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1.  Classification system of the sagittal standing alignment in young adolescent girls 
European Spine Journal  2013;23(1):216-225.
The purpose of this cohort study was to classify sagittal standing alignment of pre-peak height velocity (pre-PHV) girls, and to evaluate whether identified subgroups were associated with measures of spinal pain. This study further aimed at drawing attention to similarities and differences between the current postural classification and a previous system determined among pre-PHV boys.
557 pre-PHV girls [mean age, 10.6 years (SD, 0.47 years)] participated in the study. Three gross body segment orientation parameters and five specific lumbopelvic characteristics were quantified during habitual standing. Postural subgroups were determined by cluster analysis. Logistic regression was applied to assess the relationship between postural subgroups and spinal pain measures (pain and seeking care, assessed by self-administered questionnaire). Chi-square statistics, independent samples T test, and distribution-based methods were used for comparison with postural categorization in pre-PHV boys.
Results and conclusion
Among pre-PHV girls, clinically meaningful posture clusters emerged both on the gross body segment and specific lumbopelvic level. The postural subtypes identified among pre-PHV girls closely corresponded to those previously described in pre-PHV boys, thereby allowing the use of the same, working nomenclature. In contrast to previous findings among pre-PHV boys, no associations between posture clusters and spinal pain measures were significant in girls at pre-PHV age. When comparing discrete ‘global’ alignment scores across corresponding posture types, some intriguing differences were found between genders which might involve different biomechanical loading patterns. Whether habitual posture forms a risk factor for developing spinal pain up to adulthood needs evaluation in prospective multifactorial follow-up research.
PMCID: PMC3897822  PMID: 23955370
Posture; Sagittal balance; Classification; Adolescent; Spinal pain
2.  Efficacy of a modern neuroscience approach versus usual care evidence-based physiotherapy on pain, disability and brain characteristics in chronic spinal pain patients: protocol of a randomized clinical trial 
Among the multiple conservative modalities, physiotherapy is a commonly utilized treatment modality in managing chronic non-specific spinal pain. Despite the scientific progresses with regard to pain and motor control neuroscience, treatment of chronic spinal pain (CSP) often tends to stick to a peripheral biomechanical model, without targeting brain mechanisms. With a view to enhance clinical efficacy of existing physiotherapeutic treatments for CSP, the development of clinical strategies targeted at ‘training the brain’ is to be pursued. Promising proof-of-principle results have been reported for the effectiveness of a modern neuroscience approach to CSP when compared to usual care, but confirmation is required in a larger, multi-center trial with appropriate evidence-based control intervention and long-term follow-up.
The aim of this study is to assess the effectiveness of a modern neuroscience approach, compared to usual care evidence-based physiotherapy, for reducing pain and improving functioning in patients with CSP. A secondary objective entails examining the effectiveness of the modern neuroscience approach versus usual care physiotherapy for normalizing brain gray matter in patients with CSP.
The study is a multi-center, triple-blind, two-arm (1:1) randomized clinical trial with 1-year follow-up. 120 CSP patients will be randomly allocated to either the experimental (receiving pain neuroscience education followed by cognition-targeted motor control training) or the control group (receiving usual care physiotherapy), each comprising of 3 months treatment. The main outcome measures are pain (including symptoms and indices of central sensitization) and self-reported disability. Secondary outcome measures include brain gray matter structure, motor control, muscle properties, and psychosocial correlates. Clinical assessment and brain imaging will be performed at baseline, post-treatment and at 1-year follow-up. Web-based questionnaires will be completed at baseline, after the first 3 treatment sessions, post-treatment, and at 6 and 12-months follow-up.
Findings may provide empirical evidence on: (1) the effectiveness of a modern neuroscience approach to CSP for reducing pain and improving functioning, (2) the effectiveness of a modern neuroscience approach for normalizing brain gray matter in CSP patients, and (3) factors associated with therapy success. Hence, this trial might contribute towards refining guidelines for good clinical practice and might be used as a basis for health authorities’ recommendations.
Trial registration Identifier: NCT02098005.
PMCID: PMC4028010  PMID: 24885889
Chronic pain; Low back pain; Neck pain; Education; Exercise; Motor control; Neuroscience; Randomized controlled trial
3.  A clinical postural model of sagittal alignment in young adolescents before age at peak height velocity 
European Spine Journal  2012;21(11):2188-2197.
From a clinical point of view, knowledge of customary standing positions among healthy young adolescents is of primary importance. The purpose of this study was to document the correlations between sagittal standing posture parameters in a pre-peak height velocity (pre-PHV) cohort.
Materials and methods
This cohort study included 639 pre-PHV boys (age 12.6 [SD, 0.54] years) and 557 pre-PHV girls (age 10.6 [SD, 0.47] years). Gross body segment orientations and spinopelvic orientation/shape indexes were quantified using a clinical screening protocol. Pearson’s correlation coefficients were determined for all sagittal standing plane alignment parameters, and a postural model was used to analyze the correlations between parameters.
Both at the gross body segment and spinopelvic level, an interdependence was found between postural parameters. No correlations were observed between ‘global’ parameters related to the pelvis, trunk or body anteroposterior translation postures and ‘local’ spinopelvic geometries. A similar pattern and strength of correlations was obtained in pre-PHV boys and girls, except for the reciprocal relationships between the craniovertebral angle and adjacent anatomic segment characteristics and between thoraco-lumbar geometries.
Although the correlation schemes do not imply a causal relationship, the proposed postural model allows conjecture about standing posture to be organized slightly differently in pre-PHV boys and girls. Whereas the standing posture in pre-PHV boys might be organized predominantly according to an ascending mode, bottom-up and top-down organizations appear to coexist in pre-PHV girls.
PMCID: PMC3481087  PMID: 22763558
Postural balance; Growth and development; Spine; Pelvis; Clinical protocols
4.  Posterior muscle chain activity during various extension exercises: an observational study 
Back extension exercises are often used in the rehabilitation of low back pain. However, at present it is not clear how the posterior muscles are recruited during different types of extension exercises. Therefore, the present study will evaluate the myoelectric activity of thoracic, lumbar and hip extensor muscles during different extension exercises in healthy persons. Based on these physiological observations we will make recommendations regarding the use of extensions exercises in clinical practice.
Fourteen healthy subjects performed four standardized extension exercises (dynamic trunk extension, dynamic-static trunk extension, dynamic leg extension, dynamic-static leg extension) in randomized order at an intensity of 60% of 1-RM (one repetition maximum). Surface EMG signals of Latissimus dorsi (LD), Longissimus thoracis pars thoracic (LTT) and lumborum (LTL), Iliocostalis lumborum pars thoracic (ILT) and lumborum (ILL), lumbar Multifidus (LM) and Gluteus Maximus (GM) were measured during the various exercises. Subsequently, EMG root mean square values were calculated and compared between trunk and leg extension exercises, as well as between a dynamic and dynamic-static performance using mixed model analysis. During the dynamic exercises a 2 second concentric contraction was followed by a 2 second eccentric contraction, whereas in the dynamic-static performance, a 5 second isometric interval was added in between the concentric and eccentric contraction phase.
In general, the muscles of the posterior chain were recruited on a higher level during trunk extension (mean ± SD, 56.6 ± 30.8%MVC) compared to leg extension (47.4 ± 30.3%MVC) (p ≤ 0.001). No significant differences were found in mean muscle activity between dynamic and dynamic-static performances (p = 0.053). The thoracic muscles (LTT and ILT) were recruited more during trunk extension (64.9 ± 27.1%MVC) than during leg extension (54.2 ± 22.1%MVC) (p = 0.045) without significant differences in activity between both muscles (p = 0.138). There was no significant differences in thoracic muscle usage between the dynamic or dynamic-static performance of the extension exercises (p = 0.574).
Lumbar muscle activity (LTT, ILL, LM) was higher during trunk extension (70.6 ± 22.2%MVC) compared to leg extension (61.7 ± 27.0%MVC) (p = 0.047). No differences in myoelectric activity between the lumbar muscles could be demonstrated during the extension exercises (p = 0.574). During each exercise the LD (19.2 ± 13.9%MVC) and GM (28.2 ± 14.6%MVC) were recruited significantly less than the thoracic and lumbar muscles.
The recruitment of the posterior muscle chain during different types of extension exercises was influenced by the moving body part, but not by the type of contraction. All muscle groups were activated at a higher degree during trunk extension compared to leg extension. Based on the recruitment level of the different muscles, all exercises can be used to improve the endurance capacity of thoracic muscles, however for improvement of lumbar muscle endurance leg extension exercises seem to be more appropriate. To train the endurance capacity of the LD and GM extension exercises are not appropriate.
PMCID: PMC3716991  PMID: 23834759
Trunk extensor muscles; Multifidus; Posterior muscle chain; Extension exercise; Electromyography; Spine
5.  Long-term effectiveness of a back education programme in elementary schoolchildren: an 8-year follow-up study 
European Spine Journal  2011;20(12):2134-2142.
The purpose of this study was to investigate the long-term effectiveness of a spine care education programme conducted in 9- to 11-year-old schoolchildren. The study sample included 96 intervention subjects and 98 controls (9- to 11-year-olds at baseline). Intervention consisted of a 6-week school-based back education programme (predominantly biomechanically oriented) and was implemented by a physical therapist. Self-reported outcomes on back care knowledge, spinal care behaviour, self-efficacy towards favourable back care behaviour, prevalence of back and neck pain during the week and fear-avoidance beliefs were evaluated by the use of questionnaires. Post-tests were performed within 1 week after programme completion, after 1 year and after 8 years. Whereas the educational back care programme resulted in increased back care knowledge up to adulthood (P < 0.001), intervention did not change spinal care behaviour or self-efficacy. Pain prevalence figures increased less in the experimental group compared to the controls over the 8-year time span, yet statistical significance was not reached. Dropout analysis revealed spinal pain prevalence rates to be different in both groups throughout the study, including at baseline. Back education at young age did not reinforce fear-avoidance beliefs up to adulthood. Predominantly biomechanical oriented back education in elementary schoolchildren is effective in improving the cognitive aspect of back care up to adulthood, yet not in changing actual behaviour or self-efficacy. The current study does not provide evidence that educational back care programmes have any impact on spinal pain in adulthood. The true long-term impact of school-based spinal health interventions on clinically relevant outcome measures merits further attention.
PMCID: PMC3229732  PMID: 21647724
Education; Back pain; Child; Prevention and control
6.  Computed tomographic analysis of the quality of trunk muscles in asymptomatic and symptomatic lumbar discectomy patients 
No consensus exists on how rehabilitation programs for lumbar discectomy patients with persistent complaints after surgery should be composed. A better understanding of normal and abnormal postoperative trunk muscle condition might help direct the treatment goals.
A three-dimensional CT scan of the lumbar spine was obtained in 18 symptomatic and 18 asymptomatic patients who had undergone a lumbar discectomy 42 months to 83 months (median 63 months) previously. The psoas muscle (PS), the paraspinal muscle mass (PA) and the multifidus muscle (MF) were outlined at the L3, L4 and L5 level. Of these muscles, fat free Cross Sectional Area (CSA) and fat CSA were determined. CSA of the lumbar erector spinae (LES = longissimus thoracis + iliocostalis lumborum) was calculated by subtracting MF CSA from PA CSA. Mean muscle CSA of the left and right sides was calculated at each level. To normalize the data for interpersonal comparison, the mean CSA was divided by the CSA of the L3 vertebral body (mCSA = normalized fat-free muscle CSA; fCSA = normalized fat CSA). Differences in CSA between the pain group and the pain free group were examined using a General Linear Model (GLM). Three levels were examined to investigate the possible role of the level of operation.
In lumbar discectomy patients with pain, the mCSA of the MF was significantly smaller than in pain-free subjects (p = 0.009) independently of the level. The mCSA of the LES was significantly smaller in pain patients, but only on the L3 slice (p = 0.018). No significant difference in mCSA of the PS was found between pain patients and pain-free patients (p = 0.462). The fCSA of the MF (p = 0.186) and of the LES (p = 0.256) were not significantly different between both populations. However, the fCSA of the PS was significantly larger in pain patients than in pain-free patients. (p = 0.012).
The level of operation was never a significant factor.
CT comparison of MF, LES and PS muscle condition between lumbar discectomy patients without pain and patients with protracted postoperative pain showed a smaller fat-free muscle CSA of the MF at all levels examined, a smaller fat- free muscle CSA of the LES at the L3 level, and more fat in the PS in patients with pain. The level of operation was not found to be of importance. The present results suggest a general lumbar muscle dysfunction in the pain group, in particular of the deep stabilizing muscle system.
PMCID: PMC3079706  PMID: 21453531
7.  Differentiation between deep and superficial fibers of the lumbar multifidus by magnetic resonance imaging 
European Spine Journal  2009;19(1):122-128.
The purpose of this study was to investigate the differentiation in muscle tissue characteristics and recruitment between the deep and superficial multifidus muscle by magnetic resonance imaging. The multifidus is a very complex muscle in which a superficial and deep component can be differentiated from an anatomical, biomechanical, histological and neuromotorial point of view. To date, the histological evidence is limited to low back pain patients undergoing surgery and cadavers. The multifidus muscles of 15 healthy subjects were investigated with muscle functional MRI. Images were taken under three different conditions: (1) rest, (2) activity without pain and (3) activity after experimentally induced low back muscle pain. The T2 relaxation time in rest and the shift in T2 relaxation time after activity were compared for the deep and superficial samples of the multifidus. At rest, the T2 relaxation time of the deep portion was significantly higher compared to the superficial portion. Following exercise, there was no significant difference in shift in T2 relaxation time between the deep and superficial portions, and in the pain or in the non-pain condition. In conclusion, this study demonstrates a higher T2 relaxation time in the deep portion, which supports the current assumption that the deep multifidus has a higher percentage of slow twitch fibers compared to the superficial multifidus. No differential recruitment has been found following trunk extension with and without pain induction. For further research, it would be interesting to investigate a clinical LBP population, using this non-invasive muscle functional MRI approach.
PMCID: PMC2899729  PMID: 19777271
Multifidus muscle; Deep and superficial multifidus; Muscle functional magnetic resonance imaging; Muscle fiber type
8.  Effects of back posture education on elementary schoolchildren’s back function 
European Spine Journal  2006;16(6):829-839.
The possible effects of back education on children’s back function were never evaluated. Therefore, main aim of the present study was to evaluate the effects of back education in elementary schoolchildren on back function parameters. Since the reliability of back function measurement in children is poorly defined, another objective was to test the selected instruments for reliability in 8–11-year olds. The multi-factorial intervention lasting two school-years consisted of a back education program and the stimulation of postural dynamism in the class. Trunk muscle endurance, leg muscle capacity and spinal curvature were evaluated in a pre-post design including 41 children who received the back education program (mean age at post-test: 11.2 ± 0.9 years) and 28 controls (mean age at post-test: 11.4 ± 0.6 years). Besides, test–retest reliability with a 1-week interval was investigated in a separate sample. Therefore, 47 children (mean age: 10.1 ± 0.5 years) were tested for reliability of trunk muscle endurance and 40 children (mean age: 10.2 ± 0.7 years) for the assessment of spinal curvatures. Reliability of endurance testing was very good to good for the trunk flexors (ICC = 0.82) and trunk extensors (ICC = 0.63). The assessment of the thoracic (ICC = 0.69) and the lumbar curvature (ICC = 0.52) in seating position showed good to acceptable reliability. Low ICCs were found for the assessment of the thoracic (ICC = 0.39) and the lumbar curvature (ICC = 0.37) in stance. The effects of 2 year back education showed an increase in trunk flexor endurance in the intervention group compared to a decrease in the controls and a trend towards significance for a higher increase in trunk extensor endurance in the intervention group. For leg muscle capacity and spinal curvature no intervention effects were found. The small samples recommend cautious interpretation of intervention effects. However, the present study’s findings favor the implementation of back education with focus on postural dynamism in the class as an integral part of the elementary school curriculum in the scope of optimizing spinal loading through the school environment.
PMCID: PMC2200723  PMID: 16944227
Back education program; Prevention; Schoolchildren; Back function
9.  Electromyographic activity of trunk and hip muscles during stabilization exercises in four-point kneeling in healthy volunteers 
European Spine Journal  2006;16(5):711-718.
Stabilization exercises are intended to optimize function of the muscles that are believed to govern trunk stability. Debate exists whether certain muscles are more important than others in optimally performing these exercises. Thirty healthy volunteers were asked to perform three frequently prescribed stabilization exercises in four-point kneeling. The electromyographic activity of different trunk and hip muscles was evaluated. Average amplitudes obtained during the exercises were normalized to the amplitude in maximal voluntary contraction (% MVIC). During all three exercises, the highest relative muscle activity levels (> 20% MVIC) were consistently found in the ipsilateral lumbar multifidus and gluteus maximus. During both the single leg extension (exercise 1) and the leg and arm extension exercise (exercise 2) the contralateral internal oblique and ipsilateral external oblique reached high levels (> 20%MVIC). During exercise 2 there were also high relative activity levels of the ipsilateral lumbar part and the contralateral thoracic part of the iliocostalis lumborum and the contralateral lumbar multifidus. During the leg and arm extension exercise with contralateral hip flexion (exercise 3) there were high relative muscle activity levels of all back muscles, except for the latissimus dorsi muscle. The lowest relative muscle activity levels (< 10% MVIC) were found in the rectus abdominis and the ipsilateral internal oblique during all exercises, and in the contralateral gluteus maximus during exercises 1 and 2. The results of this study show that in exercises in four-point kneeling performed by healthy subjects, hip and trunk muscles seem to work together in a harmonious way. This shows that when relative activity of muscles is measured, both “global and local” muscles function together in order to stabilize the spine.
PMCID: PMC2213547  PMID: 16896840
Stabilization exercise; Trunk and hip muscles; Electromyography
10.  Comparison of postural control in unilateral stance between healthy controls and lumbar discectomy patients with and without pain 
European Spine Journal  2005;15(4):423-432.
Main problem: Previous studies have demonstrated that sciatica patients have poorer postural control than healthy controls and that postural control remains unchanged 3 months after lumbar discectomy in sciatica patients. The aims of the current study were to investigate whether static balance control recovers in pain-free discectomy patients long-term after lumbar discectomy. Next is to determine whether static balance responses of asymptomatic and symptomatic lumbar discectomy patients differed from each other and from healthy controls. In addition, the influence of the extent of disc resection (unilateral/bilateral removal) and the side of operation on static balance control were investigated. Methods: Fifteen pain-free lumbar discectomy patients, 23 lumbar discectomy patients with residual pain and 72 controls performed unilateral stance tasks with eyes open and eyes closed on a force plate were taken up for the investigation. Three repetitions of a 10 s unilateral stance test were performed on each leg. Postural sway was determined. Patients were divided into three age groups. Results: In the eyes open condition, there was no significant difference between postural sway of pain-free lumbar discectomy patients and controls (P=0.68), whereas balance of patients with pain was significantly worse than in controls (P=0.003). In the eyes closed condition, the sway in both groups of lumbar discectomy patients was significantly worse than in controls (pain-free P=0.009/painful P<0.001). No significant differences were found in postural sway between patients with unilateral and bilateral disc resection. In unilateral stance on the leg of the operated side, centre of gravity sway was not significantly different in the eyes open condition compared to the eyes closed condition, whereas in stance on the leg of the non-operated side, postural sway was significantly lower in the eyes open condition compared to the eyes closed condition. In both conditions, postural sway in the age group of 50–65 years was significantly higher than in the age groups of 30–39 years (eyes open P=0.005; eyes closed P<0.001) and 40–49 years (eyes open P=0.002; eyes closed P=0.006). There was no significant difference between the age group of 30–39 years and the age group of 40–49 years (P=0.51). Conclusion: As for long-term following lumbar discectomy, there is no complete recovery of postural control. Patients seem to develop visual compensation mechanisms for underlying sensory–motor deficits, which are, however, sufficient in case of pain relief only. Further study is needed to determine the cause of the balance disturbances in lumbar discectomy patients.
PMCID: PMC3489320  PMID: 16133081
Postural control; Unilateral stance; Lumbar discectomy; Visual compensation
11.  Trunk muscle activity in healthy subjects during bridging stabilization exercises 
Trunk bridging exercises are often used as therapeutic exercises for lumbopelvic stabilization. These exercises focus on the retraining of muscle coordination patterns in which optimal ratios between local segmental stabilizing and global torque producing muscle activity are assumed to be essential. However, a description of such ratios is lacking. The purpose of this study was to investigate both relative (as a percentage of maximal voluntary isometric contraction) muscle activity levels and ratios of local to global muscle activity, during bridging stabilization exercises.
Thirty healthy university students (15 men, 15 women) with a mean age of 19.6 year volunteered to perform 3 bridging exercises (single bridging, ball bridge and unilateral bridging). The surface electromyographic activity of different trunk muscles was evaluated on both sides.
During all bridging exercises, the ratio of the internal oblique to the rectus abdominis was very high due to minimal relative activity of the rectus abdominis. In general, the ratio of the internal/external abdominal oblique activity was about 1. However, during the unilateral bridging exercise, the ipsilateral internal/external abdominal oblique activity ratio was 2.79 as a consequence of the significant higher relative activity of the internal oblique compared to the external oblique. The relative muscle activity and the ratios of the back muscles demonstrated similar activity levels for all back muscles, resulting in ratios about 1.
Both the minimal relative activity of the rectus abdominis and the high internal oblique to the rectus abdominis activity ratio reported in the present study are in accordance with results of other trunk stabilization exercises. The relative muscle activity and the ratio of the abdominal obliques seem to alter depending on the task and the presumable need for stability. The findings concerning the relative muscle activity and the ratios of the back muscles support the assumption that during these bridging exercises, all back muscles contribute in a similar way to control spine positions and movements in a healthy population.
PMCID: PMC1599724  PMID: 16987410
12.  Isokinetic Scapular Muscle Performance in Overhead Athletes With and Without Impingement Symptoms 
Journal of Athletic Training  2005;40(2):104-110.
Context: Overhead activities such as throwing, tennis, or volleyball place athletes at considerable risk for overuse injuries. A relationship between scapulothoracic muscle imbalance and shoulder pain has been suggested.
Objective: To compare the isokinetic muscle performance of the scapular muscles between overhead athletes with impingement symptoms and uninjured overhead athletes and to identify strength deficits in the patient population.
Design: A repeated-measures analysis of variance with 1 within-subjects factor (side) and 1 between-subjects factor (group) was used to compare strength values and agonist:antagonist ratios across sides and across groups.
Setting: University laboratory.
Patients or Other Participants: Thirty overhead athletes with chronic shoulder impingement symptoms and 30 overhead athletes without a history of shoulder pain.
Intervention(s): A linear protraction-retraction movement in the scapular plane at 2 velocities (12.2 cm/s and 36.6 cm/s).
Main Outcome Measure(s): Isokinetic strength values and protraction:retraction ratios for both velocities.
Results: Overhead athletes with impingement symptoms showed decreased force output:body weight at both velocities in the protractor muscles on the injured side compared with the uninjured side (−13.7% at slow velocity, −15.5% at high velocity) and compared with the control group at high velocity (−20.7%). On both sides, the patient group had significantly lower protraction:retraction ratios than the control group, measured at slow velocity (nondominant = −11%, dominant = −13.7%).
Conclusions: Overhead athletes with impingement symptoms demonstrated strength deficits and muscular imbalance in the scapular muscles compared with uninjured athletes.
PMCID: PMC1150223  PMID: 15970956
shoulder; glenohumeral joint
13.  Biceps femoris and semitendinosus—teammates or competitors? New insights into hamstring injury mechanisms in male football players: a muscle functional MRI study 
British Journal of Sports Medicine  2014;48(22):1599-1606.
The hamstring injury mechanism was assessed by investigating the exercise-related metabolic activity characteristics of the hamstring muscles using a muscle functional MRI (mfMRI) protocol.
27 healthy male football players and 27 football players with a history of hamstring injuries (recovered and playing fully) underwent standardised mfMR Imaging. The mfMRI protocol consisted of a resting scan, a strenuous bilateral eccentric hamstring exercise and a postexercise scan. The exercise-related T2 increase or the signal intensity shift between both scans was used to detect differences in metabolic activation characteristics (1) between the different hamstring muscle bellies and (2) between the injury group and the control group.
A more symmetrical muscle recruitment pattern corresponding to a less economic hamstring muscle activation was demonstrated in the formerly injured group (p<0.05). The injured group also demonstrated a significantly lower strength endurance capacity during the eccentric hamstring exercise.
These findings suggest that the vulnerability of the hamstring muscles to football-related injury is related to the complexity and close coherence in the synergistic muscle recruitment of the biceps femoris and the semitendinosus. Discrete differences in neuromuscular coordination and activity distribution, with the biceps femoris partly having to compensate for the lack of endurance capacity of the semitendinosus, probably increase the hamstring injury risk.
PMCID: PMC4267196  PMID: 25388959
Hamstring; Injury; Football; Eccentric; MRI

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