Diaphragmatic-Based Complementary Training in Basketball: The Science Behind Pre-Activation of Inspiratory Muscles - A Randomized Trial
Phase: NA
Conditions: Inspiratory Muscle Strength
Sponsor: Burak Karaca

 
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Official Title: Diaphragmatic-Based Complementary Training in Basketball: The Science 
Behind Pre-Activation of Inspiratory Muscles – A Randomized Trial 
 
 
NCT Number:  
 
 
Document Date: February, 1, 2023 
 
 
 
For any inquiries regarding this document, please contact the principal investigator. 
 
 

 
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Diaphragmatic-Based Complementary Training in Basketball: 
The Science Behind Pre-Activation of Inspiratory Muscles – A 
Randomized Trial 
Burak Karaca¹*, Mustafa Özdal¹, Ali Yıldırım² 
¹Faculty of Sport Sciences, Physical Education and Sport, Gaziantep University, Gaziantep, 
Turkey 
²School of Physical Education and Sport, Kilis 7 Aralık University, Kilis, Turkey 
Conflict of Interest Disclosure: None. 
Correspondence Address: 
Burak Karaca 
Faculty of Sport Sciences, Physical Education and Sport, Gaziantep University, Gaziantep, 
Turkey 
University Boulevard 
27310 Şehitkamil - Gaziantep, TURKEY 
Phone: +905436696294 
Email: burakkaracapt@gmail.com 
Running Title: Inspiratory muscle warm-up on basketball 
 
Abstract 
Background: Inspiratory muscle pre-activation (IMpa) has been suggested as a potential 
strategy to enhance athletic performance by improving respiratory muscle function and 
reducing fatigue. However, its immediate effects on basketball skills remain unclear. This 
study aimed to investigate the impact of IMpa on passing, dribbling, and shooting 
performance in basketball players. 
Methods: Ten healthy male basketball players (aged 18–25) participated in a randomized, 
placebo-controlled, crossover study. Each player completed four different trials on separate 
days: (1) Control (CON), (2) Inspiratory muscle pre-activation (IMpa, 40% maximal 
inspiratory pressure), (3) Placebo inspiratory muscle pre-activation (IMPpa, 5% maximal 
inspiratory pressure), and (4) General warm-up (GW). Basketball skills were assessed using 
the Johnson basketball skill test and the AAHPERD speed shooting test. Statistical analyses 
were performed using repeated measures ANOVA (p < 0.05). 
Results: Significant improvements were observed in the IMpa and GW conditions compared 
to the CON and IMPpa trials. The IMpa trial increased passing accuracy by 21.97% (p < 0.05) 
and speed shooting performance by 13.09% (p < 0.05) compared to the CON trial. No 
significant differences were observed in dribbling and shooting scores among the trials (p > 
0.05). 
Conclusions: Inspiratory muscle pre-activation at 40% maximal inspiratory pressure 
improves passing accuracy and speed shooting performance in basketball players. This 
diaphragmatic-based approach can serve as a complementary warm-up strategy to enhance 
precision-based basketball skills 

 
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Trial registration 
Clinical trial number: not applicable. 
Keywords: respiratory, exercise, accuracy, innovative training 
 
 
Introduction 
The capacity of athletes to demonstrate their abilities to the fullest extent is contingent upon 
their physical fitness. Oxygen delivery and utilization become crucial during athletic pursuits, 
as muscle oxygen demand increases with exercise [1]. The mechanical functioning of the 
respiratory system is largely dependent on the capacity of the respiratory muscles [2]. For 
these reasons, inspiratory muscle pre-activation, which positively affects the efficiency of 
pulmonary circulation, increases the functional capacity of the respiratory muscles [3], 
reduces fatigue in the respiratory muscles [4], and plays a critical role in exercise physiology 
and athlete performance. 
It has been demonstrated that inspiratory muscle exercises elicit a range of effects on 
performance. Studies show reductions in blood lactate levels among short-distance runners, 
thereby facilitating a positive enhancement in the post-performance recovery process [5], 
improve respiratory functions and both aerobic and anaerobic capacity in basketball players 
[6], positively affect performance in Olympic swimmers [7], increase performance in 
professional rowers [8] and cyclists [9], enhance aerobic exercise performance in wheelchair 
basketball players [10], affect exercise performance in tennis players [11], increase 
performance in professional football players [12] and handball players [13], affect shooting 
performance in archers [14], positively affect shot-hit performance in ice hockey players [15], 
and increase shot and drag-flick hit performance in hockey players [16]. Nevertheless, there is 
a paucity of data concerning the impact of inspiratory muscle pre-activation on basketball 
performance. Many of these studies focus on longer-term training adaptations rather than a 
single short session of pre-activation. 
The fundamental techniques of basketball can be classified into four main categories: passing, 
shooting, dribbling, and rebounding. Of these, shooting and passing are skills that require a 
high degree of accuracy in order to be performed effectively within the context of the game 
[17]. A review of the literature reveals that training the inspiratory muscles is an effective 
method for improving athletic skills that require accuracy [14,15,16], as it enhances the 
stabilization of core muscles [18,19,20]. However, the exact mechanism by which a brief 
inspiratory muscle pre-activation session might benefit precision-based movements remains 
under discussion. Therefore, the aim of this study was to examine whether a diaphragmatic-
based method to prepare inspiratory muscles could improve passing, dribbling, and shooting 
among basketball players. By evaluating its immediate impact on key basketball tasks, we aim 
to clarify the value of such exercises in routine training. 
 
Methods 

 
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Participants 
The sample size was determined based on a power analysis using previous studies that 
investigated the effects of inspiratory muscle training on athletic performance. A minimum 
sample size of 10 participants was estimated to achieve a statistical power of 80% (β = 0.20) 
with an alpha level of 0.05, assuming a moderate effect size (Cohen’s d = 0.5–0.6). The study 
involved 10 healthy male participants, aged between 18 and 25 years (mean age: 21.1 ± 2.42 
years), who were engaged in competitive basketball. In order to be included in the study, the 
basketball players had to be free of both chronic and acute upper respiratory tract infections, 
as well as any chest diseases. The recruitment period took place between [01, 2023] and [02, 
2023], during which participants were screened and enrolled in the study. The follow-up 
period, consisting of four separate experimental sessions per participant with a 48-hour 
washout period between conditions, was completed by [02, 2023]. All data collection and 
assessments were finalized within this timeframe, ensuring consistency across all participants. 
No interim analyses were performed in this study. Given the crossover design and the 
relatively small sample size (n=10), all participants completed all four intervention 
conditions, and no predefined stopping criteria were established. The study was conducted in 
a controlled environment with strict adherence to standardized procedures, ensuring that all 
participants completed the experimental trials without modifications to the original protocol. 
Therefore, no early termination or adaptive adjustments were necessary.The study was 
conducted in accordance with the ethical standards of the Declaration of Helsinki (52nd 
World Medical Association General Assembly, Edinburgh, Scotland, October 2000) and was 
approved by the Gaziantep University Social and Human Sciences Ethics Committee 
(approval number: 2023-2). Prior to the commencement of the study, informed consent was 
obtained from all participants. 
Experimental design 
The study was designed according to a randomized, placebo-controlled, crossover structure. 
Following the initial familiarization session, participants underwent a series of skill tests on 
four occasions throughout the course of the study, in accordance with established pre-activity 
steps. During this initial session, participants were provided with general information about 
the research project and study procedures. Additionally, baseline measurements, including 
age, height, and weight, were recorded, and an orientation session was conducted to ensure 
participants were familiar with the testing protocols. In the subsequent four visits (1st, 2nd, 
3rd, and 4th visits), randomised trials were carried out, including a control trial (no inspiratory 
pre-activation), an inspiratory muscle pre-activation (IMpa) at 40% MIP, a placebo 
inspiratory muscle pre-activation (IMPpa) at 5% MIP, and a general warm-up (GW) specific 
to basketball. The intensity values (40% for IMpa and 5% for IMPpa) were selected based on 
prior research [21, 22] indicating that moderate loading can meaningfully engage inspiratory 
muscles, whereas near-minimal loading provides an effective placebo condition. The study 
was conducted at the Faculty of Sport Sciences, Gaziantep University, Turkey. All data 
collection procedures, including basketball skill tests and inspiratory muscle pre-activation 
sessions, were carried out in the university's sports performance laboratory and indoor 
basketball court under standardized conditions. The random allocation sequence 
was generated by an independent researcher who was not involved in data collection or 
intervention administration. The sequence was created using a card-drawing method to ensure 
allocation concealment. Participants were enrolled by the principal investigator, who provided 
detailed information about the study and obtained informed consent. The assignment of 
participants to interventions was conducted by a second researcher who was blinded to the 

 
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study hypothesis. This ensured that participants followed the assigned intervention order 
without bias. Data collection and outcome assessments were performed by a separate research 
team to maintain objectivity. Following the random selection of participants by means of a 
card-drawing method, the Johnson basketball skill test and the AAHPERD speed shooting test 
were administered. A single-blind design was implemented, where participants were blinded 
to the intervention condition (IMpa vs. IMPpa). They were unaware of the true inspiratory 
muscle pre-activation (IMpa) and the placebo condition (IMPpa), as both interventions 
followed an identical protocol except for the resistance level. The researchers conducting the 
intervention were not blinded, as they had to administer the inspiratory muscle training 
protocol and ensure proper execution. However, outcome assessors who recorded basketball 
skill test results were blinded to the intervention conditions to prevent potential bias in 
performance evaluation. Blinding was maintained by using identical devices for IMpa and 
IMPpa conditions, ensuring that participants could not distinguish between active and placebo 
interventions. This study was conducted in accordance with the CONSORT guidelines for 
reporting randomized trials, ensuring methodological transparency and reproducibility. The 
study design, participant allocation, interventions, and outcome assessments were reported 
following CONSORT recommendations. 
 
 
 
Figure 1. Schematic Overview of the Study Design and Procedures 
Procedures 

 
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Inspiratory muscle pre-activation trial (IMpa) 
The Powerbreathe brand device was used to perform inspiratory muscle pre-activation. Two 
sets of 30 breaths were carried out at 40% of each participant’s maximal inspiratory mouth 
pressure (MIP), with a one-minute rest in between [21,22]. MIP was measured once at the 
first session, and that value determined 40% and 5% for IMpa and IMPpa, respectively, in 
later visits. Participants were seated, wearing a nose clip, instructed to exhale forcefully, then 
inhale forcefully against a closed airway for one to three seconds. Measurements were 
repeated until values within 5 cmH₂O of each other were obtained, recording the best result in 
cmH₂O [21,22]. 
Placebo inspiratory muscle pre-activation trial (IMPpa) 
The Powerbreathe brand inspiratory muscle warm-up device was employed to facilitate an 
exercise regimen comprising two sets of 30 breaths, performed at an intensity of 5% of the 
participants’ maximal inspiratory mouth pressure (MIP), with a one-minute interval between 
sets [18]. This minimal load was intended as a placebo-like condition for inspiratory muscle 
usage. 
General warm-up protocol (GW) 
The participants engaged in a 10-minute jogging activity, which was followed by a 10-minute 
stretching exercise. Subsequently, the general warm-up protocol was completed with shooting 
drills tailored to the specific requirements of basketball, without inducing fatigue. 
 
Data collection 
Johnson basketball skill test 
In order to assess shooting ability, each participant was required to attempt to make as many 
successful shots as possible within a 30-second period from a distance of their own choosing, 
in close proximity to the basket. Each successful shot was awarded a value of one point. To 
assess the participants’ passing abilities, they were instructed to execute a one-handed 
baseball pass from a distance of 12 metres to rectangles delineated on a wall. The rectangles 
were arranged in an overlapping configuration, with the smallest width of 50 cm, length of 25 
cm, the central rectangle measuring 1 m by 60 cm, and the largest rectangle measuring 1.5 m 
by 1 m. A successful pass that struck the centre rectangle was awarded three points, two 
points for a pass that hit the middle rectangle, and one point for a pass that struck the outer 
rectangle. In order to assess the participants’ ability to dribble, four obstacles were positioned 
at 180-cm intervals along a line. The distance between the initial obstacle and the starting line 
was 360 centimetres. Participants commenced the dribbling task from the starting line, 
navigating the obstacles and returning to the starting line within a specified time limit of 30 
seconds. The total number of obstacles successfully negotiated was recorded as the score [23]. 
The Johnson basketball skill test yielded four parameters: passing, shooting, dribbling, and the 
total score of the test. 
AAHPERD basketball speed shooting test 
The participants commenced shooting at the starting line within the designated shot-testing 
area. The participants propelled their shots towards the hoop from the initial zone, allowing 
them to rebound the ball and subsequently dribble to the alternative shooting zone, where they 
proceeded to shoot. Each participant was required to shoot at least once from each of the five 

 
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designated shooting zones, with at least one foot within the shooting zone at the time of 
shooting. Following unsuccessful attempts at shooting, participants were permitted to attempt 
a layup after the rebound. However, it was not permitted to attempt two consecutive layups. A 
maximum of four layups was permitted throughout the course of the test. The participant was 
required to execute a legal shot or layup from the five-shot zone until the “stop” signal was 
given. Upon the expiration of the 60-second interval, the speed shooting test was concluded. 
Successful shots and layups were recorded by the practitioner as two points. In the event of a 
failed shot that subsequently returned from the hoop, the participant was awarded one point. If 
a layup shot was successfully made after the ball had been controlled and subsequently 
rebounded, two points were awarded. In the event of two consecutive successful layup shots, 
no points were awarded for the second shot. A maximum of four layups could be attempted 
within the 60-second period. No points were awarded for layup shots attempted after the 
fourth shot. No points were awarded for shots that constituted rule violations, such as steps, 
ball carrying, and shooting line violations [24]. 
 
Statistical analyses 
At the end of the research, the SPSS software package [25] was used for the statistical 
analysis of the obtained data. The data were presented as mean and standard deviation. The 
Shapiro–Wilk test was applied for normality, and the Levene test was used for homogeneity. 
Skewness and kurtosis values were checked for data sets that did not show a normal 
distribution, and data sets within ±2 were considered to have a normal distribution [26]. The 
Mauchly sphericity test was used to test the sphericity assumption. The Greenhouse–Geisser 
correction was applied in measurements where the sphericity assumption was not met. A one-
way analysis of variance (ANOVA) for repeated measures with a 95% confidence interval 
was applied to analyze the differences among the protocols. The least significant difference 
correction was used to determine in which specific protocols the differences occurred. Effect 
sizes were calculated using partial eta squared (ηp²) to determine the magnitude of observed 
differences. Statistical results were evaluated at a significance level of p < 0.05. 
 
Results 
 
Table 1. Differences in basketball skill test points between trials. 
 
 
CON 
 
IMpa 
IMPpa 
GW 
Pass (point) 
13.2 ± 1.48 
 
16.1 ± 2.56a,b 
13.2 ± 1.75 
16.3 ± 3.27a,b 
 
Difference from CON 
2.9 
0 
3.1 
 
Percent change from CON(%) 
21.97 
0 
23.48 
Shoot (point) 
13.5 ± 2.8 
 
15 ± 1.94 
14.2 ± 2.15 
15.5 ± 2.8 
 
Difference from CON 
1.5 
0.7 
2 
 
Percent change from CON 
11.11 
5.19 
14.81 
Dribbling 
(point) 
26.9 ± 2.56 
 
27.8 ± 1.48 
27.7 ± 1.42 
28.3 ± 1.34 
 
Difference from CON 
1.9 
0.8 
1.4 
 
Percent change from CON 
7.06 
2.97 
5.2 
AAHPERD 
Speed Shooting 
(point) 
19.1 ± 3.25 
 
21.6 ± 2.5a,b,c 
19.3 ± 2.16 
18.4 ± 2.91 
 
Difference from CON 
2.5 
0.2 
-0.7 
 
Percent change from CON 
13.09 
1.04 
-3.66 

 
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Total Johnson 
(point) 
53.6 ± 5.1 
 
58.9 ± 4.7a 
55.1 ± 4.12 
60.1 ± 4.28a,b 
 
Difference from CON 
5.3 
1.5 
6.5 
 
Percent change from CON 
9.89 
2.8 
12.13 
CON—control trial, IMW—inspiratory muscle pre-activation trial, IMPpa—placebo inspiratory muscle pre activation 
trial, GW— general warm-up trial. Pass—Johnson basketball pass accuracy skills test, Shoot— Johnson basketball 
shooting skills test, Dribbling— Johnson basketball dribbling skills test, Total Johnson— The average scores obtained 
from the Johnson basketball skill test. 
a Significant difference between CON 
b Significant difference between IMPpa 
c Significant difference between GW 
Table 1 presents the statistical analysis of the mean scores obtained from the subtests of the 
Johnson basketball skill test (the pass accuracy test, the dribbling test, the shooting test, and 
the total score) as well as from the AAHPERD basketball speed shooting test. Significant 
differences (df = 3, F = 8.99, p = 0.000, ηp² = 0.500) were identified in the Pass subtest (CON 
= 13.2 ± 1.48 points, IMPpa = 13.2 ± 1.75 points, IMpa = 16.1 ± 2.56 points, GW = 16.3 ± 
3.27 points) between IMpa vs. IMPpa, IMpa vs. CON, GW vs. CON, and GW vs. IMPpa. 
Similarly, the AAHPERD basketball speed shooting test (CON = 19.1 ± 3.25 points, IMPpa = 
19.3 ± 2.16 points, IMpa = 21.6 ± 2.5 points, GW = 18.4 ± 2.91 points) demonstrated 
significant differences (df = 3, F = 3.40, p = 0.032, ηp² = 0.74) between the IMpa protocol and 
all other trials. Furthermore, the total Johnson score (CON = 53.6 ± 5.1 points, IMPpa = 55.1 
± 4.12 points, IMpa = 58.9 ± 4.7 points, GW = 60.1 ± 4.28 points) demonstrated notable 
alterations (df = 3, F = 6.69, p = 0.002, ηp² = 0.426) between IMpa and CON, GW and CON, 
and GW and IMPpa (Figure 1). The results of the repeated measures analysis of variance of 
the mean scores obtained from the dribbling and shooting tests, which are subtests of the 
Johnson basketball ability test, revealed no statistically significant difference between the 
protocols (df = 3, F = 2.05, p = 0.130, ηp² = 0.186; df = 3, F = 1.52, p = 0.231, ηp² = 0.145). 
 
 
CON
IMpa
IMPpa
GW
0
10
20
30
40
26.90
27.80
27.70
28.30
Dribbling
Average Score

 
9 
 
 
 
 
Figure 2. Summary of Key Performance Metrics Under Different Inspiratory Muscle Pre-
Activation Conditions 
 
Discussion 
This study set out to determine whether incorporating an inspiratory muscle pre-activation 
could serve as a new, diaphragmatic-based training method to enhance passing, dribbling, and 
shooting in basketball. Two principal findings emerged. First, the results demonstrated that 
the inspiratory muscle pre activation trial significantly improved both pass accuracy and 
speed shooting performance compared to the control and a placebo trial. This aligns with 
previous studies suggesting that inspiratory muscle exercises may contribute to accuracy in 
sports requiring precision, such as archery and hockey [14,15]. Second, the general warm-up 
protocol also yielded significant improvements in pass accuracy, underscoring the well-
established benefits of preparatory activities on sports performance [27,28,29]. However, the 
placebo inspiratory muscle pre-activation did not yield any statistically significant 
improvements, indicating that it did not produce a placebo effect capable of enhancing 
precision-based basketball skills. 
Previous research has demonstrated the effects of inspiratory muscle interventions on a range 
of physical abilities, including repeated sprinting [30], exercise capacity [11, 13, 31], agility 
and speed [32], swimming performance [33], intermittent running to exhaustion [34], lung 
function [35] and combined pulmonary responses to exercise [36]. However, these results are 
often based on several weeks of training rather than a single pre-activation session. 
CON
IMpa
IMPpa
GW
0
5
10
15
20
13.50
15.00
14.20
15.50
Johnson Shoot
Average Score

 
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Inspiratory muscle pre-activation in basketball performance has yet to be investigated, which 
is why we focus on a single visit approach to highlight any immediate effects. 
One of the fundamental skills in basketball is passing, which requires a high degree of 
accuracy. The accuracy of a pass is influenced by several variables, including the defensive 
pressure applied by the opposition [37], the height of the passer and the level of cohesion 
within the team [38], as well as upper extremity fatigue [39]. A previous study demonstrated 
that the outcomes of the basketball passing skill test did not influence the accuracy of passing 
in competitive play [40]. However, in this study, only the Johnson basketball pass test was 
employed for determining pass accuracy. 
The factors that affect shooting include fatigue [41], ball release height, angle, and velocity 
[42], defensive pressure from opponents [43], the impact of resistance exercise [44], backspin 
alignment [45], and isokinetic strength [46]. In particular, the direct and versatile impact of 
core muscle strength on shot performance has been the subject of investigation [47]. A study 
[48] demonstrated that an intervention designed to enhance core strength resulted in a 36.2% 
increase in dynamic shooting accuracy among basketball players. It is therefore imperative 
that players possess sufficient core strength in order to maintain equilibrium and stabilise the 
body during shooting. It is therefore postulated that the abdominal muscles exert a direct 
influence on respiratory function, thereby affecting shooting accuracy in basketball by 
forming functional kinetic chains with the diaphragm, multifidus, muscles surrounding the 
abdomen, and pelvic floor muscles [49]. The importance of inspiratory muscles in activities 
requiring precision, particularly in sports involving the upper extremities, is attributed to their 
significant influence on accuracy, which outweighs the impact of core muscle stabilisation 
and respiratory rate [47,48]. The training of inspiratory muscles has been demonstrated to 
enhance the stabilisation of these muscles and contribute to increased postural stability, 
depending on the level of attention required during the shooting process [14,15,18,50]. 
Nevertheless, the immediate effect of a 2-set, 30-breath pre-activation of inspiratory muscles 
on core strength or postural stability is not conclusively shown, and the mechanism may 
involve decreased respiratory effort that indirectly improves balance or motor control. 
The Johnson basketball skill test comprises three distinct stages [51]. Upon conducting a 
statistical analysis of the mean scores obtained from the test, a notable disparity was observed 
in favor of both the experimental application and the general warm-up protocol. However, 
although an increase was observed for both protocols in the dribbling and shooting 
components of the test, no significant differences were detected. This may be attributed to the 
obstacles not being sufficiently challenging in the dribbling application, and to successful 
shots made under the basket in a limited time not being adequate to demonstrate the impact of 
the protocols in the shooting component. The absence of a time limit in the passing accuracy 
application of the test, which only measures the degree of accuracy, lends further support to 
the lack of a significant difference in the other two tests. 
In the application of the AAHPERD speed shooting test, a statistically significant difference 
was observed between the experimental trial and the other trials, with the former exhibiting 
superior performance when conducted with moving shots from a medium distance and five 
zones [52]. It is our contention that this has a more pronounced effect on the measurement of 
shooting accuracy in basketball for the participants. It can be stated that the AAHPERD speed 
shooting test is an effective method for measuring shooting accuracy. 

 
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Overall, these results highlight that pre-activation of inspiratory muscles as a simple yet 
potent method for refining passing and shooting in basketball—two skills vital for success on 
the court. Coaches looking to elevate accuracy within tight training windows can seamlessly 
integrate this diaphragmatic-based approach into existing training routines. In doing so, they 
may unlock hidden performance gains without overhauling their entire program. 
In practical terms, this can involve instructing players to perform two sets of 30 breaths at 
40% MIP prior to skill drills, requiring only a few extra minutes. Such a straightforward 
routine could be readily adopted by teams at various competition levels, from amateur to 
professional. 
Future studies could build upon these insights by combining pre-activation of inspiratory 
muscle exercises with targeted shooting and passing drills over multiple sessions, examining 
whether these initial benefits translate into lasting improvements in both skill and stamina. By 
embracing this new, diaphragmatic-based complementary training method, teams add a 
practical, cost-effective protocol to their arsenal—one capable of sharpening focus and 
precision in high-stakes moments of the game. 
Author Declarations 
Ethics approval 
This study was conducted in accordance with the ethical standards of the Declaration of 
Helsinki (52nd World Medical Association General Assembly, Edinburgh, Scotland, October 
2000) and was approved by the Gaziantep University Social and Human Sciences Ethics 
Committee (approval number: 2023-2). 
Consent to participate 
Informed consent was obtained from all participants prior to the commencement of the study. 
Clinical Trial 
Clinical trial number: not applicable. 
Consent for publication 
Not applicable. 
Availability of data and materials 
The datasets generated and/or analysed during the current study are available in the Figshare 
repository, 10.6084/m9.figshare.28536197. 
Competing interests 
The authors declare that they have no competing interests. 
Funding 

 
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No funding was received for this study. 
Acknowledgements 
The authors would like to acknowledge all participants for their valuable contributions to this 
study. 
 
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