference between groups. In 1 study of prophylactic knee braces and 2 studies of wrist protectors, the use of supports reduced injury (OR range, 0.12 to 0.43).
Training programs; balance board: Two of 4 studies (n = 1799) showed a benefit for balance-board training programs (OR range, 0.16 to 0.24), whereas 2 studies showed a nonsignificant increase in injuries with balance-board training.
Training programs; multi-interventions with balance board: Two studies (n = 400) showed that multi-interventions that included the use of balance-board training reduced injuries (OR range, 0.20 to 0.29).
Training programs; other multi-interventions: Four studies (n = 2409) showed that multi-intervention programs that included exercise and rehabilitation (without balance-board training) reduced injuries (OR range, 0.18 to 0.53; 1 study did not report data for calculating an OR).
Stretching and warm-up programs: Three studies (n = 3052) showed that stretching and warm-up exercises did not reduce injuries.
Mouth guards: One of 2 studies (n = 947) showed that custom-made mouth guards reduced head and/or facial injuries (relative risk 0.56, 95% confidence interval 0.32 to 0.97).
Modified shoes: Three studies (n = 1402) showed that modified basketball shoes did not prevent injury.
Videos: Of 2 studies (n = 1034), 1 showed that an instructional ski video reduced sports injuries. In the other study, a video-based awareness program did not reduce sports injuries.
Conclusion: The use of insoles, external joint supports, and multi-intervention training programs can reduce sports injuries. Stretching and warm-up programs and modified shoes did not reduce injuries. The evidence was mixed for balance-board training programs, mouth guards, and videos.
This well-done systematic review by Aaltonen and colleagues provides the reader with a comprehensive summary of the highest level of evidence on the effectiveness of interventions for sports-related injuries. Their overview table is a wealth of information for readers to evaluate specific interventions both by "subgroup" as well as by the individual article. For example, there is consistent clinically relevant and significant injury reduction with the use of external joint supports and multi-intervention training programs. In contrast, a stretching and warm-up program and modified shoes consistently failed to prevent injuries. The results of other interventions (balance board, mouth guards, and videos) were inconclusive. Therefore, the sports medicine health-care provider must evaluate each study on its own strengths and weaknesses for potential use.
The use of insoles results in a reasonably consistent reduction in lower-extremity overuse injuries with both "off-the-shelf" or prefabricated and custom-made insoles in a military population. Whether this is generalizable to athletes is questionable. Of more clinical relevance is whether the use of insoles prevents stress fractures. The data here do not answer this important question. In 3 level-I RCTs1-3 that used radiographs as a diagnostic method, 2 found no significant difference1,3, and 1 single study observed a significant difference2. However, the difference was observed in femoral stress fractures only, not tibial or metatarsal. Thus, no adequate prevention of stress fractures exists to date, yet stress fracture is the most troublesome overuse injury in sports medicine.
This article should be read and evaluated by every sports-medicine health-care professional, and serious consideration should be given to adopting several of the effective intervention strategies.
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