ORIGINAL RESEARCH
Effect of Neuromuscular Training on Proprioception, Balance,
Muscle Strength, and Lower Limb Function in Female Team
Handball Players
Inger Holm, PT, PhD,* Merete Aarsland Fosdahl, PT,* Astrid Friis, PT,* May Arna Risberg, PT, PhD,†
Grethe Myklebust, PT, PhD,‡ and Harald Steen, MD, PhD*
Objective: Introduction of a neuromuscular training program will
increase muscle strength, balance, and proprioception in elite female
handball players.
Design: Prospective intervention study.
Participants: Thirty-five female team handball players from 2
teams in the elite division participated. Their mean age was 23 (±2.5)
years, and their mean weight was 69.2 (±7.3) kg. They had played
handball for 14.9 (±3.2) years, 4.7 (±2.8) years at the top level. The
total number of training hours per week was 10 to 11.
Intervention: Based on earlier studies and knowledge about com-
mon risk situations in team handball, an anterior cruciate ligament
(ACL) injury prevention program with 3 different sets of exercises
was developed, each set with a 5-step progression from simple to
more challenging exercises. The teams were instructed to use the pro-
gram a minimum of 3 times a week during a training period of 5 to 7
weeks, and then once a week during the season. The duration of each
training session was approximately 15 minutes.
Main outcome measures: Balance (KAT 2000), proprioception
(threshold to detection of passive motion), muscle strength (Cybex
6000), and 3 functional knee tests. The players were tested pretraining
(test 1) and 8 weeks (test 2) and 12 months (test 3) after the training
started.
Results: There was a significant improvement in dynamic balance
between test 1 and test 2, with a balance index (BI) of 924 (±225) and
778 (±174), respectively (P = 0.01). The effect on dynamic balance
was maintained 1 year after training (BI, 730 ± 156). For static bal-
ance, no statistically significant changes were found. For the other
variables measured, there were no statistical differences during the
study period.
Received for publication February 2003; accepted November 2003.
From *Rikshospitalet University Hospital; the †Center for Clinical Research,
Ullevaal University Hospital; and ‡Oslo Sport Trauma Research Center,
Norwegian University of Sports and Physical Education, Oslo, Norway.
Reprints: Inger Holm, PT, PhD, Physiotherapy Department, Rikshospitalet
University Hospital, 0027 Oslo, Norway (e-mail: inger.holm@
rikshospitalet.no).
Copyright © 2004 by Lippincott Williams & Wilkins
88
Conclusion: The ACL injury prevention training program im-
proved dynamic balance in an elite team handball players.
Key Words: team handball, prevention program, balance, proprio-
ception, muscle strength, functional tests
(Clin J Sport Med 2004;14:88–94)
D ifferent kinds of balance exercises and other neuromus-
cular training programs have been introduced to prevent
sport injuries like ankle sprains and anterior cruciate ligament
ruptures.1–4 The exercises aim at increasing the magnitude of
neuromuscular stabilizing forces required to be generated to
resist the destabilizing load applied to the knee prior to liga-
ment damage. Some training programs are designed to im-
prove muscle function (recruitment patterns and reaction time)
and increase neuromuscular control, while others seek to im-
prove balance and proprioception at the joint.5
Wedderkopp et al1 investigated the effect of an interven-
tion program designed to reduce the number of injuries in
young female handball players. The results indicated that us-
ing a program including balance board training in combination
with a thorough warm-up program decreased the numbers of
both traumatic and overuse injuries significantly. Hewett et al4
showed that introducing a jump training program to female
athletes involved in high-risk sports decreased the overall in-
cidence of serious knee injuries. The program was designed to
decrease landing forces and abduction moments in the knee.
They concluded that the reduction in knee injuries was due to
a combination of improvement in technique and strength, but
these parameters were not measured.
Söderman et al3 performed a randomized study to evalu-
ate the effect of balance board training on the prevention of
traumatic injuries in female soccer players. In contrast to the
aforementioned studies,1,4 they found that the training pro-
gram did not prevent primary traumatic injuries. In addition to
injury incidence rates, Söderman et al3 also included postural
sway as an outcome measure to evaluate the functional effect
of the balance board training. Except for balance index on the
Clin J Sport Med • Volume 14, Number 2, March 2004
Clin J Sport Med • Volume 14, Number 2, March 2004
nondominant leg, there were no significant changes in balance
index before and after the training period.
Two of the 3 studies cited above indicated that neuro-
muscular training decreases injury risk in female athletes. Al-
though the mechanism of this protective effect of training re-
mains unknown, there exist some clear candidates. Hewett6
suggested that the effect might be due to increased dynamic
stability, increased balance between hamstrings and quadri-
ceps strength and dominant versus nondominant side ham-
strings strength following training, and decreased landing
forces and knee moments.
The extent to which the prevention exercises will im-
prove proprioception, referred to as kinesthetic signals, is un-
known. However, these proprioceptive signals are considered
important in sensorimotor function.7 Information from pro-
prioceptors is crucial for conscious and unconscious control of
limb movement, both for the initiation of movement and dur-
ing movements.7 Ashton-Miller et al5 claimed that it may be
premature to conclude that neuromuscular exercises can im-
prove true proprioception in terms of the 2 classic propriocep-
tive modalities—accuracy of joint position sense and threshold
to detection of passive motion—because relevant experiments
have not yet been performed. A rationale for progression in
proprioception following neuromuscular training is the hy-
potheses that proprioceptive exercises increase the attention
paid to proprioceptive cues by the brain, first at the conscious
level early in training, then later at the autonomous level.5
Clinicians have used single-leg hop tests to assess their
patients’ muscular strength and ability to perform tasks that
challenge knee stability.8 Previous studies including single-leg
hop tests have provided information about the relationship be-
tween the hop tests and muscle deficits,9,10 passive joint lax-
ity,9 and proprioception deficits.11 In team handball, the play-
ers’ typical movement patterns consist of rapid accelerations
and decelerations, cutting movements, hopping, and 1-leg and
2-leg landings. The single-leg hop tests are considered to be
reliable and valid measurement tools for evaluating the effect
of these exercises.12,13
Side-to-side differences between the legs expressed as
the limb symmetry index (LSI) may be of great importance in
prevention studies. LSI values (dominant/nondominant limb ×
100) has been the most frequently reported criterion to assess
whether a hop test is normal or abnormal.13 A LSI value lower
than 85% may indicate the presence of a functional deficit,8
and special care should be taken to reduce these deficits during
the training period.
In 1998, a neuromuscular prevention training program
was introduced in team handball,14 because studies showed
that the risk of experiencing an anterior cruciate ligament
(ACL) rupture was 5 times higher among females than males,
and that the gender differences were even higher at the elite
level than in the lower divisions.15,16 It is important to measure
potential physiological risk factors and to examine the useful-
© 2004 Lippincott Williams & Wilkins
Neuromuscular Training in Female Handball Players
ness of each aspect of the neuromuscular prevention training
programs introduced. The aim of the present study was to in-
vestigate the physiological effects of an ACL injury prevention
training program on balance, proprioception, muscle strength,
and lower limb function in 35 female team handball players.
The hypothesis was that introducing the neuromuscular train-
ing program would increase muscle strength, balance, proprio-
ception, and lower limb function.
MATERIALS AND METHODS
Study Design
This current work was part of a prospective intervention
study initiated and conducted by Myklebust et al.14 The study
covered 3 consecutive seasons of the 3 top divisions in the
Norwegian Handball Federation: 1 control season (1998–
1999) and 2 intervention seasons (1999–2001). The present
study covered the first intervention season. The Data Inspec-
torate and the Regional Ethics Committee for Medical Re-
search approved the study.
Participants
Thirty-five female handball players from 2 teams in the
elite division participated. Their mean age was 23 (±2.5) years,
and their mean weight was 69.2 (±7.3) kg. They had played
handball for 14.9 (±3.2) years, 4.7 (±2.8) years at the top level.
Twenty-nine were right-handed. The weekly number of train-
ing hours was 10 to 11, and the number of matches per week
varied according to the number of training games, tournament
games, and league and cup games during the season. Nineteen
of the girls had previously experienced problems with ankle
instability, but only 1 of them needed surgery. Nine players
had an earlier knee injury, 4 had an ACL rupture, 3 had a
meniscal tear, and for 2 of the players the diagnosis was un-
known. Six of the 9 players with previous knee injuries had
undergone surgery.
Anterior Cruciate Ligament Injury
Prevention Study
An ACL injury prevention program with 3 different sets
of exercises was developed, each set with a 5-step progression
from simple to more challenging exercises. Before the first in-
tervention, the teams were visited once in the preparatory pe-
riod. They were supplied with an instructional video, posters, 6
balance mats, and 6 wobble boards. The teams were instructed
to use the program minimum 3 times a week during a training
period of 5 to 7 weeks, and then once a week during the entire
season. The duration of each training session was approxi-
mately 15 minutes. The main goal of the prevention program
was to improve awareness and knee control during standing,
cutting, jumping, and landing. There were 3 types of exercises:
floor exercises, wobble board exercises, and balance mat ex-
ercises. Each set of exercises consisted of a 5-step progression
89
Holm et al
from easy to difficult. The floor exercises started with planting
and progressed to a full plant and cut, then a jump shot with a
2-foot landing with flexion in both hip and knees. The wobble
board and balance mat exercises started with throwing a ball to
each other with 2 feet on the board/mat, and progressed to
squats on the wobble board standing on 1 leg and to exercises
on the balance mats in which 2 players tried to push the partner
out of balance. The players were encouraged to focus on the
quality of their movements, and with emphasis on the knee
over toe position. They were also motivated to help and give
feedback to each other during training. The coaches were re-
sponsible for carrying out the program, and they were asked to
record the total number of training sessions the team com-
pleted. For a more detailed description of the program, see
Myklebust et al.14
Evaluation Procedures
Except for the proprioception device, all the players had
earlier experience with all the testing equipment. They were
tested pretraining (test 1) and 8 weeks (test 2) and 12 months
(test 3) after the training started. Demographic data (age,
weight, activity level, and previous injuries) were registered
using a questionnaire. To ensure that the players had normal
stability in both knees before inclusion in the study, knee joint
laxity was quantified at baseline using a KT-1000 arthrometer
(MEDmetric, San Diego, CA). Anterior tibial translation was
measured during application of a 30-pound anterior displace-
ment force.
All tests were performed by 3 experienced physiothera-
pists (A.F., M.Aa.F., I.H.).
Balance was tested using the KAT 2000 (OEM Medical,
Carlsbad, CA). The KAT 2000 consists of a moveable plat-
form supported at its central point by a small pivot. A tilt sen-
sor on the platform is connected to a computer, which registers
the deviation of the platform from a reference position 18.2
times each second. The distance from the central point to the
reference position is measured at every registration. From the
summation of these distances, a score—the balance index
(BI)—can be calculated (low BI = good ability to perform the
balance task). All the players had earlier experience with the
KAT 2000 and were familiar with the equipment. They were
not given any trial repetitions prior to the testing. Each person
completed a 1-leg static balance test (3 measurements on each
leg) and a 2-legs dynamic test (3 measurements). The position
of the feet was registered and was used for each test. The test is
described in detail by Strange Hansen et al.17
Assessment of knee kinesthesia was conducted by mea-
suring threshold to detection of passive motion (TDPM) using
a proprioception device developed at the University of Ver-
mont, McClure Musculoskeletal Research Center, Department
of Orthopedics and Rehabilitation. The device moves the knee
joint into flexion or extension with a constant angular velocity
of 0.5°/s. All testing was performed at a starting position of 15°
90
Clin J Sport Med • Volume 14, Number 2, March 2004
of knee flexion. Subjects were told that either leg could move
into flexion or extension beginning at a random time interval
up to 45 seconds after the examiner signaled the start of the
test. Once the player detected motion of the leg, she pressed a
button and confirmed which leg moved and the direction of the
motion. Each trial consisted of 3 repetitions for each of the 4
motions (flexion and extension for both legs), resulting in a
total of 12 repetitions. In the case of incorrect identification of
the motion, the repetition was returned to the randomization
list so that 3 correct repetitions of each motion were com-
pleted.18 The number of incorrect responses was registered.
The results for each leg were calculated by combining the mea-
surements for flexion and extension.
Quadriceps and hamstrings muscle strength was tested
using a Cybex 6000 (Cybex-Lumex, Ronkonkoma, NY). The
test protocol consisted of 5 repetitions at an angular velocity of
60°/s (strength) followed by a 1-minute rest period and 30 rep-
etitions at 240°/s (endurance).19 The parameter used for analy-
sis was total work. Side-to-side differences in strength be-
tween the dominant and nondominant leg and the ratio be-
tween hamstrings and quadriceps—the HQ-ratio ([hamstrings
values/quadriceps values] × 100)—were calculated.
Three functional knee tests were used to evaluate general
lower limb function.20 The 1-leg hop test was performed 2
times on each leg, and the mean value (distances measured in
centimeters) was recorded. When performing the triple jump
test, the player was asked to stand on both legs and jump twice
onto the same leg, followed by a jump onto both legs (distances
measured in centimeters). The test was performed twice on
each leg, and the mean value was recorded. For the stair hop
test, the player was asked to hop up 22 steps on 1 leg, turn
around, and hop down the same 22 steps on the same leg (time
measured in seconds). For all 3 functional tests, the procedure
was first performed on the dominant leg, then repeated on the
nondominant leg.
Statistical Methods
The mean of the 3 trials recorded for each balance test
and for each of the 4 directions from the proprioception device
was calculated. Numbers are presented as arithmetic means
and dispersion by ±1 SD. To discover significant side differ-
ences between the dominant and nondominant legs, the results
from the dominant and nondominant legs were compared by
paired t-test. A 3 (time) × 2 (leg) analysis of variance for re-
peated measures (with the least significant difference post hoc
test) was used to calculate differences from one test to the next
over the study period.
RESULTS
Of the 35 players included, 27 completed the study. Two
players were injured, 3 players ceased playing handball, and 3
did not attend the last testing session. The mean number of
neuromuscular training sessions performed during the training
© 2004 Lippincott Williams & Wilkins
Clin J Sport Med • Volume 14, Number 2, March 2004
period of 5 to 7 weeks was 15.8 (±3), and the mean number per
week was 3.2 (±0.7). During the rest of the season, 68% of the
players performed the exercises a minimum of once a week
(maintenance training). The mean knee joint laxity was 8.3
(±2.7) mm and 8.9 (±2.3) mm for the dominant and nondomi-
nant leg, respectively. The mean difference between the legs
was 0.6 (±1.8) mm.
Table 1 shows the results from the balance tests. There
was a significant improvement in dynamic balance between
test 1 and test 2, with a balance index of 924 (±225) and 778
(±174), respectively (P = 0.01). The improvement in dynamic
balance was maintained 1 year posttraining. For static balance,
no statistically significant changes were found (P = 0.52).
The results from the proprioception device showed a
TDPM of 0.8° (±0.4°), 0.8° (±0.4°), and 0.9° (±0.6°) for the
dominant leg at test 1, 2, and 3, respectively. There were no
significant differences between the right and left legs.
The isokinetic muscle strength measurements showed
no statistical changes over the study period (Table 2). The
mean side-to-side strength differences for quadriceps and
hamstrings ranged from 0.1% to 5.5% over the study period.
The hamstrings muscle strength at 240°/s showed significant
side-to-side differences pretraining (5.5% ± 11.1, P = 0.006)
and after 1 year (5.1% ± 12.9, P = 0.02). The HQ-ratios at 60°/s
were 69.9, 72.2, and 68.7 pretraining and after 8 weeks and 1
year, respectively. The corresponding values at 240°/s were
72.7, 70.2, and 66.7. For the 3 functional tests, there were no
statistical differences either between the 2 legs or between
each follow-up test (Table 3).
DISCUSSION
This study showed a significant improvement in dy-
namic balance after neuromuscular training in team handball
players, but no significant differences in static balance, pro-
prioception, muscle strength, or functional tests were ob-
served. Changes in the incidence of ACL injuries were not re-
corded in this part of the study, but results from the main study
(total population) showed a reduction from 13 injuries regis-
tered during the control season to 6 injuries during the first
intervention season.14 One of these 6 injuries occurred among
the 35 players participating in the present study. The actual
TABLE 1. Balance Index (BI) Pretraining and 8 Weeks and 1 Year After Start of Training
Pretraining
(n = 35)
BI, static right leg 438.5 (±117.8)
BI, static left leg 482.7 (±181.2)
BI, dynamic both legs 924.1 (±225.5)
*Significantly different from the previous test, P = 0.003.
© 2004 Lippincott Williams & Wilkins
Neuromuscular Training in Female Handball Players
player contracted an ACL rupture just before the prevention
program was introduced.
There was a significant improvement in dynamic bal-
ance between test 1 and test 2, and the effect was maintained 1
year posttraining. This effect might be explained by a learning
effect. Strange Hansen et al17 performed a reliability study of
the KAT 2000 and found a clear learning effect when healthy
volunteers were retested, especially in the dynamic test. Their
results showed that when a group of 25 persons was tested, a
diminution of 12% and 15% (the second series over the first)
for the dynamic and the static tests, respectively, was needed if
the balance ability was to be improved. In the present study, the
dynamic balance improved by 15.8% from test 1 to test 2, and
there was a further improvement of 6.3% from test 2 to test 3.
These results indicate that the decreased dynamic BI was a
result of better balance skills rather than random variance or a
learning effect alone. In addition, all the players had previous
experience with the testing device. These findings of signifi-
cant improvement in dynamic balance are in fact quite encour-
aging, since most of the exercises in the prevention program
facilitate this quality. The changes in static balance, however,
ranged from –5.8% to 3.3%, indicating that these measure-
ments were quite stable over the study period.
The ACL prevention program was designed to improve
neuromuscular control, especially in the plant and cut move-
ments and in landing after jump situations. Actually, we did
not find it surprising that the improvement was found in dy-
namic balance and not in static balance, while the program was
designed mainly to improve dynamic stability. So far, we do
not know the possible effects on landing forces, knee mo-
ments, technique, and other relevant neuromuscular param-
eters. These aspects need further investigation.
The results from the proprioception device showed that
TDPM remained unchanged over the study period, suggesting
that additional neuromuscular training did not influence the
TDPM for these top-level handball players. Compared with
normal data given by Beynnon et al,18 our mean values were
smaller. The normal value of TDPM in their study was 1.5°
(±1.0°), compared with 0.8° (±0.4°) in the present study. In
another study, Beynnon et al21 found a TDPM of 1.17°
(±0.50°) on the uninjured side of patients with an ACL injury.
Lephart et al22 found a significantly lower TDPM for intercol-
8 Weeks 1 Year
(n = 28) (n = 27)
464 (±168.6) 485.2 (±155)
487.5 (±211.8) 471.5 (±172.3)
778.9 (±174.4)* 730.3 (±156.2)
91
Holm et al Clin J Sport Med • Volume 14, Number 2, March 2004

TABLE 2. Isokinetic Knee Muscle Strength Pretraining, and 8 Weeks and 1 Year After
Start of Training

Pretraining 8 Weeks 1 Year

(n = 35) (n = 28) (n = 27)
Flexion TW† 60°/s, right 552.7 (±100.7) 562.7 (±118.1) 547.6 (±114.8)
Flexion TW 60°/s, left 535.9 (±103.8) 556.9 (±108.2) 534.1 (±118)
Flexion TW 240°/s, right 1574.7 (±344.7) 1585.7 (±358) 1539.4 (±389.1)
Flexion TW 240°/s, left 1490.4 (±358.6)* 1525.4 (±394.7) 1460.4 (±417.7)*
Extension TW 60°/s, right 793.5 (±127.2) 781.9 (±146.2) 795.8 (±131.2)
Extension TW 60°/s, left 791.9 (±138.1) 776.1 (±163.3) 782.6 (±136.1)
Extension TW 240°/s, right 2165.4 (±337.5) 2277.3 (±420) 2324.8 (±438.1)
Extension TW 240°/s, left 2123.6 (±323.6) 2214.2 (±353.1) 2232.3 (±444.9)
HQ-ratio 60°/sec 69.9 (±8.2) 72.2 (±9.1) 68.7 (±9.2)
HQ-ratio 240°/sec 72.8 (±11.9) 70.3 (±13.9) 66.8 (±15.2)
*Significantly different from the right side, P < 0.05.
†TW, total work.

legiate gymnasts compared with an age-matched control
group. The fact that our players were high-level athletes may
explain the differences in TDPM between our top-level players
and the populations of Beynnon et al.18,21
There were no differences in TDPM in our subjects, in-
dicating that changes in proprioception, as measured by this
device, did not occur during the study period. There may be
methodological, proprioceptional, and dose-response issues as
explanations for this lack of change. The TDPM might not
have the required validity to measure proprioception. We
know that the outcome measure is reliable.18 We also know
that the device has construct validity,18 but concurrent validity
has not yet been established. Furthermore, no other study has
evaluated the sensitivity to change over time for this proprio-
ception device. Changes in proprioception might not be an is-
sue in subjects who have no impaired proprioception to start
with; proprioception was not impaired in these players, and
they showed smaller TDPM values than previous published
normative data.18 Finally, the number of training sessions
might not have been sufficient to improve proprioception.
Previous studies have measured knee kinesthesia com-
bining the measurements for flexion and extension. Beynnon
et al18 mentioned that it is unclear whether there is a directional
dependence, and that combining the results from the 2 motions
may not be appropriate. Our analysis, however, indicate that
no such directional dependence exists, at least in uninjured fe-
male handball players.
A ratio of limb symmetry, the LSI, has been the most
frequently reported criterion to assess whether a hop test is
normal or abnormal.8 The underlying assumption has been that
detection of an abnormal LSI would indicate the presence of a
functional deficit and that individuals showing such deficits
are at risk for recurrent dynamic stability. The LSI for the three
functional hop tests included in the present study ranged from
96.3% to 103.8% over the study period (Table 4), indicating
that these players were in possession of almost equal func-
tional capacity bilaterally, eliminating 1 risk factor for future
injury. Normal LSI has been reported as greater than or equal
to 80%. We may have found LSI values near 100% because
most of the players use the nondominant leg as the push-off leg

TABLE 3. Functional Knee Tests Pretraining and After 8 Weeks and 1 Year

Pretraining 8 Weeks 1 Year

(n = 35) (n = 28) (n = 27)
One-leg hop test, right (cm) 166.4 (±13) 173.1 (±15.1) 171.2 (±13.6)
One-leg hop test, left 167.4 (±15.8) 171.4 (±15.6) 169.8 (±14.2)
Triple jump test, right (cm) 585.9 (±45.9) 584.7 (±47.7) 583 (±50.5)
Triple jump test, left 565.7 (±117.9) 577.9 (±53.8) 578.2 (±55.8)
Stair hop test, right (s) 14.6 (±1.7) 14.4 (±1.5) 14.4 (±1.5)
Stair hop test, left 15 (±2.3) 15 (±2.1) 14.6 (±1.6)

92 © 2004 Lippincott Williams & Wilkins

Clin J Sport Med • Volume 14, Number 2, March 2004
TABLE 4. Limb Symmetry Index (LSI) ([Nondominant/Dominant] ⳯ 100) for the 3
Functional Tests Pretraining and After 8 Weeks and 1 Year
Pretraining
(n = 35)
One-leg hop test 96.3 (±18.2)
Triple jump test 100.7 (±6.9)
Stair hop test 103.2 (±7.9)
when they are performing the jump shots, and the intervention
program focused on landing on 2 feet. If side-to-side imbal-
ance had existed at the pretest, the individual prevention pro-
gram should have included exercises to decrease the deficit.
The hamstring muscle is an ACL agonist, resisting
forces that strain the ACL. Specific hamstrings strength imbal-
ances (dominant leg ⱖ15% stronger than nondominant leg)
have been correlated to greater incidence of lower extremity
injury in female collegiate athletes.23 In the present study, the
hamstrings muscle strength at 240°/s showed significant side-
to-side differences pretraining (5.5% ± 11.1, P = 0.006) and
after 1 year (5.1% ± 12.9, P = 0.02). This imbalance was
smaller than the differences indicated in the study by Knapik,23
but some of the players showed higher differences and might
benefit from emphasis on specific hamstring exercises.
The importance of improvement of the HQ-ratio before
participation in high-level jumping, pivoting, and cutting
sports like handball has been underlined, especially in fe-
males.6 Hewett et al24 tested the effect of a jump training pro-
gram on landing mechanics and lower extremity strength and
found that the HQ-ratio increased from 55 to 62 and from 47 to
59 for the dominant and nondominant leg, respectively.6 The
HQ-ratio in the present study was 69.9 at 60°/s and 72.8 at
240°/s at baseline. Except for the ratio at 240°/s after 1 year,
the ratios remained stable over the study period. In 1996,
Lund-Hansen et al25 published results from isokinetic strength
testing of 114 healthy female handball players. They found a
HQ-ratio of 56 and 72 for 60°/s and 240°/s, respectively. Com-
pared with the results from the two aforementioned studies,
our players showed a significantly higher HQ-ratio on the low-
est speed. However, Hewett6 characterized a HQ-ratio at
180°/s lower than 75 as an imbalance between the 2 muscle
groups. This indicates that the players in the present study
should continue the focus on hamstring exercises in their
strength training program to reduce this risk factor even fur-
ther.
The compliance during the main intervention period
(5–7 weeks) was high, and the mean number of training ses-
sions per week was 3.2. During the rest of the year, 68% of the
players performed the prevention program once a week. The
high compliance rate in the intervention period and the mod-
erate compliance in the follow-up period alone cannot explain
the lack of effect on most outcome measures posttraining.
© 2004 Lippincott Williams & Wilkins
Neuromuscular Training in Female Handball Players
8 Weeks 1 Year
(n = 28) (n = 27)
99.1 (±4.5) 99.1 (±3.2)
99.6 (±8.5) 99.2 (±5.8)
103.8 (±7.5) 101.4 (±7.1)
The present study showed a benefit on dynamic balance
from the neuromuscular preventive training program intro-
duced to healthy female handball players. However, the results
showed no effect on muscle strength or proprioception. The
possible effects on landing forces, knee moments, improved
technique, or other neuromuscular parameters need further in-
vestigation.
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