Déclaration sur la PRÉVENTION DE LA LÉSION DU LIGAMENT CROISÉ ANTÉRIEUR
Introduction
Cet article est une revue de haut niveau concernant l’état actuel de la recherche internationale sur l’activité physique (AP). Il est divisé en 5 sections, correspondant aux points majeurs de la recherche en la matière :
- La définition de l’activité physique
- L’impact sur la santé
- La prévalence et la surveillance
- Les corrélations et les déterminants
- Les interventions permettant de modifier l’AP.
Définition
Dans son sens le plus simple, l’activité physique se réfère à n’importe quel mouvement corporel qui résulte en une augmentation de la dépense énergétique. L’AP est souvent caractérisée par l’acronyme FITT : F = fréquence, I = intensité, T = temps et T = type (aérobie, anaérobie).
Les recommandations de l’OMS en temps d’activité physique sont les suivantes :
- Les enfants de 0 à 4 ans : au minimum 180 minutes d’AP de n’importe quelle intensité, de façon quotidienne, tout au long de la semaine.
- Les enfants et adolescents de 5 à 17 ans : au minimum 60 min d’activité modérée à plus intense sur une durée quotidienne, tout au long de la semaine.
- Les adultes de 18 à 64 ans : au minimum 150 minutes d’activité aérobic modérée par semaine, ou au minimum 75 minutes d’activité plus intense par semaine.
- Les adultes de 65 ans et plus : au minimum 150 minutes d’activité aérobic modérée par semaine, ou au minimum 75 minutes d’activité plus intense par semaine.
L’OMS précise que les minutes supplémentaires apportent un réel plus pour la santé.
Impact sur la santé
- Mortalité prématurée : une étude épidémiologique récente démontre une relation quantité/conséquence claire entre l’AP et le risque de mortalité toute cause. Les groupes de personnes ayant le moins d’activité sont les plus à risque. Mais les plus grandes réductions de risque ont été constatées chez les personnes ayant le moins d’activité physique lorsqu’elles passaient à un groupe d’activité juste supérieur. De plus, les risques de mortalité ont été diminués avec simplement de petites différences dans le comportement par rapport à l’AP.
- Prévention primaire et secondaire des maladies chroniques : une AP régulière a été associée à la prévention primaire de plus de 25 pathologies chroniques. Le tableau 2 montre les réductions de risques entre les personnes actives et inactives. Il est important de souligner qu’une AP régulière améliore aussi la condition de pathologie qui ne découle pas d’un manque d’AP.
- Développement des aptitudes musculosquelettique (MS) : il y a aujourd’hui des preuves claires que les aptitudes MS sont associées à des indicateurs variés de statut de la santé (particulièrement des statuts fonctionnels)
Bénéfices de ces programmes de prévention :
Le taux de rupture est réduit de 51 à 62% lorsque les sportifs réalisent ces programmes de prévention. De plus, ils permettent également de réduire le taux de blessures du genou (54%) et du membre inférieur en général (39%). L’utilisation de ces programmes permet également d’améliorer la biomécanique, le contrôle musculaire et la performance. Une biomécanique du membre inférieur modifiée comme une amplitude limitée dans le plan sagittal ou augmentée dans les plans frontaux et transversaux entrainent des charges anormales au niveau des articulations du membre inférieur. Ces mouvements (valgus du genou, adduction de hanche, flexion de genou limitée) sont considérés comme étant des facteurs de risques modifiables dans la prévention de la rupture du LCA.
Composants des programmes de prévention :
Aucune preuve ne penche en faveur d’un programme de prévention en particulier, cependant certaines lignes directrices existent. Ces grandes lignes peuvent être modifiées en fonction de la population concernée. Les programmes de prévention doivent inclurent au moins 3 des différents types d’exercices suivants : force, pliométrie, agilité, équilibre et souplesse. Les exercices de renforcement ont pour but d’améliorer la force musculaire à l’aide du poids du corps, de poids libres ou de machines. La pliométrie intègre des mouvements explosifs comme des sauts ou des bonds répétés. Les exercices d’agilité intègrent de nombreux exercices moteurs (accélération, décélération, changement de direction…). Les exercices d’équilibre se déroulent en général en unipodal ou en bipodal en intégrant différents niveaux visuels (yeux fermés – yeux ouverts), différentes difficultés de surface (stable – instable et dur – instable et mou) et des perturbations externes (pas de perturbation – mouvement des extrémités – attraper une balle – perturbation du partenaire). Enfin, la partie souplesse intègre des exercices d’étirement dynamiques et statiques. Ces exercices sont généralement réalisés pendant 15 à 20 minutes, intégrés à l’échauffement. Cependant, d’après une étude récente, les programmes de prévention réalisés pendant plus de 20 minutes améliorent de 26% le taux de diminution de rupture du LCA par rapport aux programmes durant moins de 20 minutes. Ces sessions doivent être réalisées au moins 2 à 3 fois par semaine pour avoir une influence sur le taux de ruptures. Les auteurs conseillent également de débuter la prévention à la pré-saison et de la poursuivre longtemps pendant la saison.
Intégration des programmes de prévention (adoption et maintenance) :
Les footballeurs avec une bonne adhérence (compliance) au programme ont présenté une réduction de 88% du taux de lésion du LCA. Le taux de compliance a été déterminé comme étant le nombre de séances de prévention réalisées par le nombre total de séances. Les participants avec un niveau bas ou modéré de compliance avaient 3,1 à 4,9 fois plus de chance de présenter une lésion du LCA que ceux présentant une compliance élevée. Afin d’encourager une compliance élevée, les thérapeutes doivent faire attention à 3 paramètres principalement :
L’intégration du programme est également la clé de la compliance du sportif. Il est important de :
Il apparait judicieux de débuter ces programmes de prévention chez les individus de moins de 15 ans pratiquant des sports sollicitant.
Identification des individus nécessitant ces programmes de prévention :
Ils sont globalement recommandés pour tous les athlètes, et plus particulièrement pour ceux pratiquant des sports incluant des réceptions de saut, des changements de direction, des décélérations. Les sportifs présentant le plus de risques de lésion du LCA sont ceux ayant des antécédents de rupture. Le risque porte sur les deux genoux. Les facteurs de risques proposés ici à la rupture du LCA sont (entre autres) : un schéma moteur incorrect (flexion de genou ou de hanche limitée, un valgus du genou excessif, une adduction ou une rotation de hanche), la génétique, la laxité du genou et l’IMC. Certains mouvements cliniques sont aussi considérés comme étant des facteurs de risques et pourraient être utilisés comme moyen afin d’obtenir la compliance du sportif au programme de prévention.
Conclusion
Il serait nécessaire de faire des recherches supplémentaires notamment concernant l’efficacité des programmes de prévention chez les sportifs homme (beaucoup plus étudié chez la femme). De plus, certaines méta-analyses suggèrent qu’inclure des exercices spécifiques (force, contrôle proximal, gainage) semble plus efficace pour réduire le taux de rupture de LCA que d’autres types d’exercices (équilibre, étirements statiques). De ce fait, des études évaluant les effets de la sélection d’articles et de progression afin de déterminer la combinaison la plus efficace sont nécessaires. Des études prospectives de haute qualité évaluant les facteurs de risques comme la biomécanique, le contrôle neuromusculaire, la génétique, la composition du corps, la laxité du genou et sa géométrie ainsi que les alignements du squelette seraient utiles. Enfin, afin d’optimiser la compliance des sportifs aux programmes de prévention il serait intéressant d’étudier les stratégies d’implémentation de ces programmes.
Mots clés : blessures du genou – biomécanique du membre inférieur – contrôle neuromusculaire – prévention des blessures.
Article original : National Athletic Trainers’ Association Position Statement : Prevention of anterior cruciate ligament injury, Darin A. Padua et Al. Journal of Athletic Training, 2018 ; 53 (1) : 5-19. Doi : 10.4085/1062-6050-99-16.
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Le taux de rupture est réduit de 51 à 62% lorsque les sportifs réalisent ces programmes de prévention. De plus, ils permettent également de réduire le taux de blessures du genou (54%) et du membre inférieur en général (39%). L’utilisation de ces programmes permet également d’améliorer la biomécanique, le contrôle musculaire et la performance. Une biomécanique du membre inférieur modifiée comme une amplitude limitée dans le plan sagittal ou augmentée dans les plans frontaux et transversaux entrainent des charges anormales au niveau des articulations du membre inférieur. Ces mouvements (valgus du genou, adduction de hanche, flexion de genou limitée) sont considérés comme étant des facteurs de risques modifiables dans la prévention de la rupture du LCA.
Composants des programmes de prévention :
Aucune preuve ne penche en faveur d’un programme de prévention en particulier, cependant certaines lignes directrices existent. Ces grandes lignes peuvent être modifiées en fonction de la population concernée. Les programmes de prévention doivent inclurent au moins 3 des différents types d’exercices suivants : force, pliométrie, agilité, équilibre et souplesse. Les exercices de renforcement ont pour but d’améliorer la force musculaire à l’aide du poids du corps, de poids libres ou de machines. La pliométrie intègre des mouvements explosifs comme des sauts ou des bonds répétés. Les exercices d’agilité intègrent de nombreux exercices moteurs (accélération, décélération, changement de direction…). Les exercices d’équilibre se déroulent en général en unipodal ou en bipodal en intégrant différents niveaux visuels (yeux fermés – yeux ouverts), différentes difficultés de surface (stable – instable et dur – instable et mou) et des perturbations externes (pas de perturbation – mouvement des extrémités – attraper une balle – perturbation du partenaire). Enfin, la partie souplesse intègre des exercices d’étirement dynamiques et statiques. Ces exercices sont généralement réalisés pendant 15 à 20 minutes, intégrés à l’échauffement. Cependant, d’après une étude récente, les programmes de prévention réalisés pendant plus de 20 minutes améliorent de 26% le taux de diminution de rupture du LCA par rapport aux programmes durant moins de 20 minutes. Ces sessions doivent être réalisées au moins 2 à 3 fois par semaine pour avoir une influence sur le taux de ruptures. Les auteurs conseillent également de débuter la prévention à la pré-saison et de la poursuivre longtemps pendant la saison.
Intégration des programmes de prévention (adoption et maintenance) :
Les footballeurs avec une bonne adhérence (compliance) au programme ont présenté une réduction de 88% du taux de lésion du LCA. Le taux de compliance a été déterminé comme étant le nombre de séances de prévention réalisées par le nombre total de séances. Les participants avec un niveau bas ou modéré de compliance avaient 3,1 à 4,9 fois plus de chance de présenter une lésion du LCA que ceux présentant une compliance élevée. Afin d’encourager une compliance élevée, les thérapeutes doivent faire attention à 3 paramètres principalement :
- Le temps requis pour réaliser une seule session de prévention
- L’utilisation d’exercices spécifiques au sport pratiqué
- L’inclusion d’un large panel d’exercices pouvant être modifiés et intégrés dans une progression.
L’intégration du programme est également la clé de la compliance du sportif. Il est important de :
- Sensibiliser les participants aux bénéfices de la réalisation de ces programmes.
- Entrainer les personnes menant ces programmes afin qu’ils soient capables de fournir des feedbacks adéquats.
- Évaluer de façon régulière la compliance et les techniques de réalisation d’exercices.
Il apparait judicieux de débuter ces programmes de prévention chez les individus de moins de 15 ans pratiquant des sports sollicitant.
Identification des individus nécessitant ces programmes de prévention :
Ils sont globalement recommandés pour tous les athlètes, et plus particulièrement pour ceux pratiquant des sports incluant des réceptions de saut, des changements de direction, des décélérations. Les sportifs présentant le plus de risques de lésion du LCA sont ceux ayant des antécédents de rupture. Le risque porte sur les deux genoux. Les facteurs de risques proposés ici à la rupture du LCA sont (entre autres) : un schéma moteur incorrect (flexion de genou ou de hanche limitée, un valgus du genou excessif, une adduction ou une rotation de hanche), la génétique, la laxité du genou et l’IMC. Certains mouvements cliniques sont aussi considérés comme étant des facteurs de risques et pourraient être utilisés comme moyen afin d’obtenir la compliance du sportif au programme de prévention.
Conclusion
Il serait nécessaire de faire des recherches supplémentaires notamment concernant l’efficacité des programmes de prévention chez les sportifs homme (beaucoup plus étudié chez la femme). De plus, certaines méta-analyses suggèrent qu’inclure des exercices spécifiques (force, contrôle proximal, gainage) semble plus efficace pour réduire le taux de rupture de LCA que d’autres types d’exercices (équilibre, étirements statiques). De ce fait, des études évaluant les effets de la sélection d’articles et de progression afin de déterminer la combinaison la plus efficace sont nécessaires. Des études prospectives de haute qualité évaluant les facteurs de risques comme la biomécanique, le contrôle neuromusculaire, la génétique, la composition du corps, la laxité du genou et sa géométrie ainsi que les alignements du squelette seraient utiles. Enfin, afin d’optimiser la compliance des sportifs aux programmes de prévention il serait intéressant d’étudier les stratégies d’implémentation de ces programmes.
Mots clés : blessures du genou – biomécanique du membre inférieur – contrôle neuromusculaire – prévention des blessures.
Article original : National Athletic Trainers’ Association Position Statement : Prevention of anterior cruciate ligament injury, Darin A. Padua et Al. Journal of Athletic Training, 2018 ; 53 (1) : 5-19. Doi : 10.4085/1062-6050-99-16.
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