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Early versus Delayed Rehabilitation after Acute Muscle Injury

September 2017
The New-England Medical Review and Journal 377(13):1300-1301

DOI:10.1056/NEJMc1708134

Authors:

Stig Peter Magnusson

Bispebjerg Hospital, Copenhagen University

Michael Kjaer

Bispebjerg Hospital, Copenhagen University

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In this randomized study involving 50 amateur athletes with severe injury to thigh or calf muscles, a return to full activity was more rapid when the rehabilitation program was started 2 days rather than 9 days after injury.

Interval from Muscle-Strain Injury to Pain-free Full Recovery, According to the Timing of Initiation of Rehabilitation Therapy. Panel A shows the number of days from injury to recovery among the 50 patients who received early rehabilitation (starting 2 days after injury) or delayed rehabilitation (starting 9 days after injury). Panel B shows the median number of days from injury to recovery; the I bars indicate the interquartile range.

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Cor responde nce

The new england journal of medicine

n engl j med 377;13 nejm.org September 28, 2017

1300

Cor responde nce

Early versus Delayed Rehabilitation after Acute Muscle Injury

To the Editor: Acute traumatic muscle-strain

injuries are common and result in a substantial

loss of time and risk of recurrence. Treatment op-

tions such as platelet-rich plasma are ineffective.

The extent to which the timing of rehabilitation

inf luences clinical recovery of strain injuries re-

mains unknown. We investigated whether early

or delayed use of injured musculotendinous tissue

affected recovery after acute muscle-strain injuries.

We conducted a randomized, controlled trial

involving 50 amateur athletes with acute injury

of the thigh muscle (in approximately 60% of

the patients) or calf muscle (in approximately

40%), as confirmed on ultrasonography and mag-

netic resonance imaging. Patients (mean age, 34

years) were recruited less than 48 hours after

injury and underwent randomization to receive

early therapy (2 days after injury) or delayed

therapy (9 days after injury) and were followed

for 12 months. The injuries were most com-

monly associated with playing soccer or partici-

pating in track-and-field events. (Details regard-

ing the types of injuries are provided in the

Supplementary Appendix, available with the full

text of this letter at NEJM.org.)

All the patients completed a standardized

four-stage therapy regimen: daily repeated static

stretching (week 1), daily isometric loading with

increasing load (weeks 2 to 4), dynamic loading

with increasing resistance three times per week

(weeks 5 to 8), and functional exercises combined

with heavy strength training three times per week

(weeks 9 to 12). Five patients in the early-therapy

group and three in the delayed-therapy group

discontinued treatment. The primary outcome

was a return to sports, which was def ined as the

first time point of full participation in sports

after being asymptomatic and successful com-

pletion of a functional test (a score of ≤1 on the

Numeric Pain Rating Scale, which ranges from

0 to 10 with higher scores indicating a greater

level of pa in).

The interval between severe muscle injury and

a return to sports was shorter in the early-therapy

group than in the delayed-therapy group, with a

median interval of 62.5 days (interquartile range,

48.8 to 77.8) and 83.0 days (interquartile range,

64.5 to 97.3), respectively (P = 0.01) (Fig. 1). Re-

injury during the follow-up period occurred in

one patient in the early-therapy group and in no

patients in the delayed-therapy group.

This study shows the clinical consequences of

protracted immobilization after a recreational

sports injury. Starting rehabilitation 2 days after

injury rather than waiting for 9 days shortened

the interval from injury to pain-free recovery and

return to sports by 3 weeks without any signif i-

cant increase in the risk of reinjury. The observed

difference supports the importance of early load-

ing of injured musculotendinous tissue. Immo-

bilization can swiftly and adversely affect muscle

and tendon structure and function and has detri-

mental effects on connective-tissue cells.

2,3

The

this week’s letters

1300 Early versus Delayed Rehabilitation after Acute

Muscle Injury

1301 Prostatectomy versus Observation for Early

Prostate Cancer

1303 Changes in Diet Quality and Total

and Cause-Specif ic Mortality

1305 Beating, Fast and Slow

The New England Journal of Medicine

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Cor re spondence

n engl j med 377;13 nejm.org September 28, 2017

1301

matrix component of muscle–tendon regeneration

is substantial and prolonged,

which may con-

tribute to the difference in recovery time in our

study. Delay in rehabilitation can result in pro-

longed pain and a delayed return to sports, a

finding that emphasizes the importance of regu-

lar and controlled mechanical loading early after

trauma to large muscles.

Monika L. Bayer, Ph.D.

S. Peter Magnusson, P.T., D.M.Sc.

Michael Kjaer, M.D., D.M.Sc.

Bispebjerg Hospital

Copenhagen, Denmark

monika . lucia . bayer@ regionh . dk

for the Tendon Research Group Bispebjerg

A complete list of members of the Tendon Research Group

Bispebjerg is provided in the Supplementa ry Appendix, avai lable

at NEJM.org.

Supported by Bispebjerg Hospita l, Great er Region of Copen-

hagen Research Foundat ion, Dan ish Rheu matism Association,

Lundbeck Foundat ion, Danish Council for Independent Research,

Novo Nordisk Foundation, and Anti Doping Denma rk.

Disclosure forms provided by the aut hors are available wit h

the fu ll text of th is letter at NEJM.org.

1. Reu rink G, Goudswaard GJ, Moen MH, et al. Platelet-rich

plasma inject ions in acute muscle i njur y. N Engl J Med 2014; 370:

2 54 6 - 7.

2. de Boer MD, Maganar is CN, Seynnes OR, Rennie MJ, Narici

MV. Time course of muscula r, neura l and tendinous adaptations

to 23 day unilatera l lower-limb suspension in young men. J Physiol

2007; 583: 1079-91.

3. Bayer ML, Schjerling P, Herchenhan A, et al. Release of ten-

sile str ain on engineered huma n tendon t issue disturbs cell ad-

hesions, changes matri x architect ure, and induces an inf l am-

matory phenotype. PLoS One 2014; 9(1): e86078.

4. Mackey AL, Brandstet ter S, Schjerling P, et al. Sequenced

response of extracellu lar matri x deadhesion and f ibrotic regu la-

tors af ter muscle damage is involved in protection against fut ure

injur y in human skeletal muscle. FASEB J 2011; 25: 1943-59.

DOI: 10.1056/NEJMc1708134

Prostatectomy versus Observation for Early Prostate Cancer

To the Editor: In reporting the results of the

Prostate Cancer Intervention versus Observation

Trial (PIVOT), Wilt et al. (July 13 issue)

indicate

no significant decrease in all-cause or prostate-

cancer mortality among men assigned to sur-

gery, as compared with those assigned to ob-

servation (hazard ratio, 0.84; 95% confidence

interval, 0.70 to 1.01; P = 0.06). These results al-

most certainly reflect a type II error from a lack

of power. The authors enrolled 731 men from a

targeted accrual of 2000 men. Doubling the trial

cohort to 1462 patients (still well short of the

targeted accrual) would have resulted in a 76%

probability of a signif icant effect.

Furthermore, 74% of the cohort had low-grade

cancer. These men probably would not have died

from prostate cancer. Meaningful differences in

survival among men with prostate cancer were

likely to be seen only in the 26% of patients with

a score of 7 or higher on the Gleason scale (a

scale of 2 to 10, with higher scores indicating

a high-grade histologic subtype of prostate tu-

Figure 1. Interval from Muscle-Strain Injury to Pain-free

Full Recovery, According to the Timing of Initiation of

Rehabilitation Therapy.

Panel A shows the number of days from injury to recovery

among the 50 patients who received early rehabilitation

(starting 2 days after injur y) or delayed rehabilitation

(starting 9 days after injur y). Panel B shows the median

number of days from injury to recovery; the I bars indicate

the interquartile range.

Patient Recovery (%)

100

0 30 6050 90 120 150 233

Days since Injury

BMedian No. of Days until Recovery

AInterval between Injury and Recovery

Early-therapy group

Delayed-therapy

group

No. of Days until Recovery

150

100

0Early-Therapy Group Delayed-Therapy Group

P=0.01

The New England Journal of Medicine

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Radial ESWT combined with a specific rehabilitation program (rESWT + RP) is more effective than sham rESWT + RP for acute hamstring muscle complex injury type 3b: a randomized, controlled trial

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Objectives: This study tested the hypothesis that radial extracorporeal shock wave therapy combined with a specific rehabilitation program (rESWT + RP) is more effective than sham rESWT + RP in athletes with acute hamstring muscle complex (HMC) injury type 3b. Methods: This was a prospective, randomized, sham-controlled, single center trial with published protocol, concealed allocation, blinded patients and blinded assessors. A total of 36 semi-professional athletes (soccer, field hockey and rugby players) receiving fees or university scholarships with acute HMC injury type 3b were randomly allocated to rESWT + RP for up to 5 weeks (n=18) or sham rESWT + RP (n=18). The primary outcome was the individual time to return to sport. Secondary outcomes were the individual patient's satisfaction and presence or absence of re-injury during 6 months post-inclusion into this trial. Results: No serious adverse events occurred during the trial. The median / mean time to return to sport was 25.5 / 25.4 +/- 3.5 (mean +/- SD) days after rESWT + RP (n=18) and 27.5 / 28.3 +/- 4.5 days after sham rESWT + RP (n=18) (p=0.037). The mean patient's satisfaction was not significantly different between the groups. Only one patient in each group experienced a re-injury during 6 months post-inclusion into this trial. Conclusion: In rehabilitation of athletes with acute HMC injury type 3b, rESWT + RP is more effective than sham rESWT + RP. Registration: ClinicalTrials.gov ID NCT03473899 (registered on March 22, 2018).

Return to Sport, Reinjury Rate, and Tissue Changes after Muscle Strain Injury: A Narrative Review

Article

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A major challenge in sports medicine is to facilitate the fastest possible recovery from injury without increasing the risk of subsequent reruptures, and thus effective rehabilitation programs should balance between these two factors. The present review focuses on examining the role of different resistance training interventions in rehabilitation of acute muscle strain in the time frame from injury until return to sport (RTS), the rate of reinjuries, and tissue changes after injury. Randomized, controlled trials dealing with a component of resistance training in their rehabilitation protocols, as well as observational studies on tissue morphology and tissue changes as a result to muscle strain injuries, were included. The mean time for RTS varied from 15 to 86 days between studies (n = 8), and the mean rate of reinjury spanned from 0 to 70%. Eccentric resistance training at long muscle length and rapid introduction to rehabilitation postinjury led to significant improvement regarding RTS, and core-stabilizing exercises as well as implementing an individualized algorithm for rehabilitation seem to reduce the risk of reinjury in studies with a high rerupture rate. Independent of the rehabilitation program, structural changes appear to persist for a long time, if not permanently, after a strain injury.

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