THE EFFECTS OF PLYOMETRIC TYPE NEUROMUSCULAR TRAINING ON POSTURAL CONTROL PERFORMANCE OF MALE TEAM BASKETBALL PLAYERS ABBAS ASADI,1 EDUARDO SAEZ

DE

VILLARREAL,2

AND

HAMID ARAZI3

1

Department of Physical Education and Sport Sciences, Payame Noor University, Iran; 2Masterde Futbol Lab, Faculty of Sport, University Pablo de Olavide, Sevilla, Spain; and 3Department of Exercise Physiology, Faculty of Physical Education and Sport Sciences, University of Guilan, Rasht, Iran ABSTRACT

INTRODUCTION

Asadi, A, Saez de Villarreal, E, and Arazi, H. The effects of plyometric type neuromuscular training on postural control performance of male team basketball players. J Strength Cond Res 29(7): 1870–1875, 2015—Anterior cruciate ligament injuries are common in basketball athletes; common preventive programs for decreasing these injures may be enhancing postural control (PC) or balance with plyometric training. This study investigated the efficiency of plyometric training program within basketball practice to improve PC performance in young basketball players. Sixteen players were recruited and assigned either to a plyometric + basketball training group (PT) or basketball training group (BT). All players trained twice per week, but the PT + BT followed a 6-week plyometric program implemented within basketball practice, whereas the BT followed regular practice. The star excursion balance test (SEBT) at 8 directions (anterior, A; anteromedial, AM; anterolateral, AL; medial, M; lateral, L; posterior, P; posteromedial, PM; and posterolateral, PL) was measured before and after the 6-week period. The PT group induced significant improvement (p # 0.05) and small to moderate effect size in the SEBT (A = 0.95, AM = 0.62, AL = 0.61, M = 0.36, L = 0.47, P = 0.27, PM = 0.25, PL = 0.24). No significant improvements were found in the BT group. Also, there were significant differences between groups in all directions except PM and PL. An integrated plyometric program within the regular basketball practice can lead to significant improvements in SEBT and consequently PC. It can be recommended that strength and conditioning professionals use PT to enhance the athletes’ joint awareness and PC to reduce possible future injuries in the lower extremity.

KEY WORDS equilibrium, stretch-shortening cycle Address correspondence to Abbas Asadi, [email protected]. 29(7)/1870–1875 Journal of Strength and Conditioning Research Ó 2015 National Strength and Conditioning Association

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nterior cruciate ligament (ACL) injuries are common in basketball athletes (3). The reported incidence of ACL injury is as high as 1.6 per 1,000 player-hours for elite players in team matches (27), and the overall annual incidence of ACL injury is about 38,000 cases in the United States (33). Regardless of recent advances in the treatment of ACL injury, osteoarthritis of the knee occurs 10 times more in ACL-injured knees (10). Therefore, prevention is a key component in reducing the impact of ACL injury. Lack of postural control (PC) of the lower extremity is a key impairment after ACL injury. Poor PC is associated with injury or falls in many athletes and consequently is considered to be a critical component of common motor skills (7,11,22). Postural control is generally defined as the ability to maintain the body’s center of gravity within its base of support and can be categorized by either static or dynamic balance (7,11). The star excursion balance test (SEBT) has been described as a test of dynamic PC because it challenges an individual’s ability to maintain a stable base of support while performing the reach movement (13). Thus, the SEBT may provide an effective noninstrumented and clinically applicable test for use in assessing lower extremity balance, neuromuscular control, and PC. The SEBT was recently demonstrated to have some injury predictive value. Plisky et al. (30) reported that healthy boy and girl high school basketball athletes with limb differences in SEBT performance were 2.5 times more likely to sustain lower extremity injuries during the season. Furthermore, Plisky et al. (30) have provided initial evidence to suggest that deficits in SEBT performance in healthy basketball players may be associated with future injury. Improving balance or PC with training in athletes has positive effects with reducing injury. Several different preventive programs have been attempted (14,26,31), and each of these is based on different design concepts and emphasizes different components of preventive exercise, including plyometrics, strengthening, balancing, endurance, and stability. However, the overall effectiveness of preventive exercise

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Journal of Strength and Conditioning Research with respect to enhancing neuromuscular control and preventing ACL injuries in athletes can be different (16). It has been reported that plyometric training (PT) is an effective training modality for improving joint awareness, balance, and neuromuscular properties that used by strength and conditioning professional at preseason and in-season of training schedule for athletes (1). Plyometrics is a specialized, high-intensity training technique that enables an athlete’s muscles to deliver as much strength as possible in the shortest period so that power development can take place (2,4). Plyometrics make use of the stretch-shortening cycle, which uses the energy stored during the eccentric loading phase and stimulation of the muscle spindles to facilitate maximum power production during the concentric phase of movement (2,4,23,24). Although PT can be an effective method of training for enhancing muscular strength, speed, agility, and power (1,2,4,23,24), the exact mechanisms by which PT may decrease knee injury risk and increase PC in team basketball players are poorly understood. Nevertheless, no study has focused on the analysis of a specific PT program implemented preseason to enhance the performance of PC in basketball players. Therefore, the aim of this study was to examine the effects of 6-week plyometric type neuromuscular training on PC (SEBT) in basketball team players. We thus hypothesized that those amateur basketball players who supplemented their normal preseason basketball training with a 6-week program of biweekly plyometric exercises would enhance their PC and would be an effective training mode to decrease future lower extremity injury rates with increasing joint awareness and PC.

METHODS Experimental Approach to the Problem

This study was designed to assess the effects of 6 weeks of biweekly (12 sessions) PT preseason on PC (SEBT) performance of basketball amateur players between October and December. To achieve this, the participants were randomly allocated to undergo an additional program of plyometric type neuromuscular training or only receive usual basketball training. All the tests were carried out before (baseline test) and after (posttest) the training period. These included (a) anthropometric measures, (b) PC assessment (SEBT). After the initial measurements, a team of amateur players (N = 16) was randomly allocated to either the control group (standard preseason technical and tactical basketball training) (BT; n = 8) or experimental group that received the additional plyometric type neuromuscular training (PT; n = 8). During each training session, the participants were instructed in proper execution of all the exercises, and all sessions were supervised. The participants undertook the plyometric exercises between 18.00 and 19.00 hours (in a weight training facility) and the basketball training (in a basket synthetic court) from 19:00 to 21:00 hours. The participants were also instructed to avoid

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any strenuous physical activity and to maintain their usual dietary habits for the duration of the study. Subjects

The procedures were approved by the Institutional Ethics Review Committee of the Payame Noor University in accordance with the current national and international laws and regulations governing the use of human subjects (Declaration of Helsinki II). Before participating in the study, the subjects were fully informed about the protocol, and a written informed consent was obtained from each subject before testing. The subjects were free to withdraw from the study without penalty at any time. A questionnaire regarding medical history, age, height, body mass, training characteristics, injury history, team basketball experience, and performance level was completed before participation. An initial examination by the team physician focused on orthopedic and other conditions that might preclude resistance and highintensity training, and all the participants were found to be in good health. No history of ACL injury and no history of any lower extremity injury during the preceding 6 months were found. The subjects, 16 national-level male basketball players, were randomly divided into the PT group (age, 20.1 6 0.8 years; height, 185.1 6 8.6 cm; body mass, 76.4 6 5.6 kg; body fat, 12.4 6 3.2%; mean basketball experience, 8.5 6 4.1 years) and BT group (age, 20.5 6 0.3 years; height, 187.6 6 4.2 cm; body mass, 78.2 6 3.2 kg; body fat, 13.1 6 2.2%; mean basketball experience, 8.2 6 3.3 years); these 2 groups were wellmatched in terms of their initial characteristics. Testing Procedures

The participants were habituated with the test procedures before the measurements were taken. One week before the initiation of training program, all participants were recruited to laboratory for the measurement of weight and stature. During this session, the participants were familiarized with PC testing and PT program. In addition, several warm-up sets were recorded before the PC by SEBT tests. All the tests were conducted within a single day for each athlete, and the time of testing for baseline and posttesting (afternoon) was held consistent for individual athletes. Before the tests, the participants carried out a standardized warm-up consisting of 10 minutes submaximal running followed by light stretching and a specific warm-up of SEBT as familiarization trials with the assessment exercises. Each subject performed 4 practice trials in each of the 8 directions for each leg to become familiar with the task. Additionally, care was taken to allow sufficient rest between all the tests to limit the effects of fatigue on subsequent tests. Postural Control Assessment. In this study, star excursion balance test (SEBT) (Exercise Gymnasium at the Payame Noor University) was used for the PC assessment because a large number of studies reported the efficiency of SEBT to assess PC (13,15). To minimize the potential for a learning effect (13), participants were provided initial SEBT VOLUME 29 | NUMBER 7 | JULY 2015 |

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PT and PC Performance

TABLE 1. The plyometric and basketball training for both the experimental and control groups.* Group Intervention PT

Experimental group (PT + BT)

Control group (BT)

DJ, squat DJ, and DJ to standing long jump; 3 3 20, 45-cm box Dribbling, passing, and receiving exercises, shot and penalty exercise, team work (technical exercise)†

BT

Time 18.00–19.00

Dribbling, passing, and receiving exercises, shot and penalty exercise, team work (technical exercise)

19.00–21.00

*PT = plyometric training; BT = basketball training; DJ = depth jump. †Different skills and exercises of basketball training that matched the time of each exercise for both the groups, and these exercises

go to coach request for improving basketball players.

instruction and practice (6 reaches in each direction) in the test session. The SEBT procedures were similar to those used in previous investigations (10,13). The anterolateral (AL), anterior (A), anteromedial (AM), medial (M), posteromedial (PM), posterior (P), posterolateral (PL), and lateral (L) reach directions were used in this study. While maintaining a single-leg stance, each participant was asked to maximally reach along the identified line with the contralateral limb and lightly touch the line with the distal part of the foot. All reach trials began with both feet in contact with the ground and with the stance leg appropriately positioned in relation to the center of the SEBT grid (4,8). The participants were instructed to keep their hands on their hips while performing this task. Failed test criteria included the following: (a) if the reach foot was placed in contact with the ground for support, (b) if the stance foot was moved or lifted, (c) if equilibrium was lost during any part of the reach or return phase, and (d) if the point of contact was to either side of the taped line. A total of 5 test reaches were performed in each

direction. Reach distance was quantified by measuring the distance (in centimeters) from the center of the crosshairs to the point of distal foot-ground contact marked in ink by the investigator. Performance of SEBT for each direction was represented by an average of the 3 best reach distances and normalized to leg length. A 1-minute rest was allowed between directions. The order of the reach direction was counterbalanced for all participants (13,15). Normalizing Star Excursion Balance Test Data. Participant’s legs were measured from the anterior superior iliac spine to the distal tip of the medial malleolus using a standard tape measure while participants lay supine. Leg length was used to normalize excursion distances by dividing the distance reached by leg length then multiplying by 100 (13). Training Procedures

The plyometric type neuromuscular training was adapted from previous interventional investigations that have reported reductions in lower extremity injury risk factors (8,38).

TABLE 2. Pre-to-post changes in SEBT performance for the experimental and control groups.* Experimental group (n = 8, PT + BT) Baseline (mean 6 SD) Anterior Anteromedial Anterolateral Medial Lateral Posterior Posteromedial Posterolateral

98.19 83.29 99.68 71.41 93.3 87.6 80.81 91.64

6 6 6 6 6 6 6 6

Post (mean 6 SD)

5.05 103.02 6 3.63†z 8.07 88.32 6 7.19†z 7.15 104.04 6 6.38†z 7.48 74.12 6 6.67†z 7.92 97.08 6 5.85†z 11.62 90.82 6 10.64†z 12.29 83.93 6 10.73† 10.41 94.17 6 10.61†

Control group (n = 8, BT)

% of Effect change size 4.91 6.03 4.37 3.79 4.05 3.67 3.86 2.76

0.95 0.62 0.61 0.36 0.47 0.27 0.25 0.24

Baseline (mean 6 SD) 96.86 88.57 97.57 79.81 91.14 86.63 82.69 92.43

6 6 6 6 6 6 6 6

5.65 9.42 4.37 11.32 6.68 10.66 9.4 7.29

Post (mean 6 SD) 97.54 88.54 97.71 79.43 90.71 86.62 83.27 91.95

6 6 6 6 6 6 6 6

4.97 8.61 5.61 11.45 6.5 9.72 10.73 7.87

% of Effect change size 0.7 20.03 0.14 20.47 20.47 20.01 0.7 20.51

0.10 0.003 0.03 0.03 0.06 0.01 0.06 0.06

*SEBT = star excursion balance test; PT = plyometric training; BT = basketball training. †Significant differences between baseline and posttraining values (p # 0.05). zSignificant differences between the experimental and control group (p # 0.05).

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RESULTS

Figure 1. Effect size for the experimental and control groups.

Plyometric training took place 2 d$wk21 (Monday and Thursday) for the PT group during 6 weeks of the intervention (12 sessions) immediately before normal basketball training (Table 1). Each training session lasted 50 minutes, with 10 minutes of standard warm-up (5 minutes of submaximal running at 9 km$h21, stretching exercises for 5 minutes, and 2 submaximal exercises of jump [20 vertical jump, 10 long jumps], 35 minutes of specific PT, and 5 minutes of cooldown including stretching exercises). The training program employed were depth jump, squat depth jump, and depth jump to standing long jump that consisted of 3 sets with 20 repetitions from 45-cm plyometric box. There were a 2 minutes and 72 hours of rest between sets and training sessions, respectively. All the training sessions were fully supervised, and training diaries were maintained for each participant. Subjects in PT group were instructed to perform exercises in each training session with maximal effort. No acute injuries occurred during the training sessions. All the participants were instructed to maintain their normal daily activities throughout the 6-week study, including participation in recreation sporting activities. However, no additional strength or other forms of training were permitted. Statistical Analyses

Descriptive statistics (mean 6 SD) for the outcome measures were calculated. Data normality was checked with ShapiroWilk test. The intraclass correlation coefficient (ICC) was used to determine the reliability of the measurements. To determine the effects of intervention on PC, a 2-way repeated measure was applied. When a significant F value was achieved, Bonferroni post hoc test was performed to locate the pairwise differences between the means. The level of significant was set at p # 0.05. The statistical tests were performed using the SPSS statistical package version 16 (Chicago, IL, USA). Moreover, effect sizes (ESs) were also calculated using Cohen’s d.

There were no significant differences between groups at pretest. After 6-week training period, the PT + BT group showed significant improvements in all directions (p = 0.001), whereas the BT group did not show any significant changes (p . 0.05). Compared with BT group, the PT + BT group indicated significant group by time interaction, which indicated significant differences between them in all directions, except PM and PL direction (A: F1.14 = 9.3, p = 0.008; AM: F1.14 = 6.06, p = 0.027; AL: F1.14 = 17.5, p = 0.001; M: F1.14 = 8.5, p = 0.011; L: F1.14 = 7.8, p = 0.014; P: F1.14 = 10, p = 0.007; PM: F1.14 = 3.2, p = 0.09; PL: F1.14 = 3.5, p = 0.08) (Table 2). With regard to ES, the magnitude of increases in PC performance was higher in A direction for PT + BT group (0.95) (Figure 1). The ICC for all direction were A = 0.88, AM = 0.91, AL = 0.88, M = 0.92, L = 0.90, P = 0.93, PM = 0.89, and PL = 0.91, respectively, indicating high reliability.

DISCUSSION The outcome of this experiment adds value to previous studies on different performance adaptations in basketball athletes through the use of PT approaches. Our findings illustrate that a 6-week PT approach results in an improvement in the SEBT in all directions. An improvement in the SEBT is likely the results of improved neuromuscular control (32). The individuals in the PT + BT group in the current study showed improvements in the SEBT when compared with nontrained control subjects. However, its effect on knee injury rate was not assessed in this study. The SEBT may have the potential to be a corollary outcome measure that can be used to compare the efficacy of programs that reduce injury rates (30). The possible mechanism(s) that influenced the SEBT performance could be muscle activation, neuromuscular properties, and proprioception, which have a strong relationship to the SEBT performance (1,13,30). Similar to the present study, 7 weeks of PT induced improvements in dynamic balance performance (25). Plyometrics are a dynamic form of resistance training involving a rapid stretch-shortening cycle and can involve both vertical and horizontal displacements of the center of gravity (17). Although specific landing and balance exercises were not included with the PT in the present study, the dynamic nature of the exercises would place a training stress on PC or equilibrium. Similarly, a number of different types of athletes without specific balance training programs exhibit VOLUME 29 | NUMBER 7 | JULY 2015 |

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PT and PC Performance better balance than the average population as a result of the dynamic nature of their sports (28,36). Because PT can provide a spectrum of balance challenges, specific balance or landing exercise may be necessary for sport athletes to increase their joint awareness. Plyometric training can significantly improve neuromuscular control by promoting anticipatory postural adjustments (12). The anticipatory postural adjustments have been shown in peripheral joints. During PT, repeated exposure to balance and stability challenges results in proactive or feedforward adjustments that would appropriate muscles before landing (21,29). Furthermore, the sensitivity of afferent feedback pathway can be improved with PT (5). Also, anticipatory postural adjustments or feedforward adjustments could contribute to injury prevention. For example, PT has been reported to reduce the incidence of ACL injury in players (34). Although, in this study, the above possible mechanisms were not acutely measured, previous studies reported these findings and it can be speculated. With regard to results of the current study, the PT + BT group improved significantly their SEBT performance in 6 weeks from 8 directions compared with BT group. These differences suggest that peripheral and central neural adaptations were induced by PT, resulting in improved joint position sense and detection of joint motion. Peripheral adaptations that may have occurred because of PT likely resulted from the repetitive stimulation of the articular mechanoreceptors near the end range of motion in the knee during these exercises (9). In addition, rapid length and tension changes placed on the tendomuscular structures during eccentric loading may have facilitated adaptations to muscle spindles and Golgi tendon organs (GTOs). Several authors agree that desensitizing the GTO heightens the stretch sensitivity of the muscle spindles to length change (17,20,35). Heightening the sensitivity of the muscle spindle system may increase their afferent contributions to the central nervous system with regard to joint position. These adaptations may also be responsible for the enhanced SEBT performance demonstrated by these athletes. Central adaptations resulting from PT may also improve SEBT. The novelty of this task required preparatory muscle activation in anticipation and involuntary muscle activity for concentric force production. It has been reported that joint position sense is significantly improved when muscles are stimulated; therefore, plyometric activity may have enhanced conscious awareness of joint position, resulting in improvements in SEBT performance. However, several authors have suggested that joint position sense can be enhanced with training (6,19), and the results of this study confirm these hypotheses. Kinesthesia is another component of sensory information believed to be enhanced through the use of plyometric activities (18,37). Improvements in kinesthesia may also be related to desensitization of the GTOs and heightened sensitivity of the muscle spindles (18,37). Although this mechanism is theoretical, the results of this study suggest that

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possible adaptations do occur. In this study, acutely kinesthesia and possible mechanisms by central and peripheral adaptation were not measured, whereas previous investigations confirmed these mechanisms and this is guess and speculation. In this study, PT coupled with BT could improve SEBT measures, and then, athletes could be evaluated for SEBT composite reach before competition. The SEBT may be a sufficiently sensitive tool for trained athletes that can be used before competition to assess neuromuscular factors. The SEBT has been examined to determine the correlation between ACL injuries with the lack of PC. Therefore, the positive effect of PT and increasing SEBT score can be a noninvasive and cheap tool for screening the athletes’ balance and PC and preventing future injuries in lower extremity.

PRACTICAL APPLICATIONS This study suggests that if training programs are designed and implemented correctly, PT would provide a positive stimulus to enhance SEBT performance in basketball players. The results also suggest that the SEBT may be sensitive to determine PC level in basketball players because the basketball players who used PT and BT showed significantly greater than basketball players who used only BT in reach direction and consequently PC. The group differences in reach performance suggest that the SEBT may be sensitive to training and could be a useful tool for determining the relative effectiveness of an intervention or training program designed to improve PC and resulting decrease in future injury in lower extremity. It can be recommended that coaches and strength and conditioning professionals use PT in preparation phase (preseason) to enhance the athlete’s joint awareness and PC and consequently possible injury prevent in lower extremity.

ACKNOWLEDGMENTS The authors are grateful to the participants of this study for having performed maximal efforts until volitional fatigue. The authors have no professional relationships with companies or manufacturers that might benefit from the results of this study. There is no financial support for this project. No funds were received for this study from National Institutes of Health, Welcome Trust, University, or others. The results of this study do not constitute endorsement of any product by the authors or the National Strength and Conditioning Association.

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The Effects of Plyometric Type Neuromuscular Training on Postural Control Performance of Male Team Basketball Players.

Anterior cruciate ligament injuries are common in basketball athletes; common preventive programs for decreasing these injures may be enhancing postur...
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