MRS MATTEO BONATO (Orcid ID : 0000-0002-5589-7957)

Article type : Original Article

Accepted Article
Title. Neuromuscular training reduces lower limb injuries in elite female basketball players. A cluster

randomized controlled trial.

Running head. Neuromuscular training for female basketball players

Authors:

Matteo Bonato1, Roberto Benis1, Antonio La Torre1

Institutional Affiliation:

1. Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy

Corresponding Author:

Matteo Bonato Ph.D.

Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy

Via Giuseppe Colombo 71, 20133 Milano, Italy

Phone: +39-02-5031 4658

Fax: +39-02-5031 463

E-Mail: matteo.bonato@unimi.it

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/sms.13034

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 Abstract

The study was a two-armed, parallel group, cluster randomized controlled trial in which 15 teams
Accepted Article
(160 players) were assigned to either an experimental group (EG, 8 teams n=86), which warmed-up

with bodyweight neuromuscular exercises, or a control group (CG, 7 teams, n=74) that performed

standard tactical-technical exercises before training. All injuries during the 2015-2016 regular season

were counted. Epidemiologic incidence proportion and incidence rate, were also calculated. Counter

movement jump (CMJ) and composite Y-Excursion balance test (YBT) were used to assess lower

limb strength, and postural control. A total of 111 injuries were recorded. Chi-square test detected

statistically significant differences between EG and CG (32 vs 79, p=0.006). Significant differences in

the injuries sustained in the EG (21 vs 11, p=0.024) and CG (52 vs 27, p=0.0001) during training and

matches respectively were observed. Significant differences in post-intervention injuries were

observed between in EG and CG during training (21 vs 52, p<0.0001) and matches (11 vs 27,

p=0.006). Significant differences in epidemiologic incidence (0.37 vs 1.07, p=0.023), and incidence

rate (1.66 vs 4.69, p=0.012) between the EG and the CG were found. Significant improvement in

CMJ (+9.4%, p<0.0001; d=1.2), and composite YBT (right: +4.4%, p=0.001, d=1.0; left: +3.0%,

p=0.003; d=0.8) for the EG was noted. Significant differences in post-intervention CMJ (+5.9%,

p=0.004) and composite YBT scores (right, +3.7%, p=0.012; left, +2.3%, p=0.007) between the EG

and the CG were observed. Including bodyweight neuromuscular training into warm-up routines

reduced the incidence of serious lower limb injuries in elite female basketball players.

Key-word. Sports Injury, Injury prevention, Postural Control, Epidemiology, Basketball

INTRODUCTION

Basketball has become one of the world’s most popular physical activities: over 450 million

players from licensed to amateur, play basketball worldwide1. But as the number of players has

increased, so too has the number of injuries and particularly those involving the lower extremities.

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 Drakos et al.2 reported injuries patterns in elite athletes competing in the National Basketball

Association (NBA). They found that over 17 championship seasons 62.4% of orthopaedic injuries
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involved the lower limbs2. Moreover, injury rates are higher among female players than their male

counterparts, with women reported to sustain 60% more injuries to the knee and ankle than men in

professional basketball3. The higher injury rates may be ascribed to sex-related neuromuscular

imbalances, including ligament and quadriceps imbalance and leg dominance4.

Several warm-up programs including neuromuscular training have been shown to reduce the

incidence of lower extremity injuries in female athletes5-8. Neuromuscular training programs designed

to improve joint position sense, enhance joint stability, and develop protective joint reflexes, and

ultimately prevent lower limb injuries have been variously investigated5, 9. Studies on interventions

that target neuromuscular control have demonstrated improvements in dynamic lower extremity

alignment upon landing from a jump, shock attenuation of peak landing forces, muscle recruitment

patterns, and postural stability or balance gained through plyometric, strengthening, balancing,

endurance, and stability exercises5,10, 11. In a recent systematic review and meta-analysis, Taylor et

al.12 clearly showed that general injury prevention programs can reduce the risk of general lower

extremity injuries and ankle sprains in basketball players. Furthermore, Hübscher et al.13 published a

systematic review on neuromuscular training programs for sports injury prevention and suggested that

multi-intervention programs may reduce lower limb, acute knee and ankle injuries. Regarding female

athletes Sugimoto et al.14 first reported the prophylactic effects of neuromuscular training on the

overall anterior cruciate ligament (ACL) injury risk. Reviewing 12 large-scale neuromuscular training

studies they observed that the relative risk reduction for non-contact ACL injury was 73.4% (95% CI

62.5% to 81.1%) and 43.8% (95% CI 28.9% to 55.5%) for overall ACL injuries, with confidence

intervals that do not encompass zero14. Authors interpreted these results assuming that female athletes

who performed a given neuromuscular training program have 73.4% less risk to suffer a non-contact

ACL injury compared with those who did not perform a neuromuscular training program14. Moreover,

they stated that 43.8% of overall ACL injury risk reduction can be obtained in female athletes who

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 perform neuromuscular training compared those who served in a control group14. However, the

practical application of these findings for many individuals, teams, and clubs may be limited by the
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need to purchase special equipment (e.g., balance boards) and to conduct training sessions in addition

to normal practice and competition.

A more practical solution would be to develop neuromuscular training programs that require

no additional equipment and to incorporate them into customary warm-up routines. A recent

systematic review by Herman et al.15 showed that the incidence of lower extremity injury in young,

amateur female athletes decreased after effective implementation of practical neuromuscular warm-up

strategies. In particular, authors identified five practical neuromuscular warm-up strategies: the FIFA

11+6, KIPP16, HarmoKnee17, AKP PTP18 and PEP9, 19 and concluded that incorporating stretching,

strengthening, and balance exercises, sport-specific drills, and landing techniques for more than 3

consecutive months are greatest practical approach for reducing lower limb injury rates15. Therefore, a

practical, cost-effective approach to injury prevention would be to implement a neuromuscular

training program that requires no additional equipment and can be easily integrated into warm-up

routines. To date, research mainly focused of female soccer players and no studies were conducted for

assessing the effectiveness of a neuromuscular training for reducing lower limb injuries in elite female

basketball players.

In a previous study, Benis et al.20 examined the effects of bodyweight neuromuscular training

on Y-Balance test (YBT) performance in elite female basketball players. They observed an

improvement in anterior, posteromedial, and posterolateral reaching direction and composite YBT

scores after 8 weeks of training, which suggested an improvement in postural stability as well. The

program included a sport-specific neuromuscular warm-up designed to optimize athletic performance

and prevent lower limb injuries20. Building on these findings, we developed a neuromuscular training

program that was called “Italian Basketball Injury Prevention Program” and carried out during the

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 2015-2016 elite female Italian basketball regular season. The aim of the present study was to

determine whether a neuromuscular training program included in routine warm-up could reduce the
Accepted Article
number of lower limb injuries in elite female basketball players during the regular season. Our

rationale was that neuromuscular training aimed at correcting deficits in postural control and improve

lower limb strength could optimize athletic performance and prevent lower limb injuries in these

athletes.

MATERIAL AND METHODS

Subjects

The study was a two armed, parallel group, cluster randomized controlled trial. Participants

were recruited by letter of invitation to players from all the 17 female elite basketball teams of the

premier Italian national league during summer training camps in August 2015. In this occasion two

teams declined to participate in the study. The study ran the entire regular season, which started in

September 2015 and ended in April 2016. Inclusion criteria were age ≥ 18 years, and practice 4 times

a week for ≥ 2 hours. Exclusion criteria were a history of lower extremity injury (e.g. ankle sprain,

knee sprain, ACL lesions) or surgery in the 6 months prior to testing and prior exposure to

neuromuscular training. A total of 160 players from the remaining 15 teams were deemed eligible.

Before baseline testing all clubs that agreed to participate were randomized into an intervention or

control group in a 1:1 ratio to either an experimental group (EG, n = 86; age 20 ± 2 years; body mass

62 ± 8 kg; height 1.72 ± 0.07 cm) or a control group (CG, n = 74; age 20 ± 1 years; body mass 60 ± 6

kg; height 1.70 ± 0.06 cm). A computer-generated list of random numbers was used. R.B. who

conducted the randomization did not take part to the intervention. The players in each group were

similar in age, height, and body mass, participated in an identical level of play, and were exposed to

similar basketball training and competition schedules. Data on medical history, age, height, body

mass, training characteristics, injury history, team basketball experience, and performance level were

collected at baseline. Height was measured to the nearest 1 cm and body mass to the nearest 0.5 kg.

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 Moreover, the players in both groups were evaluated with Lower Quarter Y-Balance test (YBT) and

Counter Movement Jump (CMJ) at baseline (PRE) and at the end (POST) of the regular season. Test-
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retest reliability and measurement error of the YBT and CMJ were analyzed by repeating the test at 2

sessions 1 week apart and then comparing the scores using interclass correlation coefficients (ICCs)

The study protocol was approved by the Institutional Ethics Review Committee of the Università

degli Studi di Milano (approved on 12/10/15, Prot. N. 54/15) and conducted in accordance with

current national and international laws and regulations governing the use of human subjects

(Declaration of Helsinki II). This trial was registered at the Australian New Zealand Clinical Trials

Registry (ACTRN12616001674426).

Assessment of injuries

For each team, the medical doctor was instructed to report injuries that occurred during a

scheduled match or training session, causing the player to be unable to fully take part in the next

match or training session. Type, location, and severity of each injury was assessed according to the

criteria proposed by Junge et al.21. A recordable acute injury was one that occurred during training or

match play, had sudden onset, and led to a player to being unable to participate fully in future training

or match play. A severe injury was one that caused absence of more than four weeks. Non-contact

injuries were defined if they occurred without contact with another player or object. We defined an

anterior cruciate ligament (ACL) injury as a first or recurrent partial or total rupture of the ligament

either in isolation or associated with concomitant injuries to the knee joint. If an ACL injury was

suspected or the diagnosis was unclear from the study therapist’s examination, the player was referred

to a study physician for further evaluation. A player was considered injured until the team medical

staff allowed return to full training and declared the player available for match selection. Injuries were

classified into eight categories: ankle sprain, muscle strain, knee sprain, overuse pain, ACL lesion, leg

contusion, back pain or other injuries. Injury severity was defined according to the number of days

that elapsed from the date of injury to the date a player was returned to full participation in team

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 training or availability for competition. Injuries were captured using an electronic-based method that

was the same for all the teams. These were submitted by email weekly to the research center and
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entered into a specifically designed database by one of the authors (M.B.), who was blind to group

allocation. In addition, coaches registered individual playing time (registered as minute of actual

participation for each player or other reason) and absences (due to an injury) for each training session

and match during the season on a computer based player attendance form that was the same for all the

teams and emailed the data monthly to one of the authors (M.B.). Participation in leisure time

activities was not recorded. Epidemiologic incidence proportion (%), and incidence rate (injury x

1000h of exposure) were calculated according to Knowles et al.22. The epidemiologic incidence

proportion refers to the average probability, across all athletes to be injured during a season (or

seasons) of participation and is calculated by the number of injured athletes in a season divided by the

number of athletes at risk at start of season. Incidence rates pertains to the time spent at a risk and is

calculated by the equation:

All injuries and athletes were included in the analysis.

Counter Movement Jump

The procedures were carried out as described by Maulder and Cronin23 in which three

Counter Movement Jump (CMJ) with both legs during the push-off phase, were performed on an

Optojump Next (Microgate, Bolzano, Italy). In this setup, the Optojump photoelectric cells consisted

of 2 parallel bars (1 receiver and 1 transmitter unit) that were placed approximately 1 m apart and

parallel to each other. The transmitter contains 32 light-emitting diodes positioned 3 mm above

ground level at 31.25 mm intervals. The Optojump bars were connected to a personal computer. Jump

height was measured using proprietary software (Optojump software; version 3.01.0001). The

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 Optojump system measured the flight time of CMJ with an accuracy of 1 millisecond (1kHz). Jump

height was estimated using the equation24:

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where h is jump height, g is gravitational acceleration (9.81 m·s-2) and tf is flight time. Before

testing, subjects performed 15 minutes of standardized warm-up consisting of 5 minutes of

submaximal running followed by a dynamic stretch routine comprising functional exercises: front to

back leg swing, side to side leg swing, lateral lunge (squat to flow), and sumo squat to stand.

Stretching was not allowed since it might have introduced confounding factors due to stretching one

side more vigorously than the other. After taking several submaximal jumps to familiarize themselves

with the jump movement, the subjects performed three trials of CMJ. From the standing position, the

subjects dropped into a squat position to a knee angle of ~90°, cued by a countdown of “1, 2, 3 and

jump” given on reaching the correct squat position and then jumped vertically. Take off was

monitored with no preliminary steps of movement during the eccentric phase. The hands were kept on

the hips during the CMJ. Both legs were used during the landing phase. Subjects were allowed 20

seconds’ recovery time between each trial. CMJ were executed starting from a standing position with

feet aligned parallel. CMJ not meeting these criteria were repeated. The best CMJ was recorded for

analysis. As inclusion criterion, only players which made a return in an official match at least 20 days

before the POST intervention testing were included in the analysis (EG, n = 80; CG, n = 66).

Lower quarter Y-Balance test

The Y-Balance Test (YBT) was carried out using a standardized testing protocol that has been

shown to be reliable25, 26. None of the subjects were known to have had prior exposure to YBT, which

might have interfered with the validity of the testing protocol. The subjects were fully familiarized

with the testing procedures. After watching a standard video demonstration, they were provided initial

YBT instructions and allowed six practice trials with six reaches in each direction 26. Assessment with

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 the YBT was performed using a Y-Balance Test kit comprising a stance platform to which three

pieces of PVC pipe are attached in the anterior (AA), posteromedial (PM), and posterolateral (PL)
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reach directions. The posterior pipes were positioned 135 degrees from the anterior pipe with 45

degrees between them. Each pipe was marked in 5-millimeter increments for measurement. The YBT

was performed with the distal aspect of the great toe centered at the junction of the Y. The subjects

had to reach with the opposite leg in the anterior, posteromedial, and posterolateral directions and

push a target (reach indicator) along the pipe that standardized the reach distance. The target remained

over the tape measure after completion of the test. The order of the tests was performed according to

the guidelines published in Plinsky et al.25: three trials were performed with the subjects standing on

the right foot while reaching with the left foot in the anterior direction, followed by three trials with

the subject standing on the left foot and reaching with the right foot in the anterior direction. The

procedure was repeated for the posteromedial and then the posterolateral reach directions. During the

trials, the reach foot was not allowed to touch the floor or gain balance from the reach indicator or

support pipe. If the subject was unable to perform the test according to the above criteria in six

attempts, she failed that direction, no data were collected, and another trial was attempted. Reach

distance was measured from the most distal aspect of the toes of the stance foot to the most distal

aspect of the reach foot in the anterior, posteromedial, and posterolateral directions. The YBT scores

were analyzed using the average of the last three trials for each reach direction for each lower

extremity, as well as the average of the total of reach directions (composite score). The YBT

composite score was calculated according to Plisky et al.26 by dividing the sum of the maximum reach

distance in the anterior, posteromedial, and posterolateral directions by 3 times the limb length (LL)

of the subject, then multiplied by 100: [(AA + PM + PL) / (LL * 3)] * 100. The maximum value

measured for each excursion direction was also analyzed, as well as the summed composite score of

the maximums for each lower extremity. In order to control for the effect of limb length between

subject, the YBT values were normalized to percent of average anatomical limb length (average of

right and left side). As inclusion criterion, only players which made a return in an official match at

least 20 days before the POST intervention testing were included in the analysis (EG, n = 80; CG, n =

66).

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 Neuromuscular training program

Table 1 illustrates the neuromuscular warm-up protocol which was developed from theory and
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findings from previous injury prevention research6-9, 11, 20. Each 30-min session consisted in 5 different

parts. The initial part consisted of running exercises at low speed with the ball. The running course for

each exercise included four basketball courts. The second part consisted of seven exercises of active

stretching. The third part consisted of four exercises focused on general strength. The fourth part

consisted of four sets of plyometric, balance and jumping exercising. The final part consisted of speed

running combined with basketball movements with sudden changes of direction. All strength and

conditioning coaches from all clubs in the intervention group were introduced and familiarized with

the warm-up program during a seminar in which they received theoretical and practical instructions in

how to teach the exercises as well as common biomechanical mistakes. Moreover, the principles of

progression in the exercise prescription was also described. When introducing the program to the

clubs, the main focus was to improve awareness and neuromuscular control during standing, running,

planting, cutting jumping and landing. Strength and conditioning coaches were encouraged to focus

on the quality of the movement and put emphasis on core stability, hip control and proper knee

alignment. Coaches were also instructed to give verbal and visual feedback on exercise technique.

Sessions took place 4 times a week before every training session during the warm-up immediately

before regular basketball training. The warm-up of CG consisted of light aerobic exercises, basketball

and team drills, and dynamic stretching of the major muscle groups before the regular practice

sessions. Athletes of both EG and CG were blinded them about the aim of the study, in order to avoid

the risk of contamination between the two groups. The strength and conditioning coaches of the EG

documented the execution of the warm-up program on the players’ attendance form for each training

session. Compliance to the warm-up program for both EG and CG was defined as the proportion of

sessions attended during the regular season. Players needed to complete 75% of the warm up to be

considered compliant. A.L.T, that was not blinded to the group allocation, made two unannounced

visits to each intervention team to monitor compliance and execution of the program. A.L.T. was

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 instructed to observed the beginning of the training session out sight of the on-field coach. After

having observed the execution of the warm-up program, A.L.T corrected any training errors.
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Statistical Analysis

Descriptive statistics (mean ± standard deviation [SD]) for the outcome measures were

calculated. The ICCs was used to establish intersession repeatability of all measures, where r < 0.50

was classified as weak, from 0.50 to 0.79 as moderate, and 0.80 as strong. The normality of the

distribution of the subjects’ characteristics at baseline were checked using the D’Agostino Pearson

test. Since all variables were normally distributed, differences between EG and CG were checked

using an unpaired Student’s t-tests. A chi-square test was used to compare the type and the location of

injuries occurred during the basketball regular season during training and matches, between EG and

CG. Furthermore, this test was applied for assessing differences between epidemiologic incidence

proportion, and incidence rate between EG and CG. Intra- and inter-group differences between EG

and CG for CMJ and YBT composite score for right and left limb were checked using two-way

analysis of variance with Bonferroni’s multiple comparisons test. The level of significance was set at

p<0.05. Statistical analysis was performed using GraphPad Prism version 6.00 for Mac OSX

(GraphPad Software, San Diego, CA, USA). As a measure of effect size, Cohen’s d (d) was

calculated: values of 0.2, 0.6, and above 0.8 were considered as small, medium, and large,

respectively27.

RESULTS

Un-paired t-tests showed that groups were equally matched, showing no significant

differences in age, body mass and height. The premier Italian national league started the 4th October

2015 and ended the 10th April 2016. During the regular season a total of 26 match and 120 training

sessions for each team were monitored. Un-paired t-test did not reveal significant differences between

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 the average playing time for each athlete between EG and CG (20.2±5.4 min vs 19.8±5.2 min,

p=0.635, d=0.1) respectively. Due to several practical aspects (e.g. trips, travels, recovery etc.) the EG
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performed the neuromuscular training program for 98 sessions (81%), which was similar to the

average number who participated to the conventional warm up (102, 85%). EG players’ compliance to

the neuromuscular training 78%, so each athlete was exposed to 46.8 hours of neuromuscular training.

Table 2 illustrates the type, location and statistical significance of injuries occurred during the

basketball regular season. A total of 111 injuries were recorded, 32 for the EG and 79 for CG

(p=0.006). Moreover, statistically significant differences were noted between EG and CG in knee

sprain (p=0.037) and ACL lesions (p=0.038). No statistically differences in ankle sprain (p=0.507),

muscle strain (p=0.581), overuse pain (p=0.145), back pain (p=0.225), leg contusion (p=0.688) and

other incidents (p=1.00) were detected.

The injuries that occurred during training and matches (Table 3) were analyzed separately.

Chi-square test did not reveal statistical differences when analyzing the single location separately for

type and location and for training and matches, except for leg contusion in the EG (0 vs 3, p=0.033).

Significant differences in the injuries sustained in the EG (21 vs 11, p=0.024) and CG (52 vs 27,

p=0.0001) sustained during training and matches were found respectively. Significant differences in

post-intervention injuries between in EG and CG during training (21 vs 52, p<0.0001) and matches

(11 vs 27, p=0.0005) were observed. Moreover, significant post-intervention differences between EG

and CG in ankle sprain (5 vs 11, p=0.004), knee sprain (2 vs 8, p=0.023), and ACL lesion (0 vs 4)

p=0.029) were detected. Regarding matches post-intervention differences between EG and CG in

ankle sprain (4 vs 11, p=0.027), and knee sprain (0 vs 4, p=0.029) were found. No significant post-

intervention differences in the other locations were detected.

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 Significant differences in the combination of match and training epidemiologic incidence

(0.37 vs 1.07, p=0.023), and incidence rate (1.66 vs 4.69, p=0.012), between the EG and the CG were
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found.

The ICCs (1,1) of CMJ and composite YBT were 0.91, 0.83 (right limb) and 0.82 (left limb)

respectively. At the end of the regular season, two-way analysis of variance with Bonferroni’s

multiple comparisons test showed significant increments over PRE CMJ in POST conditions

(29.9±3.1 cm vs. 32.7±3.6 cm, +9.4% p<0.0001, d=1.2), whereas no significant differences for the

CG (30.7±4.3 cm vs. 30.8±4.0 cm, +0.3%, p=0.999, d=0.1) were detected. Post-hoc inter-group

comparisons indicated that the EG and CG differed in POST CMJ performance (32.7±3.6 cm vs

30.8±4.0 cm, +5.9%, p=0.004, d=0.6, interaction p=0.0007). Two-way analysis of variance with

Bonferroni’s multiple comparisons test showed significant differences between PRE and POST

intervention composite YBT scores for the EG, but not the CG. For the EG, improvements of 4.4%

for the reaching right limb (85.0±6.2% vs. 88.8±7.4%, p=0.001, d=1.0) and 3% (85.4±6.0 vs.

89.0±7.0%, p=0.003; d=0.8) for the reaching left limb were noted, whereas no significant differences

were noted for reaching right limb (85.7±7.3 % vs. 85.6±7.0 %, p=0.999, d=0.1) or reaching left limb

(85.1±6.5 % vs. 85.8±6.9 cm, p=0.999, d=0.1).

Post-hoc inter-group comparisons showed that the EG and CG differ in YBT composite score

for the right (88.8.0±7.4 vs. 85.6±7.0%, +3.7%, p=0.012, interaction p=0.008) and left limb (88.0±7.0

vs. 85.8±6.9%, +2.3%, p=0.007, interaction p=0.02) respectively.

DISCUSSION

During the 8 months of injury surveillance, fewer lower limb injuries were recorded for the

EG than the CG. In addition, comparison of PRE- and POST-intervention CMJ and composite YBT

scores of both lower limbs showed significant improvement in the EG as compared with the CG.

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 Hamer3 observed that the injury literature on women’s basketball suffers from a broad range

of methodological shortcomings, including widely varying definitions on reportable injury, limited

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measures of exposure, different metrics of risk, and poor delineation of the population at risk, which

make it very difficult to obtain a clear picture of the risk elite female basketball players may be

exposed to during training and competition. In order to accurately interpret our injury data, we

followed the criteria proposed by Knowles et al.22, which define a reportable injury as an accident

event that necessitates at least 2 days of absence from participation. For the purposes of the present

study, the metric of risk included epidemiologic incidence proportion, and incidence rate. Published

evidence28-30 has demonstrated that female players are at a higher risk of injury, particularly to the

knee and ankle joints. According to the systematic review of Herman et al.15 we included a

neuromuscular training component in each session before usual basketball practice. Like the previous

study of Benis et al.20 we integrated the training program into the warm-up routine to ensure high

compliance with the exercises. Our choice was also in accordance with the systematic review of Ter

Stege et al.31 in which reported that short duration programs involving sessions up to 25 minutes

allowed compliance rates of more than 75%. This strategy decreased lower extremity injury incidence

like the studies of Hewett et al.32, Pasanen et al.7, Soligard et al.6, and Waldén et al.8, which observed

significant reductions of the incidence of serious knee injuries in female athletes. Hewett et al.32

reported that after neuromuscular training with a jump training program focused on landing

mechanics and lower extremity strength in female athletes involved in jumping sports, the incidence

of serious knee injuries was 2.4-3.6 times higher in the untrained group than in the trained group.

Moreover, Pasanen et al.7, reported that a neuromuscular training program focused on the

enhancement of players’ motor skills and body control was effective in reducing acute non-contact

injuries of lower limbs in female floorball players, with the injury incidence that was significant lower

in the intervention group (0.65, 95% confidence interval 0.37 to 1.13) relative to the control group

(2.08, confidence interval 1.58 to 2.72). In addition, Soligard et al.6, observed that a comprehensive

warm-up program for the improvement of strength, awareness, and neuromuscular control during

static and dynamic movements in female youth football was effective in reducing the risk of injuries

overall (0.68, 95% confidence interval 0.48 to 0.85), overuse injuries (0.47, 95% confidence interval

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 0.26 to 0.85) and severe injuries (0.55, 95% confidence interval 0.36 to 0.83) in the intervention

group. Furthermore, Waldén et al.8, demonstrated that a 15-minute neuromuscular warm-up program
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targeting core stability, balance and proper knee alignment carried out twice a week throughout the

season significantly reduced the rate of ACL injury in adolescent female football players (0.36, 95%

confidence interval 0.15 to 0.85). According to the systematic review of Ter Stege et al.31 the

participants’ attention was directed to perform a correct execution of technique and biomechanical

movements to better prepare them for multidirectional activities, to address neuromuscular

imbalances and to reduce the risk of serious ligament injuries31. During the 8 months of injury

surveillance in the regular season, significantly fewer lower limb injuries were recorded in the EG

than in the CG. These results indicate that neuromuscular training may help to reduce the risk of

lower limb injury in elite female basketball players. Moreover, neuromuscular training can also be

effective in training the muscles, connective tissues, and nervous system to harness the elasticity of

the stretch-shortening cycle and utilize the energy stored during the eccentric loading phase and

stimulation of muscle spindles to facilitate maximum power production during the concentric phase of

movement. Therefore, it is plausible that the lower injury incidence in the EG might also have been

due to increased dynamic stability and coordination of lower limb joints after neuromuscular training.

Our observation of more frequent injury during practice than games contrasts with the data from

Hamer (2005), who reviewed only studies investigating injury among young basketball players.

Neuromuscular training can have various different biomechanical effects, including decreased

landing forces and adduction-abduction moments, and increased hamstring-to-quadriceps ratio31. The

exercises selected for this neuromuscular training program were based on findings from previous

injury prevention programs9, 11, 20. We included bodyweight exercises, plyometric, and basketball-

specific exercises in the warm-up routine in order to improve lower limb strength and postural

control. These dynamic exercises targeted the rapid stretch-shortening cycle with vertical and

horizontal displacement of the center of gravity. Moreover, specific landing and bodyweight balance

exercises were included in order to increase training stress on postural control or equilibrium and to

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 promote anticipatory postural adjustment in the peripheral joints33. Building on observations by

Marigold and Patla34, we reasoned that exposing the subjects to balance and stability challenges could
Accepted Article
create the appropriate proactive or feed-forward adjustment that would activate muscles before

landing. According to this, Zebis et al.35 showed that a specific neuromuscular training program

increased pre-landing and landing activity electromyography for the medial hamstring muscles in the

intervention group, thereby decreasing the risk of dynamic valgus and suggesting a potentially

reduction of the risk for non-contact ACL injury. Indeed, anticipatory postural adjustment or feed-

forward adjustments have also been associated with reduced risk of ankle sprains in volleyball

players37. We integrated our neuromuscular training program in the warm-up routine before basketball

practice because it has been demonstrated that agility and plyometric exercises performed during the

first 20 minutes of team practice for 8 weeks can improve muscle strength, as measured on the

double-legged vertical jump, enhance biomechanical properties associated with ACL injury, and

lower the risk of injury37. In addition, we directed the subjects’ attention to correct execution of

technique and biomechanical movements to better prepare them for performing multidirectional

movements. Each aspect of the neuromuscular training program was guided by verbal feedback and

visual demonstration to improve execution of the biomechanical technique38.

Jump tests are a valid and reliable tool to measure lower limb strength. We observed

improvement in performance of the CMJ at post-training assessment in the EG. The rationale for

assessment with vertical jump tests was derived from a study by Hewett et al.32 who tested the effects

of neuromuscular training and reported that a 10% increase in jump height allowed for a significant

effect on knee stabilization and prevention of serious knee injury among female athletes. Moreover, it

has been reported that hamstring and quadriceps co-contraction may provide dynamic joint stability

and therefore protect the knee during sport-related tasks. Our results are shared by those of Lephart et

al.40 and Myer et al.41 who examined the effects of plyometric and basic resistance training and found

an improvement in leg muscle strength in female basketball players. In an earlier study, Hewett et al.5

reported a mean improvement of 9% in vertical jump height following 6 weeks of training in female

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 volleyball players. However, the training sessions lasted 90 minutes and the plyometric training was

not designed to serve as a warm-up routine. In a similar study conducted by Steffen et al.32 designed
Accepted Article
to reduce the risk of non-contact ACL injuries in female soccer players, the authors found no change

in CMJ height in the experimental group after 6 or 12 weeks of training and a decrease of

approximately 9% in CMJ height in the control group after 12 weeks.

The YBT used in this study has been demonstrated to have the potential to be a good measure

for comparing the efficacy of a training program to reduce injury rates25. At the final assessment, the

scores for the EG after neuromuscular training were significantly higher for both lower limbs with

respect to baseline and significantly higher than for the CG, whereas the scores for the CG were

similar to the baseline values. The mechanisms that might have led to better YBT performance by the

EG included muscle activation, neuromuscular properties, and proprioception, which are closely

related to YBT performance25, 26. One explanation for the differences in test performance between the

two groups is that neuromuscular training may induce peripheral and central adaptations, resulting in

improved joint position sense and detection of joint motion. These peripheral adaptations may have

resulted from the repetitive stimulation of the articular mechanoreceptors near the end range of

motion in the knee during these exercises. Furthermore, central adaptations require preparatory

muscle activation in anticipation and involuntary muscle activity for concentric force production43.

This trial has some limitations. Firstly, this study encompassed only one season, so it is unknown

whether coaches can implement the warm-up consistently over several seasons or require retraining to

maintain compliance. Secondly, we did not involve a survivor analysis. In fact, because all athletes

were part of professional teams we did not have any drop-outs during the 6 months of the study. For

this reason, we were not able to assess any survivor effect because we included only the regular

season. Thirdly, our prevention program addresses many factors that could be related to the risk of

injury (jogging and active stretching for general warm-up, strength, balance, awareness of vulnerable

hip and knee positions, technique of planting, cutting, landing and running), and it is not possible to

determine exactly which exercises or factors might have been responsible for the observed effects.

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 PERSPECTIVES

This bodyweight neuromuscular warm-up was effective in reducing the risk of lower limb
Accepted Article
injury in female basketball players. Moreover, this type of program involves no extra costs for

equipment purchases and it can be easily included as a component in injury prevention programs.

Such training should be included in the weekly training in female basketball players.

ACKNOWLEDGEMENTS

The authors wish to thank the athletes and the team coaches for their voluntary participation

in the study and in the experimental procedures. We also extend our gratitude to Kenneth A. Britsch

for checking the manuscript for English. No financial assistance for the project was received.

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FIGURES

Figure 1. Study flow diagram.

Figure 2. Changes in CMJ (A), and YBT composite score for the reaching right (B) and left (C) limb

in the experimental group before (PRE) and after (POST) neuromuscular training and in the control

group (*p < 0.05; **p < 0.01).

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 Table 1. Bodyweight neuromuscular warm up.

1. General activation (with the ball)

Accepted Article
 Jog line to line 4 basketball courts
 Shuttle run 4 basketball courts
 Lateral and backward running 4 basketball courts

2. Mobility Exercises
 Leg swing front-to-back site to side 1/2x12
 Lateral squats 1/2x12
 Lunge superior reach One basketball court
 Walking quad stretch One basketball court
 Monster walks One basketball court
 Inverted hamstring stretch One basketball court
One basketball court
 Lateral crossover step

3. Strength Exercises
 Multidirectional lunges 2/3x10 bilaterally
 Nordic hamstrings 2/3x5
 Single toe raises 2/3x12 bilaterally
 Lateral bridge 2/3x30 sec bilaterally

4. Plyometric Exercises
 Vertical jumps 1/2x12
 Lateral hops 2/3x20 bilaterally
 Single legged hops 2/3x20 bilaterally
 Forward hops 2/3x10

5. Agility Exercises (with the ball)

 Four way close-out 4 basketball courts
 Line drills and sprint 4 basketball courts
 Zigzag cones 4 basketball courts
 Four corners 4 basketball courts
 Pass-sprint and layup 4 basketball courts

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 Table 2. Injuries by body region recorded during the female Italian Basketball regular season.

Significance
Experimental Group Control Group
Accepted Article
Injuries N % N % p

Ankle sprain 9 28.1 26 32.9 0.507

Muscle strain 8 25.0 9 11.3 0.581

Knee sprain 2 6.3 12 15.2 0.037

Overuse pain (legs) 3 9.4 9 11.4 0.145

ACL lesion 0 0 7 8.9 0.038

Back pain 4 12.5 4 5.0 0.225

Leg contusion 3 9.4 5 6.3 0.688

Other incidents 3 9.4 7 8.9 1.00

Total 32 100% 79 100% 0.006

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ccepted Articl
TABLE 3. Injuries by body region recorded during training and matches during the female Italian Basketball regular season.

Experimental Group Control Group

Training Match Significance Training Match Significance

Injuries N % N % p N % N % p

Ankle sprain 5 20.8 4 36.4 0.406 15 28.8 11 40.7 0.320

Muscle strain 5 20.8 3 27.3 1.00 7 13.4 2 7.4 0.711

Knee sprain 2 9.5 0 0 0.534 8 15.4 4 14.8 1.00

Overuse pain (legs) 3 14.3 0 0 0.534 7 13.4 2 7.4 0.711

ACL lesion 0 0 0 0 1.00 4 7.7 3 11.1 0.685

Back pain 3 14.3 1 9.1 1.00 3 5.7 1 3.7 1.00

Leg contusion 0 0 3 27.3 0.033 3 5.7 2 7.4 1.00

Other incidents 3 14.3 0 0 0.534 5 9.6 2 7.4 1.00

Total 21 100% 11 100% 0.024 52 100% 27 100% 0.0001

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Accepted Article

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