The purpose of this systematic review was to evaluate the efficacy and safety of plyometric training for improving motor performance in young children. The current evidence suggests a twice a week program for 8-10 weeks beginning at 5060 jumps a session and increasing exercise load weekly results in the largest changes in running and jumping performance.
Original Description:
Original Title
A Systematic Review Plyometric Training Programs for Young Children
The purpose of this systematic review was to evaluate the efficacy and safety of plyometric training for improving motor performance in young children. The current evidence suggests a twice a week program for 8-10 weeks beginning at 5060 jumps a session and increasing exercise load weekly results in the largest changes in running and jumping performance.
The purpose of this systematic review was to evaluate the efficacy and safety of plyometric training for improving motor performance in young children. The current evidence suggests a twice a week program for 8-10 weeks beginning at 5060 jumps a session and increasing exercise load weekly results in the largest changes in running and jumping performance.
BARBARA A. JOHNSON, 1 CHARLES L. SALZBERG, 2 AND DAVID A. STEVENSON 1,3 1 Movement Analysis Laboratory, Shriners Hospitals for Children Salt Lake City, Salt Lake City, Utah; 2 Department of Special Education and Rehabilitation, Utah State University, Logan, Utah; and 3 Department of Pediatrics, Division of Medical Genetics, University of Utah, Salt Lake City, Utah ABSTRACT Johnson, BA, Salzberg, CL, and Stevenson, DA. A systematic review: plyometric training programs for young children. J Strength Cond Res 25(9): 26232633, 2011The purpose of this systematic review was to evaluate the efcacy and safety of plyometric training for improving motor performance in young children; to determine if this type of training could be used to improve the strength, running speed, agility, and jumping ability of children with low motor competence; and to examine the extent and quality of the current research literature. Primary research articles were selected if they (a) described the outcomes of a plyometric exercise intervention; (b) included measures of strength, balance, running speed, jumping ability, or agility; (c) included prepubertal children 514 years of age; and (d) used a randomized control trial or quasiexperimental design. Seven articles met the inclusion criteria for the nal review. The 7 studies were judged to be of lowquality (values of 46). Plyometric training had a large effect on improving the ability to run and jump. Preliminary evidence suggests plyometric training also had a large effect on increasing kicking distance, balance, and agility. The current evidence suggests that a twice a week program for 810 weeks beginning at 50 60 jumps a session and increasing exercise load weekly results in the largest changes in running and jumping performance. An alternative program for children who do not have the capability or tolerance for a twice a week program would be a low- intensity program for a longer duration. The research suggests that plyometric training is safe for children when parents provide consent, children agree to participate, and safety guidelines are built into the intervention. KEY WORDS strength, running speed, agility, jumping ability, motor competence, prepubertal children INTRODUCTION I mproving physical activity is a national health initiative for children of all abilities (22). Current national health initiatives recommend 60 minutes or more of moderate to vigorous physical activity most days of the week for school-aged children. The physical activity should be enjoyable, developmentally appropriate, and should consist of a variety of activities. Children have the opportunity to begin playing competitive sports at the age of 78. However, before that time, young school-aged children engage in playground games and recreational sports where they run, skip, hop, jump, kick, and throw. Children with low motor competence have lower levels of physical tness (13), lower levels of physical activity (24), and participate in fewer organized recreational and play activities (2). Wrotniak et al. (24) suggested that running and jumping are fundamental skills for participation in active games and sports. Therefore, improving running and jumping in children with low motor competence may be an appropriate intervention for increasing physical tness, for increasing physical activity levels, and for improving participation in recreational and play activities. However, there is a paucity of research on interventions that aim specically to improve running and jumping ability in children with low motor competence or in young children. Plyometric exercise starts with a rapid stretch of a muscle followed by a rapid shortening. The nervous system is conditioned to react more quickly to the stretch-shortening cycle. This type of exercise can enhance a childs speed of movement, increase power production (5,15,18,21), and strengthen bone (11). Plyometric training programs have been shown to be effective in adults and pubertal children for improving running speed and jumping ability (17) and for increasing strength (21). Strength training can improve muscle performance and coordination of muscle groups, however, to improve sport performance, children benet more from practicing and perfecting skills of the sport (4). Therefore, plyometric training may be an appropriate intervention for improving the motor ability of children to run, jump, hop, skip, kick, and throw. Plyometric training produces dynamic movements and greater force on muscles and bones. Historically, plyometric BRIEF REVIEW Address correspondence to Barbara A. Johnson, bajohnson@shrinenet. org. 25(9)/26232633 Journal of Strength and Conditioning Research 2011 National Strength and Conditioning Association VOLUME 25 | NUMBER 9 | SEPTEMBER 2011 | 2623 Copyright National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited. training was deemed unsafe for youth, and a predetermined level of strength was a prerequisite for participation in a plyometric program. However, an update fromthe National Strength and Conditioning Association determined that this recommendation was not supported by current research or observation of everyday play activities (10). Currently, a limited number of studies have examined the inuence of plyometric exercise on young children. Only 2 studies of prepubertal children were included in a meta-analysis of plyometric training (17,21). Clearly, more research is needed to understand young childrens response to plyometric exercise. It will also be necessary to determine the safest and most effective method for progressing exercise load and to clarify the need for strength or motor skill prerequisites for participating in plyometric training. The purpose of this systematic review was to examine the extent and quality of the current research literature, to evaluate the efcacy and safety of plyometric training for improving motor performance in young children, and to determine if this type of training could be used to improve the motor skills of children with low motor competence. METHODS Experimental Approach to the Problem To obtain relevant literature on plyometric training, abstracts and citations were identied through a search using the Elton B Stephens Company (EBSCO) and Proquest search engines in March 2010. Databases selected within these search engines include Cumulative Index to Nursing and Allied Health Literature (CINAHL), HealthSource, SportDisc, and MEDLINE. The initial search focused on nding literature using plyometric training in children with low motor prociency or low motor competence. Search terms included physical therapy interventions, developmental coordina- tion disorder, low motor competence, low motor prociency, running training, jump training, and plyo- metric exercise in various combinations. Two hundred twenty-seven articles were located. The abstracts were reviewed, and there were no articles that described using plyometric training as an intervention for children with low motor competence, low motor prociency, or for children with developmental coordination disorder. A new search was undertaken to identify articles describing plyometric training programs for children. The following search terms were used in various combinations to identify primary research articles: plyometric exercise, plyometric training, jump training, children, strength, balance, bone density, motor training, neuromotor training, and sport performance. The earliest randomized control trial to describe motor outcomes of plyometric training on strength and balance in young children was published in 1998. Therefore, only research articles published in the last 12 years were selected for review. Inclusion Criteria. Primary research articles were selected if they (a) described the outcomes of a plyometric exercise intervention; (b) included measures of strength, balance, running speed, jumping ability or agility; (c) included prepubertal children 514 years of age; and (d) used a randomized control trial or quasiexperimental design. Articles that met the 4 inclusion criteria were chosen for the nal review. The reference lists of primary articles were searched for additional research. Judging the Quality of the Evidence. The Physiotherapy Evidence Database (PEDro) Scale was used to evaluate the quality of the research, and each study was coded for the 11 items described in the PEDro criteria (19). Table 1 describes the results of the quality rating. Intrarater agreement for this review was determined by having a second physical therapist rate the quality of 3 randomly selected studies and comparing agreement between the 2 raters. The operational denitions of the PEDro criteria for rating quality were reviewed and consensus was established for the rating process. The 2 raters were in exact agreement for the 3 studies. Synthesis of the Research. The GRADE method (1) is a recent system for rating medical evidence which considers the consistency or homogeneity of the effect size across studies and the directness of the evidence (the extent to which the people, interventions, and outcome measures are similar to those of interest). Effect sizes were calculated for those studies that reported means and SD s using Cohens d. Cohens description was used to classify effect sizes as small, mediumor large (3). The concepts of consistency and directness from the GRADE method were adopted to synthesize the results of the research. The author, source, date of publication, purpose, design, exercise protocol, sample characteristics, primary outcomes and study results are listed in Table 2. The articles were organized into categories to assist with synthesis (Tables 35). We looked for information about the directness of the intervention (Table 3), the dosage of the intervention, that is, frequency, duration, intensity, number of repetitions (Table 4), the inuence on motor skill perfor- mance, that is, running, jumping, agility, balance, throwing, and kicking, strength or power (Table 5), and safety. RESULTS The process for identifying, screening, and selecting the nal studies for analysis is depicted in Figure 1. The 8 studies were judged to be of low quality (values of 36). Across the 8 studies, the strengths were (a) similarity of groups at baseline; (b) statistically signicant results; and (c) methods that addressed biases from maturation, gender, and age. The weaknesses were (a) the lack of blinding of evaluators, subjects, and coaches; (b) the lack of the use of condence intervals to demonstrate statistical precision; (c) the lack of reporting of effect sizes to describe the magnitude of change; and (d) the exclusion of drop-outs in the statistical analysis (intention to treat). The mean PEDro rating for the studies was 4.5 out of 10. The low quality rating of the studies reects 2624 Journal of Strength and Conditioning Research the TM Plyometric Training Review Copyright National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited. TABLE 1. Quality rating. PEDro criteria Study Witzke and Snow (23) Diallo et al. (5) Ingle et al. (14) Kotzamanidis (15) Meylan and Malatesta (18) Rubley et al. (20) Faigenbaum et al. (9) DiStefano et al. (6) Eligibility criteria specied Yes Yes Yes Yes Yes Yes Yes Yes Random group allocation 0 1 1 0 0 0 0 1 Concealed allocation 0 0 0 0 0 0 0 0 Similar groups at baseline 0 1 1 1 1 1 1 1 Blinding of subjects 0 0 0 0 0 0 0 0 Blinding of coaches 0 0 0 0 0 0 0 0 Blinding of assessors 0 0 0 0 0 0 0 0 85% of subjects received 1 key measurement 1 1 0 1 1 1 1 1 Intention to treat 1 1 0 1 0 0 0 0 Statistical sig reported for 1 key outcome 0 1 1 1 1 1 1 1 Effect sizes (Cohens d) or condence levels reported 0 0 0 0 0 0 0 1 Totals (10 possible) 3 6 4 5 4 4 4 6 V O L U M E 2 5 | N U M B E R 9 | S E P T E M B E R 2 0 1 1 | 2 6 2 5 J o u r n a l o f S t r e n g t h a n d C o n d i t i o n i n g R e s e a r c h t h e TM | w w w . n s c a - j s c r . o r g Copyright National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited. TABLE 2. Evidence table.* Author source Purpose Design (D), Protocol (P) Sample population Outcome measures Results Witzke and Snow (23), Med Sci Sports Exerc To investigate the effects of 9 mos of plyometric jump training on bone mineral content, lower extremity performance and static balance. Design (D) quasiexperimental Power analysis not reported.(N = 54 women) Isokinetic dynamometry Groups equivalent in pretest Protocol (P) weeks 14 = 40100 jumps, weeks 59 = 3601,000 jumps per week; 100 per session. Purposive selection Static balance No signicant difference in any variables between groups Instruction included Matching for age and months postmenarche Block Food Frequency Questionnaire T tests demonstrated Home program performed 33 wk for the 9-mo school year. Mean age = 14 6 6 y SD 0.6 Signicant [ in leg strength and bone mineral content at hip in exercise group PE class recruitment (both athletes and nonathletes) Diallo et al. (5), J Sports Med Phys Fitness To examine the effectiveness of plyometric training and maintenance on performance of prepubescent soccer players. (D) Random assignment purposive selection Power analysis not reported (N = 20 men) SJ, CMJ, DJ, M5B Body mass [ in both groups (p , 0.01) (P) 33 wk for 10 wks Mean age = 12 6 3 y, SD 0.4 Sensitivity/specicity of outcome measures reported % Body fat Y in the experimental group (p , 0.05) then increased in maintenance (p , 0.05) 70 Per session per session initially, progressed to 200 300 jumps per session at the end Tanner stage reported Sprint-cycling performance [ (p , 0.01) Intensity [ after 5 wks Participants were athletes CMJ [ (p , 0/01) M5B [ (p , 0/01) Kotzamanidis (15), J Strength Cond Res To examine the effectiveness of plyometric training and maintenance on performance of prepubescent soccer players (D) Quasiexperimental convenience sample Power analysis not reported SJ Sig [ in running velocity in 1020 m run and 2030- m run, not 10-m run (P) 10 wks, 23 wk N = 20 male soccer players Used Chus protocol for increasing intensity Mean age = 12 6 3 (no SD) Running velocity Sig [ in jump time 60 Jumps per session initially, progressed to 100 jumps per session at the end Compared a plyometric training group to a group receiving physical education 2 6 2 6 J o u r n a l o f S t r e n g t h a n d C o n d i t i o n i n g R e s e a r c h t h e TM P l y o m e t r i c T r a i n i n g R e v i e w Copyright National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited. Meylan and Malatesta (18), J Strength Cond Res To determine the inuence of a short-term plyometric training within regular soccer practice on explosive actions of early pubertal soccer players during the in season. (D) Quasiexperimental Power analysis not reported SJ (ight time) No impact on ground contact time Purposive sample N = 25, mean, age = 13 6 3 y, SD = 0.6 CMJ No impact on M5BT (P) 8 wks, 23 wk Gender not reported Agility test Sig [ in sprint time 32 Jumps per session initially, 92 jumps per session at the end All played soccer in the same league Running velocity Sig [ in agility time Tanner stage not reported M5B Rubley et al. (20), J Strength Cond Res To measure the effects of low frequency, low- impact plyometric training on vertical jump and kicking distance in female adolescent soccer players (D) Quasiexperimental Power analysis not reported Vertical jump 5 trials, 3 best ave No sig diff over time in control group Purposive selection N = 16, 10 training, 6 control No diff between groups pretest or 7 wks posttest (P) 14 wks, 13 wk Mean age = 13 6 4 y, SD = 0.5 Kicking distance Sig higher jump height at 14 wks 16 Jumps per session initially, progressed to 60 jumps per session at the end Female soccer players Sig greater kicking distance at 14 wks in training group Faigenbaum (9), Physical Ed To examine the effects of a school-based plyometric training program on childrens tness performance (D) Quasiexperimental Power analysis not reported Presidential Council of Physical Fitness test Sig greater gains in long jump, push-up, and half mile run Purposeful selection N = 74, 40 children training group, 34 children control Random assignment Mean age = 8 6 11 y HR met guidelines for vigorous physical activity (P) 23 wk, 9 wks, Reps Y as intensity [ 120 per session initially, progressed to 72 jumps per session at the end Boys and girls, 2 third- grade classes and 2 fth- grade school PE classes from the same school DiStefano et al. (6), J Strength Cond Res Compare the effects of a pediatric program to a traditional program (D) Randomized control trial Power analysis not reported Ground reaction forces during countermovement vertical jump Sig greater improvement in TTS in the anterior/ posterior direction Purposeful selection N = 66, 22 traditional training, 22 pediatric training protocol, 22 control group TTS on depth jump on 1 leg No sig differences in ground reaction forces during countermovement vertical jump Stratied assignment to group based on age and sex Mean age = 10 6 1 y, 37 men, 29 women from 67 soccer teams (P) 33 wk, 9 wks Exercise load remained constant *SJ = squat jump; CMJ = countermovement jump; DJ = drop jump; M5B = running velocity multiple 5 bound test; TTS = time to stabilization; HR = heart rate. V O L U M E 2 5 | N U M B E R 9 | S E P T E M B E R 2 0 1 1 | 2 6 2 7 J o u r n a l o f S t r e n g t h a n d C o n d i t i o n i n g R e s e a r c h t h e TM | w w w . n s c a - j s c r . o r g Copyright National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited. the limited amount of research into this topic area and suggests that caution be exercised when interpreting the results. These 8 studies are the initial attempts of researchers evaluating the efcacy of plyometric exercise training in prepubertal children. Despite the low quality ratings, useful information can be gained to determine the current state of knowledge regarding plyometric training and to identify future research recommendations. The aims of this review were to rst determine the efcacy of plyometric training for improving motor performance, then to determine the optimum exercise dosage, and nally to determine the safety of plyometric training for children. The following paragraphs describe our ndings. Efcacy of Plyometric Training for Improving Motor Performance Seven of the 8 studies (5,6,9,14,15,18,20) found statistically signicant effects for improving motor performance. The study by Witzke and Snow (23) did not nd statistically signicant results. A close examination of the Witzke and Snow (23) study suggested that the control group had greater initial strength and power values and had participated in more sports than the treatment group, possibly inuencing their results. Therefore, only the results of 7 studies will be discussed. The evidence describing the efcacy of plyometric training is described in Table 5. A total of 275 children participated in the 7 studies. The participants ranged in age from 8 to 14 (mean age of 13). Diallo et al. (5), Ingle et al. (14), Kotzamandis (15), and Rubley et al. (20) all studied participants of the same sex and age (12- to 13-year-old boys) which accounted for possible age/sex bias. All 7 studies described programs consisting of jumping, hopping, skipping, bounding, and jumping over hurdles. Ingle et al. (14) added resistive exercises, Rubley et al. (20) added footwork and sprint drills, Faigenbaum et al. (9) added sprints and throws, and DiStefano et al. (6) added strengthening and balance TABLE 3. Directness of the intervention. Construct Articles Results Conclusion Age Witzke and Snow (23) Mean =14.6-y-olds The studies included children 814 y of age although tended to enroll at the older end of the age spectrum. Those enrolling older children used Tanner levels to determine prepubertal status. One study used stratied sampling by age and gender of 9- to 10-y-olds Diallo et al. (5) Mean = 12.3-y-olds Ingle et al. (14) Mean = 12.3-y-olds Kotzamanidis (15) Mean = 12.3-y-olds Meylan and Malatesta (18) Mean = 13.3-y-olds Rubley et al. (20) Mean =13.3-y-olds Faignebaum et al. (9) 2 Classes of 8- to 9-y-olds, 2 classes of 10- to 11-y-olds DiStefano et al. (6) Mean = 10.1-y-olds Gender Witzke and Snow (23) Women The majority of studies (71%) studied 1 gender of participants. Diallo et al. (5) Men Ingle et al. (14) Men Kotzamanidis (15) Men Meylan and Malatesta (18) Women Rubley et al. (20) Gender not reported Faignebaum (9,10) Both DiStefano et al. (6) Both Motor prociency Witzke and Snow (23) Typical children All studies used typically developing children or athletes with average or above average motor abilities. Diallo (5) Athletes Ingle et al. (14) Typical children Kotzamanidis (15) Athletes Meylan and Malatesta (18) Athletes Rubley et al. (20) Athletes Faignebaum (9) Typical children DiStefano (6) Athletes Primary outcome Witzke and Snow (23) Reliability reported The reliability was reported in 50% of the studies. Validity was not reported in any study. Diallo et al. (5) Reliability not reported Ingle et al. (14) Reliability not reported Kotzamanidis (15) Reliability not reported Meylan and Malatesta (18) Reliability reported Rubley et al. (20) Reliability reported Faignebaum et al. (9) Reliability not reported DiStefano et al. (6) Reliability reported 2628 Journal of Strength and Conditioning Research the TM Plyometric Training Review Copyright National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited. exercises to the plyometric program. Five studies (5,6,17,18,20) included athletes from sports programs, and 2 studies (9,14) included typical children from local schools. The outcomes evaluated were jumping (squat jumps, long jumps, vertical jumps, depth jumps, countermovement jumps, and multiple bounding), running velocity (distances from 10 m to one-half mile), balance, agility, strength, and kicking distance. Three studies (15,18,20) measured the ability to jump and found statistically signicant improvements in jumping ability with large effect sizes (d = 2.2, 2, and 1.41, respectively). One study (9) had a small effect size (d = 0.24) possibly because the outcome instrument used may not have been as sensitive to change (Presidential Fitness Test vs. timed tasks from take-off to landing), and the purpose was to examine the effects of a school-based plyometric training program. One study (6) did not nd a statistically signicant change in vertical jump although it did not progress the plyometric exercise load during the 9-week program. Four studies measured running velocity (5,9,15,18). Three demonstrated statistically signicant improvements and provided sufcient data to calculate effect size. Meylan and Malatesta (18) had a large effect size (21.28), Kotzamanidis (15) had a moderate effect size (d = 20.75), and Faigenbaum et al. (5) had a small effect size (d = 0.22). Faigenbaum et al. (5) included sprint drills and measured a half mile run. The 2 studies with the larger effect sizes performed only jump exercise and demonstrated a large effect for running short distances (between 10 and 30 m). Two studies (9,14) measured strength outcomes and both demonstrated statistically signicant improvements. The study by Faigenbaum et al. (9) produced a small effect size (d = 0.23), and the study by Ingle et al. (14) a moderate effect size (d = 0.59). The study by Ingle et al. (14) may have shown a larger effect because of the addition of resistive exercise training to the plyometric program. Outcomes for agility, balance, and kicking were measured in 1 study each. Meylan and Malatesta (18) measured agility and demonstrated a statistically signicant improvement, with a large effect size (d = 22.15). Rubely et al. (20) measured kicking distance and demonstrated a statistically signicant improvement with a large effect size (d = 2.62). DiStefano et al. (6) measured balance and demonstrated TABLE 4. Consistency intervention effect.* Construct Articles Results Conclusion Strength power Witzke and Snow (23) No signicant improvement (typical) The current evidence suggests that plyometric training produces a small effect on strength and a moderate effect on power Faigenbaum et al. (9) Signicant [, small ES (typical) Ingle et al. (14) Signicant [, mod ES (typical) Running Diallo (5) Signicant [, ES not known (athlete) The current evidence suggests that plyometric training produces a variable effect on running speed with athletes making the greatest improvement in shorter distance running. Kotzamanidis (15) Signicant [, mod ES (typical) Faigenbaum et al. (9) Signicant [, small ES (typical) Meylan and Malatesta (18) Signicant [, large ES (athletes) Jumping Diallo et al. (5) Signicant [, ES not known The current evidence suggests that plyometric training produces a large effect on jumping ability Kotzamanidis (15) Signicant [, large ES (typical) Meylan and Malatesta (18) Signicant [, large ES (athlete) Rubley et al. (20) Signicant [, large ES (athlete) Faigenbaum et al. (9) Signicant [, small ES (typical) DiStefano et al. (6) No sig improvement Throwing Ingle et al. (14) Not signicant Unknown effect on throwing Agility Meylan and Malatesta (18) Signicant [, large ES (athlete) The current evidence suggests that plyometric training produces a moderate effect on agility Kicking Rubley et al. (20) Signicant [, large ES (athlete) The current evidence suggests that plyometric training produces a large effect on kicking (1 study) Balance DiStefano et al. (6) Signicant [ in the forward and backward direction The current evidence suggests a traditional comprehensive training program including plyometric training improved in the forward and backward direction *ES = effect size. VOLUME 25 | NUMBER 9 | SEPTEMBER 2011 | 2629 Journal of Strength and Conditioning Research the TM | www.nsca-jscr.org Copyright National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited. TABLE 5. Consistency of exercise dosage. Construct Articles Results Strength rating and conclusion Duration Witzke and Snow (23) No effect from 9 mos home program Moderate (3 studies): The current evidence suggests that a training effect could be achieved with a 10-wk program. Two studies suggest that a training effect could be achieved with a 9-wk program. One study suggests that a training effect could be achieved in 8 wks Diallo et al. (5) Effect from 10-wk program Ingle et al. (14) Effect from 12-wk program Kotzamanidis (15) Effect from 10-wk program Meylan and Malatesta (18) Effect from 8-wk program Rubley et al. (20) No effect at 7 wks, effect at 14 wks Faignebaum et al. (9) Effect from 10-wk program DiStefano et al. (6) Large effect from a 9-wk program Frequency Witzke and Snow (23) 3 Times a wk Moderate (3 studies): The current evidence suggests that a twice a wk program with a minimum of 1620 sessions can produce a training effect. Diallo et al. (5) 3 Times a wk, 30 sessions Ingle et al. (14) 3 Times a wk, 36 sessions Kotzamanidis (15) 2 Times a wk, 20 sessions Meylan and Malatesta (18) 2 Times a wk, 16 sessions 13 wk with 14 sessions showed changes although required a longer period of time. Rubley et al. (20) 1 Time a wk, 14 sessions Faignebaum et al. (9) 2 times a wk, 20 sessions DiStefano et al. (6) 3 Times a wk, 27 sessions No. of jumps Witzke and Snow (23) 100 Jumps per session initial, 360 end Moderate (3 studies) Diallo et al. (5) 200 Jumps per session initial, 300 end Ingle et al. (14) 64 Jumps per session initial, 120 end Kotzamanidis (15) 60 Jumps per session initial, 92 end Meylan and Malatesta (18) 50 Jumps per session initial, 192 end The current evidence suggests beginning at 5060 jumps per session at the beginning of the intervention and performing 92190 jumps per session by the end of intervention. One study suggests that 60jumps a session over a longer period of time will produce a training effect. One study demonstrated that 30 jumps over 27 sessions would improve balance. Rubley et al. (20) 16 Jumps per session initial, 60 end Faignebaum et al. (9) 120 Jumps per session initial, 72 end DiStefano et al. (6) 30 Jumps per session initial, 30 jumps end Progression of intensity Diallo et al. (5) Approximate [ 10 jumps per wk. Very low Ingleet al. (14) Approximate [ of 5 jumps per wk The intensity of the program was progressed in all but 1 study. No 2 studies [ # of reps per week at the same rate. Kotzamanidis (15) Approximate [ of 12 jumps per wk The Meylan and Kotzamanidis studies demonstrated large effects on jumping with their interventions Meylan and Malatesta (18) Approximate [ of 18 jumps per wk Rubley et al. (20) Approximate[ of 3 jumps per wk Faignebaum et al. (9) Decreased repetitions as intensity increased DiStefano et al. (6) Did not progress exercise load Maher, G, Sherrington, C, Herbert, RD, Moseley, AM, and Elkins, M. Reliability of the PEDro Scale for Rating Quality of Randomized Controlled Trials. Phys Ther 83: 713721, 2005. 2630 Journal of Strength and Conditioning Research the TM Plyometric Training Review Copyright National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited. a statistically signicant improvement with a large effect size (d = 2.30). The participants in all of these studies were soccer players, and the soccer training may have inuenced kicking and agility. The evidence suggested that plyometric training had a large effect on improving the ability to jump. This result would be expected because the interventions in all studies included jump training. The evidence suggested that plyometric training also had an effect on running velocity, although the effects were not consistently large across studies. The effects were greatest for the 30-m distance and small for the half mile run. Plyometric training also had a large effect on improving kicking distance and agility. The jump training may have had some transfer effect to these skills, although the participants soccer training may have accounted for the improvements seen in agility and kicking distance. Despite the large effect size for agility and kicking improvement, there was only one randomized controlled trial on each outcome. Exercise Dosage The evidence for recommending an exercise dosage is summarized in Table 5. Seven studies (5,6,9,14,15,18,20) demonstrated statistically signicant results and were used for judging the consistency of the exercise dosage. The categories evaluated were frequency, duration, number of jumps, and the method for increasing exercise load. The frequency of the training programs varied across studies from once a week to 3 times a week. The early studies performed by Witzke and Snow (23) and Diallo et al. (5) exercised children 3 d wk 21 with large number of jumps per session (100200 at the beginning of the session and 300360 at the end). Witzke and Snow (23) did not nd signicant results. The Diallo et al. (5) study demonstrated statistical signicance; however, they did not include data for calculating the effect size, so the magnitude of the change was unknown. Later studies exercised children twice a week starting at 5060 jumps and ending at 92192 jumps a session. Meylan and Malatestas (18) study showed the largest effect sizes on running, jumping, and agility and incorporated a twice a week program for 8 weeks. These authors began at approximately 50 jumps per session and increased 18 repetitions a week to approximately 192 jumps per session by the end of the intervention. Kotzamandis (15) had a similar program and also produced large effect sizes for running and jumping. Rubley et al. (20) exercised children once a week for 14 weeks with a low number of jumps (16 jumps per session progressing to 60 at the end of 14 weeks). This study did not have as large an effect size on jumping as the studies by Meylan and Malatesta (18) or Kotzamandis (15). Faigenbaum et al. (9) and Ingle et al. (14) exercised children twice a week for 20 weeks and decreased repetitions as intensity increased. These authors also used a method for increasing exercise load. However, they did not describe their methods in as much detail and their training program resulted in smaller effect sizes for running, jumping, and strength improvement. DiStefano et al. (6) exercised children 3 times a week for 9 weeks; however, this did not increase the exercise load. This study had a large effect on improving balance. The current evidence suggests that a twice a week program for 8 to 10 weeks beginning at 5060 jumps a session and increasing repetitions weekly by 1218 repetitions to a maximum of 90190 results in the largest changes in running and jumping performance. An alternative program for children who do not have the capability or tolerance for a twice a week program would be a low intensity program for a longer duration (20). Only 1 study (14) performed a follow- up evaluation 12 weeks after the intervention. A decline of strength occurred toward baseline at the follow-up evalua- tion indicating a need to continue the exercise training to maintain strength gains. Safety Two studies documented that there were no injuries during the intervention. Faigenbaum et al. (9) exercised 74 children and DiStefano et al. (6) exercised 66 children without a single injury or complaint of muscle soreness. Additionally, every study addressed safety in the description of the intervention. Each study reported Institutional Review Board approval and consent of parents and assent of participants. Two studies (5,9) reported low participant to instructor ratios (1:4 and 1:5, respectively) during the intervention. Five studies (5,6,9,15,18) Figure 1. Summary of the review process. VOLUME 25 | NUMBER 9 | SEPTEMBER 2011 | 2631 Journal of Strength and Conditioning Research the TM | www.nsca-jscr.org Copyright National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited. described a warm-up and cool-down period, emphasized instruction and correct technique, and assured the use of appropriate exercise surfaces and exercise spaces. Meylan and Malatesta (18) described a program that was tailored to the childs capability. DISCUSSION Previous reviews of research on adults suggested that plyometric exercise improves strength (21), running, and jumping (17). The results of this review of the literature on young children also suggested that plyometric training had a large effect on improving the ability to jump (15,18,20) and run (15,18), but only a small effect on improving strength (9,14). The small effect on improving strength may be explained by the differences in the mechanisms for strength gain in prepubertal children. Strength gains in young children have been attributed to intrinsic muscle adaptation and neural adaptation because prepubertal children lack circu- lating androgens responsible for muscle hypertrophy (12). The evidence suggested that plyometric training also had a large effect on improving kicking distance (20), balance (6), and agility (18), although replication of these results with another carefully controlled study would improve our condence in the outcomes from this research. The participants in the research for this review had average or above average motor competence (healthy, typically developing children or athletes). More information is needed to determine if children with low motor competence and possible comorbidities such as learning and attention problems or musculoskeletal impairments can participate in and benet from plyometric training. Children develop motor prociency by spontaneously engaging in running and jumping activities on a daily basis. Children with low motor competence are not as procient at running and jumping resulting in decreased participation in active games and sports. Plyometric training has the potential for improving running and jumping abilities if similar improvements can be obtained safely in children with low motor competence. Future research should also evaluate the generalization of learning beyond the intervention sessions and the transfer of skills to physical activity in daily routines. There are many components of motor performance that contribute to learning how to run, skip, hop, jump, kick, and throw. Task-specic interventions emphasize teaching func- tional motor skills and using principles of motor learning (verbal instructions; amount, structure and schedule of practice; and frequency of feedback) to enhance the intervention and enhance the generalization or transfer of learning to new situations (16). Meylan and Malatestas (18) study resulted in the largest effect size on running and jumping. The authors provided a comprehensive description of the intervention, the exercise dosage, detailed participant instructions, and described the focus for each session. First, they emphasized technique including an upright posture, body alignment, avoiding excessive side to side movement in vertical jumps, soft landings, and instant recoil to prepare for the next jump. The specicity of verbal instruction about the task requirements may have resulted in enhanced understanding of the task. Verbal feedback on the results of task performance may have also enhanced learning. Next, they adapted the exercises to the coordination capacity of the children and encouraged children to perform at full speed. The drills lasted only 10 seconds with a 90-second rest period between drills. Sessions were separated by 48 hours. The focus of 1 session was to work on vertical power, the second session to work on horizontal power. The intensity and progression were determined by considering both intensity of the exercise and number of ground contact times. The load was varied and the researchers used a blocked practice paradigm. Load was progressed for 3 weeks, decreased slightly the fourth week, increased again for weeks 5 and 6, decreased slightly for week 7, and increased in week 8. The attention to principles of exercise and sport science for optimizing the benets of plyometric exercise may have been responsible for the greater improvements. DiStefano et al. (6) found that a pediatric program with 3 progressive phases was not as effective as a traditional program. The 9-week progressive pediatric program may not have performed phase 3 exercises long enough or provided a sufcient exercise load to cause change in jumping ability and balance. Safety is always a concern when initiating an exercise intervention for children because of the possibility of injury, muscle soreness, overtraining, or frustration. Many of the studies included a description of procedures to address safety concerns. The plyometric training programs were relatively short (1025 minutes), included a warm-up and cool down, had a low instructor to student ratio, emphasized correct technique, provided guidelines for progressing the work load, and were carried out on appropriate exercise surfaces and in exercise spaces. The research suggests that plyometric training is safe for children when parents provide consent, children agree to participate, and safety guidelines are built into the intervention. The National Strength and Conditioning Association guidelines call for adequate supervision and a properly designed resistance training program for children. Plyomteric exercise may be one of a variety of developmentally appropriate activities included in a training program for young children. However, coaches should use caution when undertaking plyometric training interventions for young children because the research to determine the safety and efcacy is in its infancy. Future research is necessary (a) to determine if there should be strength or motor skill achievement prerequisites for participating in plyometric training, (b) to replicate the safety and efcacy of plyometric training for prepubertal children, and (c) to identify appropri- ate progression of the exercise load during plyometric training. PRACTICAL APPLICATIONS The plyometric training programs used in the studies reviewed for this manuscript can be used to design an exercise program. The results of this review indicate that 2632 Journal of Strength and Conditioning Research the TM Plyometric Training Review Copyright National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited. plyometric training programs are effective for improving running and jumping abilities in school children and athletes between 8 and 14 years of age when the following guidelines are followed. The studies which demonstrated the greatest improvements used plyometric training alone without additional training methods such as strengthening exercises, sprinting drills, or throwing during the 8- to 10-week program. Because the safety of plyometric training has not been rigorously evaluated in young children, coaches should include safety precautions in implementing these exercises. Training effects can be achieved with a twice a week programfor 810 weeks on nonconsecutive days. The focus of the exercise should be specic to the desired outcome, that is, if vertical jump height is the desired outcome, vertical power should be emphasized in the plyometric training program. Training effects can also be achieved with a low intensity, 1 day a week program for 14 weeks. Exercise load should be increased weekly by increasing the repetitions or the level of difculty of the jumps. Research on adults has used time to stabilization (7) and electromy- ography (8) to quantify the intensity and nature of different plyometric exercises and these studies may be useful for determining an exercise load in children. Exercise load must be increased to cause improvement; however, no study has been conducted to evaluate the most effective means of increasing the exercise load safely in young children. Research suggests beginning the 10-week exercise session with 5060 jumps the rst week and progress to 90100 jumps by the end of the 10-week session. If a once a week program is chosen, begin with 16 jumps the rst week and progress to 60 jumps by the end of a 14-week session. A once a week low-intensity program results in smaller improvements in running and jumping ability. Exercise sessions should be 1025 minutes in duration with a sufcient warm-up and cool-down. Children should wear appropriate footwear, exercise in appropriate environ- ments, and exercise on absorbent surfaces (grass or mats). Plyometric drills should last approximately 10 seconds with a 90-second rest between drills. There should be a low instructor-to-student ratio (1 in- structor to 4 or 5 students). Instructors should emphasize the correct technique and adapt the drills to the capacity of the child. REFERENCES 1. 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