What does the lack of NHE compliance mean for number of hamstring injuries prevented? A look at the REAIM framework

So I am currently sat on a plane heading off on holiday and am doing some reflection of the season that has just gone. I am also reading up on all of the literature which was highlighted by everyone from the Football Medicine Conference out in Barcelona, which I unfortunately couldn’t attend. I just wanted to discuss the piece that was written by James O’Brien and colleagues in the Aspetar Journal of Sports Medicine.

As a Physiotherapist who has an interest in, and job role directly relating to the development of injury prevention programs I found this article really interesting reading. The RE-AIM framework as described below is one that I have found particularly interesting when related to the Nordic Hamstring Exercise (a topic that I am very interested in, in case you hadn’t already realised from the previous topics!!). So this will be the theme of the discussion as it progresses, and I will try and use the appropriate numbers based upon the research.


Reach- People have to know about it

Effectiveness- The program needs to work

Adoption- People have to decide to use it

Implementation- People have to use it correctly

Maintenance- People need to continue to use it

 Taken from O’Brien et al. (2018).

 So, if we then take the NHE figures from the study of Bahr, Thorborg & Ekstrand (2015) who looked at the implementation of a NHE protocol within elite football settings we can understand the true impact of the exercise within injury prevention practice.


Findings from NHE Research

% Hamstring injuries prevented


59% effectiveness in Systematic Review



88% reach



17% adoption


I 65% fully compliant


M 35% maintain it



I have taken a majority of these figures from Bahr et al. (2015) in order to devise the figure of 2% hamstring injuries prevented through current adoption of the Nordic Hamstring Exercise protocol. In order to come up with the compliance figures I have done calculations such as 17% adoption of the program, but only 65% of these 17% have demonstrated full compliance.

When starting out this blog piece I really didn’t expect to find such a low figure of hamstring injuries reduced by the Nordic Hamstring Exercise when using the framework. We all know the headline figure of 59% reduction of injuries, and also the work of Ekstrand et al (2016) who suggest a 4% increase in training-related hamstring injury burden. Until this time I probably hadn’t realised just how much of this may be down to non-compliance with the set protocol. Having said this though, as a therapist I would also be classed as non-compliant with the original protocol requiring up to 100 repetitions per week. Therefore I again refer people to the work of Joel Presland et al. (2018) who recently highlighted that low repetitions of the NHE may be a sufficient stimulus to maintain and develop the required physiological change which are deemed to reduce the risk of hamstring injury in our athletes. The key appears to be maintaining a supramaximal element to the exercise, as opposed to maybe just volume of repetitions. It would be great if we could look to analyse the reach of Joel’s work and if this is low, then spread the word that it is what we prescribe to our athletes that might help ease the curse of the hamstring injury, rather that just the volume we prescribe. Hopefully this in turn would increase compliance and this then filters down the “RE-AIM” chain to improve our changes of preventing the most common injury in football.


Bahr, R., Thorborg, K. & Ekstrand, J. (2015). Evidence-based hamstring injury prevention is not adopted by the majority of Champions League or Norwegian Premier League football teams: the Nordic Hamstring survey. British Journal of Sports Medicine, 49, 1466-1471.

Ekstrand, J., Walden, M. & Hagglund, M. (2016). Hamstring injuries have increased by 4% annually in men’s professional football, since 2001: a 13-year longitudinal analysis of the UEFA Elite Club injury study. British Journal of Sports Medicine, 50, 731-737.

O’Brien et al. (2018). The Rocky Road from RCT to Real World Injury Prevention. Aspetar Sports Medicine Journal, 7(16), 70-76.

Presland et al. (2018). The Effect of Nordic Hamstring Exercise training volume on Biceps Femoris Long Head Architectural Adaptations. Scandinavian Journal of Medicine & Science in Sports.

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