Participants
This quasi-experimental study consisted of forty physically active male military athletes prone to injury (with a score of ≤ 14 in the FMS) between the ages of 24 and 33 that volunteered for this study. Military athletes (martial arts = 10, wrestling = 8, futsal = 12, volleyball = 10) were defined as militaries who participated in military sport teams, were currently in their off-season, and that were training at least 3 times per week (> 1.5 h/week). All participants were currently free from any kind of musculoskeletal injury, had not sustained any kind of musculoskeletal injury within the past 6 weeks, and had never undergone surgery for a musculoskeletal condition. For this purpose, the individuals were entered into the study with the approval of a physician and reviewing medical records.
Participants were selected by availability and purposive sampling that were assigned to either the training group (20 male: age = 27.45 ± 2.3 years, height = 176.72 ± 5.1 cm, weight = 75.02 ± 3.5 kg) or the control group (20 male: age = 27.20 ± 2.4 years, height = 176.42 ± 5.5 cm, weight = 74.05 ± 3.6 kg) based on their availability to participate in training. All participants completed all phases of the investigation and gave written informed consent before any data collection.
Procedures
All testing and training was done in the School of Sports Sciences health Center. This study was comprised of three phases: 1) pre-testing, 2) a supervised neuromuscular training three times per week for 8 weeks, and 3) post-testing. Prior to pre-testing, participants were familiarized to all aspects of the study protocol and performed practice trials of all assessments. During pre- and post-testing, all testers utilized the same verbal instructions. Once assigned, the intervention group was required to complete neuromuscular training 3 times per week in addition to their usual training routine. The Control group received no intervention. They were instructed to maintain usual daily activities for the duration of the 8-week intervention. All participants were in the off season of their respective sports and none of the athlete’s off season training programs included neuromuscular training. Post-testing was conducted in a manner identical to pre-testing. All sessions were supervised by the one of researchers, who has qualifications as a personal trainer. The neuromuscular training program was designed to enhance movement control and, as well as to increase the stability of the trunk, knee and ankle. The focus of all of the exercises was on the use of proper technique, such as good posture, maintenance of core stability or positioning of the hips, knees and ankles, especially “knee over toe” position. The neuromuscular training program included 9 exercises: 1) One-leg standing with a stick, 2) Squat exercises with a stick using, respectively, two legs or one leg, 3) Horizontal side support, 4) Jumping from side to side, 5) Modified pushups, 6) Stretching exercise for hip flexor muscles, 7) Hamstring exercise on the knees, 8) Stretching exercise with a stick for hamstring muscles and 9) Upper-body rotation while lying on one’s side; a “yoga stretch”. Participants were instructed to maintain a neutral position of the spine while holding the correct exercise position. The intensity and volume of each neuromuscular exercise were progressed gradually at a standard rate as previously described and shown in the Supplemental file [16].
Measures
The Functional Movement Screen (FMS) is composed of the following seven tasks: 1) Deep squat (DS); 2) Hurdle step (HS); 3) In-line lunge (ILL); 4) Shoulder mobility (SM); 5) Active straight leg raise (SLR); 6) Trunk stability push-up (PU); 7) Rotary stability (RS) (Fig. 1). “Clearing” tests (impingement, press up, and posterior rocking) are also included with the SM, PU and RS to expose other painful movements that may be overlooked while performing the primary FMS tasks. Additional details of each task have been published previously [4, 17, 18]. Each task is scored, and a 4-point scale (0–3) and on tests where left and right sides are measured, the lowest score is used, giving a total score out of 21 [4, 17, 18]. A score of 3 was assigned if the participant performed a functional movement pattern with no movement compensation. A score of 2 was assigned if the participant performed a functional movement pattern, with some degree of compensation. A score of 1 was assigned if the participant was unable to perform or complete a functional movement pattern according to published guidelines, and a score of 0 was reserved for participants who had pain with the movement or presented with pain while performing a clearing test [4]. Screens were performed in a convenience order, and participants were given adequate rest to account for fatigue. FMS has internal reliability and high router (ICC = .98) between experienced and novice experimenters [19, 20]. Before starting the study, the examiners conducted a preliminary study of 14 participants to obtain the reliability of the interrater in proportion to the previously published values.
Scores were reported and analyzed in several ways to determine the efficacy of the neuromuscular training program. First, a composite score was calculated for the 7 tests by summing the final score for each assessment. Second, individual FMS tests were subcategorized into one of the following 3 categories: 1) Mobility, 2) Stability, and 3) Advanced movements. Mobility tests included the active straight leg raise and shoulder mobility assessment. Stability tests included the trunk stability push-up and the rotary stability assessment. Advanced movements included the deep squat, hurdle step, and inline lunge. Final scores for each category were summed to determine a composite score for that category [21].
Analyses
Data were analyzed using SPSS statistical software 22 (IBM, Armonk, NY, USA). ). Independent t-test was used to compare the mean of Participants' descriptive characteristics between intervention and control groups. Analysis of covariance test was performed to determine statistically significant differences between- FMS scores between the two groups. Significance level was set a priori at p < 0.05.