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Archived Comments for: Successful management of hamstring injuries in Australian Rules footballers: two case reports

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  1. Successful management of hamstring injuries in Australian Rules footballers: two case reports

    Stephen Perle, University of Bridgeport

    23 April 2005

    Thank you for these case reports. There is a critical need for more papers on the common treatment methods of sports chiropractors, as well as clinical trials of those methods we use.

    However, I am unclear as to why the authors claim in their abstract that this paper is the first to document the use of manipulation in the treatment of hamstring injury. I thought that the first such paper was a clinical trial by Cibulka et al (1) in 1986 which, despite the title, describe their treatment as sacroiliac joint manipulation.

    It is even more surprising that Drs. Hoskins and Pollard claim that this paper is the first when I find that they even used Cibulka as their last reference. I am left wondering if there is some specific difference in their method of sacroiliac joint manipulation from Cibulka's?

    Further, the authors claim that spinal manipulation was an effective treatment and preventive measure. This is a difficult claim to make when the patients were treated with a variety of other methods (ART, PNF, manipulation of extraspinal joints) in addition to the spinal manipulation. With case reports claims of effectiveness are not very robust but when multiple treatments are provided how can one ascribe efficacy to only one of the treatments instead of suggesting effectiveness of the whole therapeutic approach?

    Stephen M. Perle, D.C., M.S.

    Associate Professor of Clinical Sciences

    Adjunct Professor of Mechanical Engineering

    University of Bridgeport

    Bridgeport, CT 06601 USA

    1. Cibulka MT, Rose SJ, Delitto A, Sinacore DR. Hamstring muscle strain treated by mobilizing the sacroiliac joint. Phys Ther. 1986; 66(8):1220-3.

    Competing interests

    None

  2. reply

    Wayne Hoskins, Macquarie Injury Management Group, Department of Health & Chiropractic, Macquarie University, NSW 2109, Australia

    3 May 2005

    We would like to thank Assoc Prof Stephen M. Perle for taking the time to read our publication and for offering his opinions.  However, there are issues raised by Assoc Prof Perle that require clarification.

    Firstly, Dr. Perle is correct with the statement that Cibulka was the first to document manipulation in the treatment of hamstring injuries.  However, the obvious difference between our documentation of manipulation and Cibulka's is that the Cibulka study was an experimental study and our study was a clinical study.  Cibulka only considered hamstring and quadriceps femoris peak torque and hamstring length following his randomized controlled trial of sacroiliac joint manipulation. Importantly, return to play outcomes were not considered.  This was the primary outcome variable in our case reports, followed by prevention of recurrent injury.  Our paper involved a pragmatic approach in deciding where manipulation was to be applied in a multi-modal approach to the management in high level athletes.  In Cibulka's trial, a uni modal or monotherapy (manipulation) approach to treatment of the sacroiliac joint was used.

    Further,  Dr. Perle comments that we claim that it was the spinal manipulation which was an effective treatment and preventive measure, when we clearly used a multi-modal approach.  A closer read of the manuscript would find this not the case.  For example:

    * In the abstract we state: "We present two cases of hamstring injury that had full resolution after spinal manipulation AND correction of lumbar-pelvic biomechanics"

    * In the introduction we state: "The purpose of this paper is to present two cases of hamstring injury that were effectively managed with spinal manipulative therapy AND correction of lumbar-pelvic biomechanics"

    * In the discussion we state: "Improvement of these biomechanical factors, including the use of SMT resulted in successful treatment and prevention of the hamstring injuries"

    * In the conclusion we state: "spinal manipulation AND improving lumbar-pelvic biomechanics and function may play a role in treatment and prevention of hamstring injury" and "This should be further investigated in prospective, randomly controlled trials with long-term follow up".

    The above quotes do not say that spinal manipulation alone caused the changes.  The necessity of a multi-modal approach for the management of hamstring injuries is echoed in recent literature reviews on the topic (1,2).  Perhaps the statements about  improving lumbar-pelvic biomechanics should have been worded to better reflect the multi-modal aspect of the treatment. 

    The confusion may have stemmed from our statement in the abstract calling for specific research.  We state that "the use of spinal manipulation in the treatment and prevention of hamstring injury" "should be further investigated in prospective randomized controlled trials".  This is the subject of a current randomized controlled trial at the moment.

    Furthermore, the point should be made that our spinal and peripheral manipulation was added to a protocol that is in common usage in sports medicine (massage and stretching techniques, various aspects of strength and conditioning).  The addition facilitated resolution in the absence of improvement with the usual protocol (in one case).

    In conclusion, we did not overstate the importance of spinal manipulation in the general management, rather we highlighted its inclusion into what should be the normal protocol.

    References

    1. Hoskins WT, Pollard HP. Hamstring injury management - part one: issues in diagnosis. Manual Therapy. 2005 (in press).

    2. Hoskins WT, Pollard HP. Hamstring injury management - part two: treatment. Manual Therapy. 2005 (in press).

    Wayne T Hoskins B.ChSc, M.Chiro, PhD (cand.)

    Henry P Pollard B.Sc, Grad. DC, M.SportsSc, PhD

    Competing interests

    No competing interests

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